Balancing Resident Training with Complication Risk and Liability

Editor’s note: The Final Cut is a recurring editorial series written by a member of the AAOS Now Editorial Board.

For most of us who are attendings in teaching institutions, the opportunity to train residents is extremely rewarding. We began the teaching process as residents ourselves, instructing those who were junior to us. The general style of training is one of graduated responsibility. Junior residents are supervised by senior residents and attendings. As residents progress, they are given increasing surgical responsibilities to the point where they can operate independently as graduating senior residents. At this point, having been out of residency for almost 20 years and having trained residents myself, I look back with great appreciation to the many attendings who trained me in residency and fellowship. As attendings, we look forward to the next generation of residents and feel a sense of giving back when we teach new residents the skills that were once taught to us.

Whenever one learns a new skill, there is a learning curve—and with that will inevitably come mistakes. We have all had complications in our practice, even as experienced attendings. Residents, especially early in their careers, are obviously more prone to making mistakes. Some of these are minor mistakes, but occasionally a more serious error can occur. The most serious consequence of a complication is potential harm or morbidity to our patient. Our goal as surgeons is to always provide safe and competent patient care, and a complication falls short of our goal. Complications can also result in substantial liability to the surgeon and the hospital, which can result in malpractice premium increases. At the extreme, severe or multiple complications can result in suspension or termination of privileges and disciplinary action, including losing the license to practice medicine. Even if complications do not rise to the level of litigation, they can result in angry patients, who can use social media or the multitude of physician-rating websites to tarnish a surgeon’s reputation.

How do we balance resident training with the expected commission of errors and the associated complication risk? It starts with a shared responsibility between the teaching attending surgeon and the junior resident. We cannot expect residents to operate at a competent level early in training. Residents, even at senior levels, lack the years of experience that many of us have. However, most residents do learn to become skilled and competent surgeons. Perhaps 5 percent of all residents are naturally gifted at surgery and pick up techniques very quickly. The rest of us, myself included, must work very hard to gain confidence and skill in the OR. Therefore, as mentors, we have to be patient with residents. No skill is too remedial to teach. At the early stages (postgraduate year [PGY] 1 to 3), we are making an investment teaching junior residents the proper way to operate, which begins with being a competent assistant (adjusting lights, suctioning appropriately, etc.). We should anticipate the mistakes that residents will make, often by thinking about the mistakes we made when we were in training. It is important to make residents aware of which portions of an operation are risky and which portions are relatively safe.

In many ORs, hospital policy dictates that the surgeon be present for the critical parts of surgery. Therefore, leaving a resident to operate independently, although popular in the past, may result in the surgeon violating hospital or insurance policies. Aside from that, we are there as attending surgeons to share the wealth of experience that we have accumulated in our training and experience. The time we spend with residents in the OR is extremely valuable for their development as surgeons. This patience and effort will be worthwhile when residents progress to their senior years, when their knowledge and skills will become great assets to us. Furthermore, they will teach junior residents what we have taught them and therefore maintain the quality of the surgeries we perform, which in turn will reduce complication risk. Practically, this means that as residents progress through training, attendings will permit them to perform more surgical tasks. This can mean staying scrubbed in the room while the PGY4 resident does the operation with a PGY2 and allowing them to proceed until they need guidance, or allowing a PGY 5 to start an exposure while the attending is just outside the room scrubbing or dictating. Ideally, the attending should have worked with the resident throughout their training and observed their development as a surgeon over the years. This relationship can form the basis for trusting the resident to be safe and knowing their limitations in terms of performing surgery.

For residents, the advice I would give is to first stay humble. As orthopaedic surgeons, we are blessed to be able to care for patients while doing something very enjoyable and rewarding. As a resident, you have a responsibility to learn from the attending and take care of the patient. Read before cases so that you have a thorough understanding of the anatomy and the surgical approaches. Learn to set yourself up well when operating—have your instruments and retractors in place, the field well-lit, and all bleeding controlled. Do not rush through your surgeries; instead, take your time and do a good job. Your attending will notice your attention to detail. Always strive to do a better job next time, and treat your work as if it were a piece of art. You should be proud but also critical of the work that you do. Surgical speed will come naturally with experience.

The desire to continue learning and improving your knowledge and skills should not end with residency or fellowship. Even as an attending, you should continue to improve your skills with every surgery you perform. This can involve scrubbing with other surgeons, attending surgical skills and cadaver-dissection courses, and visiting experts. At these meetings, you will see experienced surgeons at all stages of their careers continuing to improve their skills. As an attending, I have found many surgeon courses, such as those at the AAOS Orthopaedic Learning Center, to be highly educational and directly relevant to my practice. They are also pleasant social events where you can meet and network with surgeons from around the country (and world) with similar interests. If you continue striving to improve, you can only get better throughout your career. Although this attitude will help build your reputation as a competent surgeon and minimize complications and liability, the main reason to consider this is to provide the best possible care for your patients. Residency and fellowship will pass quickly, and you will soon find yourselves as attendings, training the next generation of skilled surgeons.

Paul S. Issack, MS, MD, PhD, FAAOS, FACS, is a clinical associate professor in the Department of Orthopaedic Surgery at Weill Cornell Medical College and a trauma and adult reconstruction orthopaedic surgeon at New York–Presbyterian/Lower Manhattan Hospital. He is also a member of the AAOS Now Editorial Board.