Trainee Involvement in Emergency General Surgery: Is It the Team, or the Players?
We appreciate Li and colleagues’ interest in our recent article titled “Trainee Participation Is Associated with Adverse Outcomes in Emergency General Surgery: An Analysis of the National Surgical Quality Improvement Program.”1 In the letter, they express their concern that we attribute the adverse outcomes commonly observed after emergency surgical procedures to the involvement of trainees. We feel, however, that Li and colleagues have misinterpreted our findings and our intentions.
A careful review of our article would reveal that not only we do omit the mention of a direct cause-and-effect link between trainee involvement and adverse outcomes anywhere in the article, but also we stress the absence of one repeatedly in the discussion. We also concur that resident involvement is essential to the delivery of emergency surgical services worldwide, and that training—safely—the next generation of surgeons is vital to maintaining an adequate workforce for the future. We do believe, however, that these data are consistent with the hypothesis that when trainees are involved, procedures take longer in the operating room, as has been extensively demonstrated.2–6 This in turn may be associated with an increase in pulmonary, wound-related, and thromboembolic complications, as a result of the prolonged anesthesia, wound exposure, and immobility, respectively. This effect is likely more pronounced in emergency surgery, because patients may be inflamed, and are commonly malnourished and under-resuscitated. While in this inflammatory state, they receive an additional inflammatory insult (that of surgery) that could account for the outcome differential between emergency and elective procedures. Unnecessary prolongation of this secondary insult may account for the slightly worse outcomes when trainees are involved.7,8
Additionally, Li and colleagues state that it is the entire team, not merely the trainees, could be held accountable for the inferior outcomes seen in emergency surgery. It is unclear, however, what they define as “team,” and how they arrived at this conclusion, as no justification, plausible mechanism, or references to published literature are provided to support such a statement.
We appreciate that Li and colleagues reiterate our points stressed repeatedly in both the “Discussion” and “Q & A” sections of our article that information on degree of supervision was not available, and warn the reader to interpret our findings with caution. The single cited study that demonstrated no difference in outcomes in a low morbidity procedure (appendectomy) by trainees versus staff surgeons9 does not account for a significant body of evidence that demonstrates an association between resident participation and adverse outcomes after even these procedures.2,6,10–12
Finally, we agree with their observation that our study offers no information on procedure-specific outcomes; however, that was not our objective. There is a significant body of available literature that already addressed that issue,2,3,6,10 and we aim to delve deep into it further in the near future with additional projects.