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Original Investigation
Association of VA Surgeons
December 22, 2021

Association Between Operative Autonomy of Surgical Residents and Patient Outcomes

Author Affiliations
  • 1Department of Surgery, VA New Jersey Healthcare System, East Orange
  • 2Department of Surgery, Rutgers New Jersey Medical School, Newark
JAMA Surg. Published online December 22, 2021. doi:10.1001/jamasurg.2021.6444
Key Points

Question  Is surgical resident operative autonomy associated with worse patient outcomes?

Findings  In this cohort study of 1 319 020 surgical procedures recorded in the Veterans Affairs Surgical Quality Improvement Program database, those performed by residents alone were not associated with differences in all-cause mortality or morbidity compared with those performed by attending surgeons alone or by attending surgeons and residents together.

Meaning  This study found that appropriately selected surgical procedures were safely performed by residents alone and may be further encouraged.


Importance  Resident operative autonomy has been steadily decreasing. Whether this reduction in autonomy has been associated with changes in patient outcomes is unclear.

Objective  To assess whether surgical procedures performed by residents without an attending surgeon scrubbed are associated with differences in patient outcomes compared with procedures performed by attending surgeons alone or by residents with the assistance of attending surgeons.

Design, Setting, and Participants  This retrospective propensity score–matched cohort study analyzed 30-day outcomes among patients who received operations at US Veterans Affairs (VA) medical centers and were recorded within the VA Surgical Quality Improvement Program (VASQIP) database from July 1, 2004, to September 30, 2019. Among 1 797 056 operations recorded in the VASQIP during that period, 1 319 020 were eligible for inclusion. Operations performed by a surgical resident without an attending surgeon scrubbed (resident primary) were propensity score matched on a 1:1 ratio (based on year of procedure and patient age, race, sex, American Society of Anesthesiologists physical status classification, functional status, emergency status, inpatient status, presence of multiple comorbidities, and Current Procedural Terminology code) to operations performed by an attending surgeon only (surgeon primary) and operations performed by a resident with assistance from an attending surgeon (resident plus surgeon).

Exposures  Level of resident involvement.

Main Outcomes and Measures  Thirty-day adjusted all-cause mortality.

Results  Among 1 319 020 surgical procedures included, 138 750 were performed by residents only, 308 724 were performed by surgeons only, and 871 546 were performed by residents and surgeons. For the 1 319 020 total cases, patients’ mean (SD) age was 61.6 (12.9) years; 1 223 051 patients (92.7%) were male; and 212 315 (16.1%) were Black or African American, 63 817 (4.9%) were Hispanic, 830 704 (63.0%) were White, and 212 814 (16.1%) were of other or unknown race and ethnicity. Propensity score matching produced 101 130 pairs of resident-primary and surgeon-primary procedures and 137 749 pairs of resident-primary and resident plus surgeon procedures. Patient all-cause mortality and morbidity were no different among those who received surgeon-primary procedures (mortality: odds ratio [OR], 1.03 [95% CI, 0.95-1.12]; morbidity: OR, 1.01 [95% CI, 0.97-1.05]) vs resident plus surgeon procedures (mortality: OR, 1.03 [95% CI, 0.97-1.11]; all-cause morbidity: OR, 0.97 [95% CI, 0.95-1.00]). Resident-primary procedures had longer operative times than surgeon-primary procedures (median, 80 minutes [IQR, 50-123 minutes] vs 70 minutes [IQR, 41-114 minutes], respectively; P < .001) but shorter operative times than resident plus surgeon procedures (median, 71 minutes [IQR, 43-113 minutes] vs 73 minutes [IQR, 45-115 minutes]; P < .001). Hospital length of stay was unchanged among resident-primary vs surgeon-primary procedures (median, 4 days [IQR, 2-10 days] vs 4 days [IQR, 2-9 days]; P = .08) and statistically significantly shorter than resident plus surgeon procedures (median, 4 days [IQR, 1-9 days] vs 4 days [IQR, 2-10 days]; P < .001).

Conclusions and Relevance  In this cohort study, surgical procedures performed by residents alone were not associated with any changes in all-cause mortality or composite morbidity compared with those performed by attending surgeons alone or by residents with the assistance of attending surgeons. Given these findings and the importance of operative autonomy to prepare surgical residents for independent practice, efforts to increase autonomy are both safe and needed.

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