Tag Archives: Residents

More on Malpractice: Can Surgical Residents Be Sued?

Respondeat superior. Let the master answer. This is a common law term that allows employers to be held responsible for the misdeeds of their employees or agents.

And more than half a century ago, the “captain of the ship” doctrine arose in surgery. This held the supervising surgeon responsible for everything that happened in the operating room.

And because of these two premises, there has been widespread presumption that surgical trainees are immune to being named in a malpractice action. Unfortunately, this is not true! There is no law that prevents residents from being included in a lawsuit.

So how common is resident involvement in malpractice suits? What are the damages? What are the consequences?  Researchers at the Mayo Clinic reviewed 10 years of data from the Westlaw online legal research database. They included all cases that involved surgical interns, residents, or fellows.

Here are the factoids:

  • A total of 87 malpractice cases involving surgical trainees were identified over 10 years (!)
  • 47% involved general surgical cases, 18% orthopedics, and 11% OB. The remainder were less than 5% each.
  • 70% of cases involved elective surgical procedures. The most common one was cholecystectomy (6 cases).
  • Half involved nonoperative decision making, and 39% involved intraoperative errors and injuries. The remainder had both components.
  • Failure of the trainee to evaluate a patient in person was cited in 12% of cases.
  • Lack of attending supervision was involved in 55%.
  • Informed consent issues were cited in 21%, documentation errors in 15%, and communications problems in 10%
  • There were twice as many cases involving junior residents compared to seniors and fellows
  • Median payout to the patient (and his attorney) was about $900K

Bottom line: At first, I though this was going to be an interesting paper. But it went downhill as soon as I started to read the analysis. Yes, it scanned 10 years worth of detailed malpractice data. BUT IT DIDN’T GIVE US A DENOMINATOR! There must have been tens of thousands of surgical malpractice cases during that time period across the US. And they found only 87 involving surgical trainees!

The authors conclude that this work “highlights the importance of perioperative management, particularly among junior residents, and appropriate supervision by attending physicians as targets for education on litigation prevention.”

This is ridiculous. The mere fact that the authors do not mention the total number of surgical malpractice cases in the database over the study period (denominator) implies that they were trying to emphasize the numbers they did publish. They didn’t want to show you how low the resident numbers were by comparison. On average, 9 were involved in a lawsuit every year. 

How many surgical residents and fellows are there? This is a bit hard to pin down. There are roughly 1200 categorical surgical residency spots every year. And then there are some prelim spots. Let’s add a few thousand more (wild ass guess), so that puts us at 5,000. Include orthopedics and other surgical specialty residencies? Add a few thousand more. And then fellows. Who knows? Add another  thousand? (If anybody has more accurate answers, please leave a comment!)

So 9 out of 10,000+ surgical trainees get sued every year. Do we really need to set up some kind of formal education on malpractice avoidance??? Not for those numbers. Just read, see your patients, especially when they are having problems, document everything you do, and practice good handoff communications. Then worry about more important things!

Reference: Medical malpractice lawsuits involving surgical residents  JAMA  Surg, published online Aug 30, 2017  

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Are Graduating General Surgery Residents Qualified To Take Trauma Call?

Trauma training during general surgery residency has changed dramatically over the past two decades. Although we like to blame the 80-hour work week rule on everything, there are other factors that may be at play. Increasing use of nonoperative management, availability and increasing scope of interventional radiologists, and the increasing number of surgical subspecialists are certainly significant.

The surgical group at LAC+USC looked at changes in operative caseloads, type of surgery performed, and the impact that concurrent subspecialty training has had on trauma operative volumes. The authors reviewed 16 years of ACGME data on resident surgical procedures in various body regions by year of training. They specifically looked at the impact of implementation of the 80-hour work week.

Here are the factoids:

  • There was a trend only (p=0.07) toward decreased operative trauma cases
  • The number of trauma laparotomies increased, vascular procedures decreased, and neck explorations and thoracotomies remained stable
  • Trauma vascular procedures decreased for surgical residents, but increased for vascular fellows
  • Individual resident operative volumes in chest, abdomen, solid organ, and extremities decreased after implementation of the 80-hour work week
  • Based on this, the authors recommend residents who are interested in a career in trauma and acute care surgery have fellowship training (??)

AAST2016-Paper29

Bottom line: Well, it was a catchy title, at least. Or is it a promotion for trauma fellowships? I hope the authors have some really good statistics to help this paper out. You may not be able to read the table above well, but the differences between pre-80 hour and post-80 hour are not that impressive, and the SD or SEM (can’t tell what they are) are uncommonly narrow, which amplifies the p values. And other than the number of laparotomies going up, the other numbers looked fairly constant. I look forward to the presentation and critique of this paper at the meeting. Not sure it will escape unscathed.

Reference: Is your graduating general surgery resident qualified to take trauma call? A 15-year appraisal of the changes in general surgery education for trauma. AAST 2016, Paper 39.

Who’s Better At Invasive Procedures? Residents vs NP/PAs

With the implementation of resident work hour restrictions more than 10 years ago, resident participation in clinical care has declined. In order to make up for this loss of clinical manpower and expertise, many hospitals have added advanced clinical providers (ACPs, nurse practitioners and physician assistants). These ACPs are being given more and more advanced responsibilities, in all clinical settings. This includes performing invasive procedures on critically ill patients.

A recent study from Carolinas Medical Center in Charlotte NC compared complication rates for invasive procedures performed by ACPs vs residents in a Level I trauma center setting.

A one year retrospective study was carried out. Here are the factoids:

  • Residents were either surgery or emergency medicine PGY2s
    ACPs and residents underwent an orientation and animal- or simulation-based training in procedures
  • All procedures were supervised by an attending physician
  • Arterial lines, central venous lines, chest tubes, percutaneous endoscopic gastrostomy, tracheostomy, and broncho-alveolar lavage performances were studied
  • Residents performed 1020 procedures and had 21 complications (2%)
  • ACPs performed 555 procedures and had 11 complications (2%)
  • ICU and hospital length of stay, and mortality rates were no different between the groups

Bottom line: Resident and ACP performance of invasive procedures is comparable. As residents become less available for these procedures, ACPs can (and will) be hired to take their place. Although this is great news for hospitals that need manpower to assist their surgeons and emergency physicians, it should be another wakeup call for training programs and educators to show that resident education will continue to degrade.

Reference: Comparison of procedural complications between resident physicians and advanced clinical providers. J Trauma 77(1):143-147, 2014.

Trends In Resident Trauma Operative Experience

Even though it’s called trauma surgery, the operative experience in trauma tends to be somewhat limited. This is due mostly to the fact that most trauma centers see predominantly blunt trauma. Yes, there are hospitals around the world where the penetrating injury load remains high and there is operative experience aplenty.

But in the US, the vast majority of trauma centers see mostly blunt trauma. Surgical residents in the US are required to log 10 operative and 20 nonoperative cases to successfully meet residency completion requirements. And blunt trauma is tending to get less and less operative in nature. A good example is the evolution of blunt solid organ injury to mostly nonoperative management.

So what is happening with surgical resident operative trauma experience? And has there been any impact from the work hour restrictions that have gone into effect in the US? A study from Harborview, Denver Health and Seattle Children’s looked at the ACGME operative logs for surgical residents annually from 1989 to 2010. They combined the data into 5 year blocks, with the last two having work hour restrictions in place.

Some interesting findings:

  • Overall mean caseload of major cases (all types) remained steady at about 925 per resident
  • Mean trauma operative caseload decreased from 76 to 39 (beginning of work hour restrictions)
  • Mean trauma operative caseload remained steady at 39 for the 7 years in which work hour restrictions were in effect
  • The number of intra-abdominal trauma operations decreased from 31 to 17, and the number of liver/spleen operations decreased from 5 and 4 to 3 and 2

Bottom line: Resident trauma operative experience has declined and stabilized in the US. This is due to the evolution of our management of blunt trauma. Unfortunately, this decline will reflect on how well prepared surgeons at outlying hospitals are, and in the quality of emergency surgery they may provide. The impact will be felt most by seriously injured patients who cannot be taken to a high level trauma center initially. We need creative solutions to address this issue, such as mini-clerkships in trauma or structured experiences at high level trauma centers for surgeons in outlying hospitals.

Related post: ED at the busiest hospital in the world!

Reference: ACGME case logs: surgery resident experience in operative trauma for two decades. J Trauma 73(6):1500-1506, 2012.

Trends In Resident Trauma Operative Experience

Even though it’s called trauma surgery, the operative experience in trauma tends to be somewhat limited. This is due mostly to the fact that most trauma centers see predominantly blunt trauma. Yes, there are hospitals around the world where the penetrating injury load remains high and there is operative experience aplenty.

But in the US, the vast majority of trauma centers see mostly blunt trauma. Surgical residents in the US are required to log 10 operative and 20 nonoperative cases to successfully meet residency completion requirements. And blunt trauma is tending to get less and less operative in nature. A good example is the evolution of blunt solid organ injury to mostly nonoperative management.

So what is happening with surgical resident operative trauma experience? And has there been any impact from the work hour restrictions that have gone into effect in the US? A study from Harborview, Denver Health and Seattle Children’s looked at the ACGME operative logs for surgical residents annually from 1989 to 2010. They combined the data into 5 year blocks, with the last two having work hour restrictions in place.

Some interesting findings:

  • Overall mean caseload of major cases (all types) remained steady at about 925 per resident
  • Mean trauma operative caseload decreased from 76 to 39 (beginning of work hour restrictions)
  • Mean trauma operative caseload remained steady at 39 for the 7 years in which work hour restrictions were in effect
  • The number of intra-abdominal trauma operations decreased from 31 to 17, and the number of liver/spleen operations decreased from 5 and 4 to 3 and 2

Bottom line: Resident trauma operative experience has declined and stabilized in the US. This is due to the evolution of our management of blunt trauma. Unfortunately, this decline will reflect on how well prepared surgeons at outlying hospitals are, and in the quality of emergency surgery they may provide. The impact will be felt most by seriously injured patients who cannot be taken to a high level trauma center initially. We need creative solutions to address this issue, such as mini-clerkships in trauma or structured experiences at high level trauma centers for surgeons in outlying hospitals.

Related post: ED at the busiest hospital in the world!

Reference: ACGME case logs: surgery resident experience in operative trauma for two decades. J Trauma 73(6):1500-1506, 2012.