The volume of surgical cases that residents are performing autonomously have decreased over time.1 The impetus for this decline in autonomy is multifactorial. Several studies have cited that cases involving residents increase operative time equating to higher O.R. utilization and increasing cost to patients and institutions.2,3 A greater push for productivity from teaching faculty has also influenced this trend as resident involvement is perceived to come with opportunity costs.4 Survey data from attending surgeons have shown that duty hour restrictions, time constraints, and changes in mentality toward shiftwork are all factors that limit attending willingness to transfer autonomy to residents in the operating room.5,6 Despite these many reasons for limiting autonomy, the existing literature repeatedly supports that resident involvement in the operating room, and specifically resident operative autonomy, is safe and does not increase morbidity or mortality.7, 8, 9, 10, 11, 12, 13, 14

With decreased autonomy, a major question is whether outcomes worsened for cases where autonomy has been granted? No study has specifically analyzed whether resident outcomes have worsened over time concurrent to the decrease in autonomy. Our previous studies comparing outcomes in relation to supervision included year of procedure in the logistical models and in the matching to control for possible changes in outcomes over time but did not explicitly look at the temporal trends.7,8 Overall surgical morbidity and mortality has been improving over the past several decades, particularly as reported in the private sector as seen in the National Surgical Quality Improvement Program (NSQIP) as well as in the in the Veteran's Affairs (VA) hospital system in the VA Surgical Quality Improvement Project (VASQIP).15, 16, 17, 18 These outcome improvements have occurred concurrently with decreasing resident operative autonomy, but that does not necessarily imply causation. More likely this indicates overall improvements in systems processes and our treatment options. While the most common procedures performed by residents autonomously include predominantly cases many would consider “bread and butter” cases for each specialty8; it is unclear if the trend of decreased autonomy is also being coupled with a decrease in acuity of the patients and the complexity of the cases being performed.

Therefore, we sought to examine if there is a change in outcomes over time for cases performed by residents. We hypothesize that resident autonomous cases will have improvements in morbidity and mortality over time, following the trends of surgical outcomes reported in the literature. Furthermore, in these cases, there will be no difference in outcomes compared to those with more supervision. Secondarily, we sought to understand whether the demographics and characteristics of resident autonomy cases have changed over time as autonomy has decreased. We hypothesize that resident primary cases have shifted to lower complexity cases and on lower acuity, progressively healthier patients over time in the setting of declining autonomy.