Brain and spine surgery no more risky when physicians-in-training participate

A report on the study appears in the April issue of the Journal of Neurosurgery.

"Patients often ask whether a resident is going to be involved in their case, and they're usually not looking to have more residents involved," says Mohamad Bydon, M.D., himself a resident in neurosurgery at The Johns Hopkins Hospital. "Some people have a fear of being treated in a hospital that trains doctors."

To see whether that fear is borne out by real-world outcomes, Bydon worked with Judy Huang, M.D., a professor of neurosurgery and director of the neurosurgery residency program at the Johns Hopkins University School of Medicine, and other collaborators to analyze data from the American College of Surgeons National Surgical Quality Improvement Program database. Specifically, they examined outcomes for all patients who had brain and spine surgeries between 2006 and 2012 -- 16,098 in total.

The initial analysis appeared to affirm the fear, showing that patients operated on by a fully trained physician -- known as an attending -- plus a resident had a complication rate of 20.12 percent, while patients with only an attending had a complication rate of 11.7 percent. The patients operated on by attendings plus residents also had a slightly higher risk of death within 30 days after the surgery.

But, the research team suspected, that might not be a difference caused by the participation of the residents. Residents are most often found in teaching hospitals associated with academic medical centers, and such hospitals are also the most likely to treat higher-risk, more complicated cases. So the team did a deeper analysis of the data, one that took into account patients' conditions and severity of illness prior to surgery. That analysis showed that having a resident present in the surgery had no effect on patients' risks for postsurgical complications or death.

In her experience, having a resident present is likely to benefit patients, Huang says. "It means that there's an extra pair of hands, an extra pair of eyes," she explains. The experience is also essential for training the next generation of surgeons. "It's not just about the physical performance of the procedure," she says. "It's also about the reasoning involved, the understanding of what the pitfalls are and how to avoid complications. And that thought process is something that can only occur in the setting of the operating room when a trainee and a teacher work side by side together."

Bydon agrees. "When you are in the operating room, you see how senior surgeons approach the simpler cases and how they approach the more complex cases, and it's really invaluable, because that's how you learn to one day become an attending yourself," he says.

The authors say the study's results may help physicians reassure nervous patients about the prospect of having a trainee assist with a surgery. Explains Huang: "It allows us to say, 'Not only do we believe this, but it's also been shown in a population of patients across the country who undergo neurosurgery that there is no downside.'"

Neurosurgeons have some of the longest residencies in medicine, with seven years of training. Their roles in surgery grow as they acquire more experience, from tasks such as handing tools to the attending and suturing the surgical incision to performing the bulk of the surgery under the attending's close supervision.