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Ann Thorac Surg 2002;74:1043-1049
© 2002 The Society of Thoracic Surgeons

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Original article: cardiovascular

Is it safe to train residents to perform cardiac surgery?

^a The Maritime Heart Centre, Dalhousie University, Halifax, Nova Scotia, Canada

* Address reprint requests to Dr Baskett, The Maritime Heart Centre, Room 2269, 2nd Floor, 1796 Summer St, Halifax, NS B3H 3A7, Canada
e-mail: rogerbaskett{at}hotmail.com

Presented at the Thirty-eighth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 28–30, 2002.

	Abstract

Top Footnotes Abstract Introduction Patients and methods Results Comment Discussion References

 
Background. The impact of surgical training on patient outcomes in cardiac surgery is unknown.

Methods. All cases performed by residents from 1998 to 2001 were compared to staff surgeon cases using prospectively collected data. Operative mortality and a composite morbidity of: reoperation for bleeding, perioperative myocardial infarction, infection, stroke, or ventilation more than 24 hours were compared using multivariate analysis.

Results. Four residents performed 584 cases. The cases were as follows: coronary artery bypass grafting (CABG), 366 cases; aortic valve replacement (AVR) with or without CABG (AVR ± CABG), 86 cases; mitral valve replacement, 31 cases; mitral valve repair, 25 cases; thoracic aneurysm/dissection, 22 cases; aortic root, 20 cases; transplantations, 14 cases; and adult congenital defect repairs, 20 cases. There were 2,638 CABGs and 363 AVR ± CABG performed by the staff during the same period. Crude operative mortality in CABG patients was 2.5% (resident) and 2.9% (staff) (p = 0.62). In multivariate analysis, resident was not associated with operative mortality odds ratio (OR) of 0.59 (p = 0.19). Resident cases had a higher incidence of the composite morbidity outcome for CABG cases (19.4% vs 13.6% for staff; p = 0.003). However, in multivariate analysis, resident was not associated with increased morbidity (OR = 1.23, p = 0.16). The AVR ± CABG crude mortality was 3.6% (resident) and 2.8% (staff) (p = 0.69). Because of the small number of cases (n = 447), operative mortality was combined with the composite morbidity outcome for the AVR ± CABG model. In all, 16.7% of resident cases and 19.8% of staff cases had the composite outcome or died (p = 0.51). In multivariate analysis resident was not associated with this outcome (OR = 0.74, p = 0.35).

Conclusions. In this analysis of our experience with residency training, the operative morbidity and mortality in CABG and AVR patients was similar for residents and staff. Training residents to perform cardiac surgery appears to be safe.

	Introduction

Top Footnotes Abstract Introduction Patients and methods Results Comment Discussion References

 
There has been a growing interest in medical education over the past decade. In particular, surgical training has always functioned as an apprenticeship, a model largely unchanged for more than 100 years [1, 2]. Gradually, formal curricula have been developed, and better standardization of examinations has been adopted [3]. In addition, there has been growing concern over the increasing length of many training programs as specialties become more complex [4–6].

Parallel to this, there has been a growing interest and demand for public reporting of cardiac surgical outcomes [7]. It is clear that surgeon experience and, in particular, the volume of cases performed by an individual as well as by the hospital are important determinants of patient outcomes [8]. This has resulted in much greater scrutiny and pressure to improve outcomes. Concern has been expressed that this has led to less experience for surgeons in training [9].

In light of this and the increasing complexity of cardiac surgery cases, it is important to assess the impact of training residents on patient outcomes. There has been limited study in the area of the effect of residency training on patient outcomes. Most of these are from 20 years ago, and likely do not reflect the current state of training and cardiac surgical practice [10–14]. All of these studies concluded that it was safe to train residents; however, many of these studies were methodologically weak [9, 15]. The only thorough study in the cardiac surgery literature is more than 20 years old [11, 16].

Our objective in this study was to evaluate the impact on in-hospital morbidity and mortality of residents performing cardiac surgery.

	Patients and methods

Top Footnotes Abstract Introduction Patients and methods Results Comment Discussion References

 
All cases between January 1998 and May 2001 were included in the study. For purposes of the statistical analysis, patients undergoing isolated coronary artery bypass grafting (CABG) and aortic valve replacement (AVR) with or without CABG (AVR ± CABG) were evaluated. There were insufficient numbers of other types of cases to allow meaningful analysis. All patient data were collected prospectively using the Society of Thoracic Surgeons (STS) database [17]. The database captures 100% of cases and is validated annually by auditing a random sample of 10% of patient charts. At our last audit, less than 5% of data forms contained random errors, and no systemic errors were found. The missing data points in the database constitute less than 5%.

A resident database was established and the individual residents were responsible for keeping track of their own cases. A resident case was defined as a case in which the resident performed the entire case skin to skin, and certainly the more critical elements thereof, with the staff acting as assistant, or supervising while another person directly assisted the resident. The resident cases were selected by the residents themselves.

In the Canadian system, residents begin the 6-year cardiac surgery training directly from medical school. After 2.5 years of core surgery and cardiology, the residents spend 6 months as juniors (3 years after medical school) and 12 months as seniors (a sixth-year resident) on the adult cardiac surgery service. The cases presented here include the cumulative experience of 4 residents: 3 junior 6-month rotations, and 16 months of senior rotations (2 residents).

The primary outcome of interest was in-hospital mortality. In the interest of looking at several morbidity outcomes, a composite morbidity was used that consisted of any of the following: reoperation for bleeding, superficial or deep sternal wound infection, permanent stroke, myocardial infarction, or ventilation more than 24 hours. The STS definitions were used for all variables and outcomes [17]. Preoperative and intraoperative variables and patient outcomes were compared using ² and t tests.

Backward logistic regression models were constructed for each of the outcomes (in-hospital mortality and the composite morbidity outcome) to assess the independent effect of resident as surgeon on patient outcomes. The models were assessed using the "C statistic" and goodness of fit. In addition, the logistic regression models were used to calculate individual surgeon and resident (the four combined as a single surgeon) observed-to-expected ratios for morbidity and mortality [18]. These were displayed graphically with 95% confidence intervals to assess the variability among surgeons and the residents.

	Results

Top Footnotes Abstract Introduction Patients and methods Results Comment Discussion References

 
A total of 4,433 cases were performed over the 3.5 years. The majority of cases were isolated CABG (73%) or AVR ± CABG. The 4 residents scrubbed for 993 of the cases and performed 584 (59%) of them (Table 1). During the chief residency period (2 residents over a 16-month period), the residents performed 315 of the 373 cases for which they scrubbed (84%).

View larger version (11K): [in this window] [in a new window]   Fig 1. Observed-to-expected ratios for the residents as a group (top) and each of the staff surgeons who performed more than 200 isolated coronary artery bypass grafting cases during the study period of the study (bottom). Each horizontal bar displays the point estimate for the observed-to-expected ratio for mortality and the 95% confidence intervals. Expected mortality is calculated for each surgeon’s patients based on the coefficients from the logistic regression model for mortality.

View larger version (10K): [in this window] [in a new window]   Fig 2. Observed-to-expected ratios for the residents as a group (top) and each of the staff surgeons who performed more than 200 coronary artery bypass grafting cases during the period of the study (bottom). Each horizontal bar displays the point estimate for the observed-to-expected ratio for morbidity and the 95% confidence intervals. The expected composite morbidity (reoperation for bleeding, superficial or deep sternal wound infection, permanent stroke, myocardial infarction, or ventilation >24 hours) is calculated for each surgeon’s patients based on the coefficients from the logistic regression model for composite morbidity.

View larger version (10K): [in this window] [in a new window]   Fig 3. Observed-to-expected ratios for the residents as a group (top) and each of the staff surgeons who performed more than 50 AVR± CABG cases during the study period (bottom). Each horizontal bar displays the point estimate for the observed-to-expected ratio and the 95% confidence intervals. The expected composite outcome, mortality, or composite morbidity (reoperation for bleeding, superficial or deep sternal wound infection, permanent stroke, myocardial infarction, or ventilation >24 hours) is calculated for each surgeon’s patients based on the coefficients from the logistic regression model for composite morbidity.

	Comment

Top Footnotes Abstract Introduction Patients and methods Results Comment Discussion References

These results are similar to those described for isolated mitral and aortic valve replacement 20 years ago in a study from Veterans Affairs hospitals [11, 16]. However unlike the cases in that study, the resident cases in our series were, by most important measures, higher risk than the staff cases (Table 2). Other studies have also found that residents are usually delegated the lower-risk cases [9, 15, 19]. In addition, in these reports, the vast majority of resident cases (88%) were isolated CABG, versus 60% for staff [9]. In our series, 62% of resident cases were isolated CABG compared with 73% for staff.

The higher-risk cases performed by the residents and the higher proportion of non-CABG cases is a reflection of the practices of staff with whom the residents tended often to operate. With few residents in a large-volume center, the residents are given the choice daily for which room or case they wish to scrub.

A weakness of this study is the use of a composite outcome for morbidity, which makes the result somewhat more difficult to interpret. This was required to achieve a sufficient number of outcomes, but also allowed us to look at several morbidities with low incidences. The majority of the excess morbidity in the resident cases was prolonged ventilation (14.8% vs 9.5%) (Table 4). However, much of this may be the result of the greater proportion of preoperative IABP use (Table 2). In addition, the residents selected the cases, a practice that may not exist in other centers. This resulted in the residents spending a greater proportion of time with more experienced staff surgeons, which may bias the results. The definition of a resident case is, by nature, somewhat imprecise. Each resident was responsible for collecting and recording which cases they considered that they did or did not perform. There likely was some variation in perception among the individual residents. However, we did attempt to set out in advance clear criteria for a resident case.

It has been shown that there is a learning curve over the course of a surgeon’s career that can affect patient outcomes [20]. Clearly, no matter how well trained residents are, their results will improve over the course of their careers. The more experience that residents can have while under the supervision of staff, particularly with the more complex cases, the less they will need to improve as staff surgeons and, presumably, the less impact this will have on patient outcomes.

We have found that it is safe to allow residents, even at quite a junior level (third postgraduate year), to perform cases under staff supervision. There is perhaps a slight increase in morbidity in the CABG only cases; although, after accounting for the higher-risk status of the patients, this was not a significant difference, despite adequate power to detect such a difference. We are confident that it is safe to allow residents, even at a junior level, to perform cardiac surgery. Patients can be reassured that their outcomes are not compromised (and may, in fact, be enhanced) by the participation of residents in their surgery.

	Footnotes

Top Footnotes Abstract Introduction Patients and methods Results Comment Discussion References

 
This article has been selected for the open discussion forum on the CTSNet Web site:, http://www.ctsnet.org/discuss

	Discussion

Top Footnotes Abstract Introduction Patients and methods Results Comment Discussion References

 
DR EDWARD D. VERRIER (Seattle, WA): Thank you very much for the opportunity to discuss this interesting and superbly presented paper. I am also pleased that the Program Committee of The Society of Thoracic Surgeons included this presentation on resident education. Doctor Baskett and colleagues at the Maritime Heart Center in Halifax have retrospectively analyzed morbidity and mortality of myocardial revascularization and valve replacement in 3,001 patients operated on in their institution over a 3-year period: 452 of the operations were done by residents at various levels of advanced training, and 2,549 were performed by attending staff. Overall, the residents scrub on 22% of the cardiac cases and are primary surgeon on 59% of those cases they select to participate in. The overall conclusions are that the residents tend to operate on sicker cohorts of patients than the attendings and achieve similar and certainly "safe" results. As a cardiac surgical educator, I obviously agree that the residents are safe, but I am not sure that the design of the study substantiates all of the conclusions drawn. Success still might have something to do with case selection and subtle decisions about risk management, selected attending intervention within cases reflecting the quality, skill, or maturity of the attending educator, and for comparison’s sake, even the quality and experience of a long-standing nonresident surgical team. There are actually three different groups involved in this review: (1) cases done by the residents with staff assistants, (2) attending staff cases assisted by a resident, and (3) a very large group of staff patients helped either by another staff member or a trained first assistant. The authors have lumped the latter two groups only and have then compared the residents to the combined staff group. My first questions relate to potential biases and subsequent comparisons. Why did the residents only act as primary surgeon in 59% of the cases they elected to scrub on? If this study compared outcomes in cases done by the residents to cases done by the attending with the resident assisting, or to exclusively the group that the residents were not involved at all, would the results and conclusions be similar? Since the present comparison included the other 78% of cases performed by a more mature staff team, this may account for why the resident cases appeared to be higher risk. On the other hand, one might argue that resident results should have been significantly better than reported if the attending subsequently, or subjectively or objectively, tended to do the higher risk cases (ie, surgical judgment). If the resident has the option to select their attending, is there a very real potential for bias for the resident to select the more experienced, potentially more mature surgeon, therefore providing a bias that might impact the conclusions that the residents are safe regardless of the attending or the first assistant? My second set of questions relate to the individual and complete morbidity conclusions. Why is there such inconsistency in the CABG versus the CABG/valve group? For instance, the composite outcome was worse if the residents were involved in the CABG cohort compared to the staff, ie, 19.4% versus 13.6%, but better in the arguably more challenging CABG/valve group. In that cohort the resident composite score was 16.7% compared to 19.8% for the staff. Intuitively, this is somewhat difficult to understand. Were there rigid clear definitions for the morbidities, and was the investigator blinded to each cohort at the time of data acquisition? My final comment has to do with extrapolating these results. These cases were done in Canada, which has a centralized model of cardiac surgical care, therefore creating a large diverse denominator within the academic medical center. We need to be careful in extrapolating these data to the United States, which is increasingly a more decentralized model with less volume and potentially even more complexity in the academic medical center. Therefore, even more emphasis on the quality and judgment of the surgical educator might be required. Obviously, to most broadly answer the question whether residents are safe to perform cardiac surgery, one would have to perform some sort of prospective randomized trial of all cases or at least carefully defined cohorts. That study will never be done. Clearly, in Nova Scotia, however, in the system of cardiac surgical care there, resident education is excellent and safe. Thank you for the opportunity to discuss this excellent presentation.

DR AGUSTIN ARBULU (Detroit, MI): Our experience is similar to what the presenter of this excellent paper has expressed. We heard yesterday Dr Khuri describing some of the complex regulatory policies developed by consumer groups as mechanisms of grading the "quality" of services. My questions are: Do you have any regulations (policies) that describe what segments of the operations can be independently performed by the residents; and if you have these rules or regulations, how specific are they? I enjoyed your paper and congratulate all the authors.

DR BASKETT: Thank you very much, Dr Verrier. I will try to answer your questions. As to why only 60% of the cases were done by the residents, almost half of this experience represents the experience of third-year residents, that is, a resident who is 3 years out of medical school. So clearly during the 6 months as a junior resident there is quite a steep learning curve; and in the first 3 months you are not going to be doing "skin to skin" cases, although very quickly we do seem to get up to speed. In terms of dividing the three groups, I think you make a very good point that there are three groups: those where the residents assisted, versus the ones that they did, versus the ones the staff did by themselves. There are not enough numbers, as I imagine you would appreciate, to divide it into three groups to look at this. So we elected to just divide it into two, recognizing the faults of this approach. In terms of selection of cases, that is a very important point. I think our program is perhaps different from many, in that we only ever have one resident on service. There are six cases a day, and the resident has the luxury of choosing what they want to do on that given day. So, yes, there is a selection bias. The resident chooses who they want to go with and what case they want to do, which is a great luxury for us. So there is an inherent bias, as you point out, in the way the cases are selected. In terms of the morbidity tending to be higher in the CABG patients but not the AVR ± CABG patients, I think perhaps the confusion there is that in the multivariate analysis, to look at the aortic valve patients, we combined mortality and morbidity—again, just for numbers, and this is a reflection of the different composite outcome. In terms of data acquisition and blinding, we have a version of the STS database, so the definitions of the outcomes and preoperative and intraoperative variables were predefined and are familiar to most of you, and the data acquisition people were in fact blinded. They certainly were blinded when this was done, because this was a retrospective study. The data were already collected when we sat down to do this. Regarding the comments of the second discussant, I believe the main question was over our definitions and selection of cases. I think I have dealt with the selection of cases. In terms of definitions of what a resident case really is, we were pretty strict that it had to be "skin to skin." Each resident may have a slightly different perception of what that means, although we did sit down when we started the program and said, "This is how you will define having done a whole case." So I don’t believe there is a lot of bias there, although certainly there will be some variability. Thank you very much.

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Roger J. F. Baskett Jean-Francois Legaré Ansar Hassan David B. Ross John A. Sullivan Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Baskett, R. J. F. Articles by Sullivan, J. A. Search for Related Content PubMed PubMed Citation Articles by Baskett, R. J. F. Articles by Sullivan, J. A. Related Collections Education