Resident participation in laparoscopic hysterectomy: balancing education with safety

In our own experience as medical students in the 1990s, preparatory materials for a day in the operating room consisted of a surgical atlas, suture obtained from a wellmeaning nurse, and, if you were fortunate, a needle driver or Kocher clamp. These tools used to learn anatomy and the basic skills of knot tying and proper instrument handling have since been augmented by realistic manikins, laparoscopic and robotic trainers with computer-generated simulation, and mock interviews with actors. The saying of practice makes perfect is imprecise. Rather, we should eschew the concept that perfect practice makes perfect. These education tools provide house staff with the opportunity to practice perfectly in a safe environment away from patients and enter the operating room with greater confidence and skills. We hope these improvements will enhance the speed and efficiency with which our house staff mature into independent, caring physicians within a restricted work week, ensuring high-quality care. Adoption of these methods has occurred inconsistently among training programs, but nevertheless, it is clear that the phase, see one, do one, teach one, has become an artifact of the 20th century, absent from the lexicon of modern medical education. But the question remains: does resident involvement compromise surgical quality, even with these advances? We tend to flatter ourselves with the assumption that outcomes correlate only with our surgical skills and clinical judgment, rather than the care provided by other members of the team including anesthesiologists, nurses, pharmacists, and even house staff. Care processes and surgical expertise are critical contributors to high-quality outcomes, but investigations have demonstrated that nonmodifiable variables such as disease and patient characteristics dominate the value equation. 1 Nevertheless, an inexperienced or, in the worst case, incompetent team member has a great capacity to do harm, emphasizing the importance of leadership and supervision. Thus, assessments of the impact of residents on patient outcomes are more accurately assessments of the attending surgeons’ ability to provide appropriate oversight. In this issue of the Journal, Igwe et al 2 investigate the impact of resident involvement on surgical outcomes for 3441 patients undergoing benign total laparoscopic hysterectomy from the National Surgical Quality Improvement Program (NSQIP). To date more than 400 hospitals have contributed data from millions of patients to the NSQIP, which provides state-of-the-art, validated, risk-adjusted outcomes for the purposes of quality assessment and improvement. Details not available in NSQIP were inferred through the use of relative value units and Current Procedural Terminology codes. This allowed the authors to control for potential differences in patient factors such as surgical complexity in this nonrandomized study. Overall, there was no increase in morbidity or mortality rates when a resident was involved in the procedure, a reassuring finding for patients, surgeons, educators, and residents alike, and consistent with prior findings. 3 However, closer examination of specific endpoints provides additional observations that may prove useful in our endless quest to improve surgical and educational quality. Unsurprisingly, cases including residents were significantly longer, 43 minutes on average, compared with cases performed by attending physicians alone. This is one of the most frustrating aspects of teaching, but certainly it is unreasonable