The Team—Not the Resident—Impacts on Outcomes After Emergency Surgery

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To the Editor:
We read the article by Kasotakis et al1 with much interest. The authors conclude that trainee involvement in emergency surgery leads to greater postoperative adverse events. We agree with the authors’ discussion that high-quality training must be balanced with the delivery of safe and effective patient care. However, the conclusions drawn are controversial and, in the presence of notable limitations, must be interpreted with caution.
The role of the surgical trainee is an important consideration but is not adequately considered by the data presented. First, and perhaps most notably, the role of the surgical trainee in the wider team is poorly acknowledged. For example, the authors describe a longer anesthetic time in the trainee group (134.51 ± 75.15 vs 107.54 ± 61.08), possibly arising from involvement of inexperienced anesthetic trainees. However, they fail to consider how such variation in the wider team concurrently impacts patient outcomes. This serves as a source of confounding, which may extend far beyond the immediate operative team. To attribute the described outcomes to the involvement of surgical trainees in isolation is not justified.
Second, as acknowledged by the authors in their discussion, data provided by the National Surgical Quality Improvement Program database lacks detailed information on the specific contribution of surgical trainees and the level of senior supervision. This is an important deficit, especially in the setting of emergency surgery, where the level of supervision is variable, particularly for procedures performed “out of hours.” It is unclear from the data presented if the described outcomes are a function of residents performing the procedure themselves, or rather a function of their contribution. Of note, a recent multicenter assessment of outcomes after urgent appendectomy demonstrated no difference in 30-day complications between procedures with and without presence of an attending surgeon.2
Finally, postgraduate level of training is an important variable for assessing trainee-related outcomes. It is pleasing that the authors explore the effect of this on morbidity, mortality, and duration of surgery; however, the pooled analysis of all procedures precludes an accurate assessment of postgraduate year-specific outcomes. The results suggest that the risk of adverse outcomes is greater with increasing postgraduate year, which, as acknowledged by the authors, may be owing to senior residents performing more complex procedures. Of greater interest may be the effect of trainee grade on procedure-specific outcomes, which would more realistically reflect surgical practice. This would permit an assessment of timing and acquired competency for procedures of differing type and complexity.
An awareness of the limitations of this study is essential. The results must be interpreted with care, as the conclusions have the potential to exert a significant impact on surgical training and trigger substantial policy changes. Patient safety is at the forefront of clinical practice; however, trainees are an essential reality in the delivery of emergency surgical services around the world. Further studies must focus on identifying and addressing factors that optimize the learning curve experienced by trainee surgeons. This is in the best interest of safe and sustainable patient care.
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