See One, Do One, Teach One: An Analysis of Chief Resident Teaching Assist Cases Under Varying Levels Of Attending Supervision

Avery Walker, MD, Josh Smith, DO, John McClellan, MD, Eric Johnson, MD, Matthew Martin, MD. Madigan Army Medical Center

Introduction:  The traditional paradigm of surgical training depends on a graduated program of increasing levels of responsibility and autonomy, but this may conflict with current realities of GME and patient safety concerns.  Chief residents are often permitted to supervise junior residents on operative cases, with varying degrees of attending supervision. We sought to analyze the epidemiology of these cases, and to determine the impact of different levels of attending supervision on outcomes.

Methods:  Review of all cases performed by chief residents categorized as a teaching assistant (TA) case were identified at our center between 2009-2014.  Demographic data, operative time, complications, case complexity, and level of staff involvement were analyzed. Cases were categorized by the level of staff supervision as either staff not present (NP), staff present but not scrubbed (SP), or staff scrubbed (SS).

Results:  There were 114 cases reviewed (mean age 38 years, 44% female). The majority of chief resident TA cases were laparoscopic (63%) and were most commonly laparoscopic cholecystectomies (30%) and appendectomies (28%). Most of these cases (72%) were performed without direct staff supervision, with the remaining 28% performed with SP or SS. The majority (82%) of TA cases performed without direct staff supervision (NP) had operative times of less than 2 hours and had low intraoperative blood loss (mean 10.5 cc) with no intraoperative transfusions or major complications. SP and SS cases were significantly more likely to last > 2 hours (50%) and had greater intraoperative blood loss (mean 30 cc, p<0.05). When subjectively stratified by difficulty (most difficult = 5, 3=moderately difficult, least difficult = 1), 73% of cases categorized as easy to moderate were performed without attending present.  When an attending needed to scrub, 46% of cases were deemed more difficult as categorized with a > 3 difficulty level. Overall, senior residents required staff involvement significantly more often when the case was perceived to be more difficult 36% vs. 2%, p<0.01. There was no difference in the incidence of wound complications or infections based on attending presence (0.8% for NP vs. 3% for SP/SS, p=0.7). There was no difference in overall or specific complication rates between the 3 groups.

Conclusion: There was no difference in outcomes or complications during chief resident TA cases with or without direct attending supervision. Chief residents were appropriately allowed greater degrees of autonomy on less complex or difficult procedures, with no adverse impact on patient safety, operative times, or postoperative complications.

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