PRACTICE ENVIRONMENT AND RESIDENT OPERATIVE EXPERIENCE

An important aspect of resident training is a graduated increase in responsibility and experience. The level of resident participation in operative procedures is influenced by many factors. Our aim was to determine the effect of the practice environment and staff perception of required surgical skills on the assignment of resident operative responsibility. Questionnaires were sent to 100 surgeons affiliated with the Department of Surgery at the University of Nebraska Medical Center, and the completion rate was 12%. Data were collected on the practice environment of the surgeons and their perception of appropriate resident level and required skills for performance of 20 common general surgery procedures. Surgeons in private practice (n = 34) and affiliated hospitals (n = 15) were more likely to assign cases to higher level residents than those at the University Hospital (n = 23) (mean: 3.0 +/- 0.5 and 3.0 +/- 0.3 versus 2.7 +/- 0.3 years, P <0.05). Surgeons more than 15 years out of training (n = 28)were more likely to assign a higher level resident to procedures than those (n = 44) more recently trained 13.1 +/- 0.5 versus 2.1 +/- 0.3 years, P <0.05). Surgeons who worked regularly with residents (n = 44) were more likely to assign a lower level resident to a given procedure (2.8 +/- 0.3 versus 3.1 +/- 0.5 years, P <0.05). Multivariate analysis, however, found that only time since training was an important factor in the assignment of responsibilities. Laparoscopic procedures caused the greatest disagreement and were more likely to be assigned to higher level residents than the corresponding open procedures (hernia repair 3.3 +/- 0.1 versus 1.2 +/- 0.1 and cholecystectomy 3.2 +/- 0.1 versus 2.0 +/- 0.9 years, P <0.05). Anatomy (46%) and judgment (36%) were most commonly considered the important surgical factors in determining operative responsibility. However, there was no correlation between assignment of operative responsibility and the perception of required skills for each surgeon. Thus staff perception of the appropriate resident level to perform general surgery procedures is more heavily influenced by factors in the practice environment than surgical aspects of the procedure.