Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Mass.
Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Mass.
J Thorac Cardiovasc Surg. 2018 May;155(5):2058-2065. doi: 10.1016/j.jtcvs.2017.11.109. Epub 2018 Feb 10.
Teaching the next generation operative cardiac surgery while maintaining the highest level of patient care is an ever-increasing challenge given the growing proportion of patients with multiple comorbidities, the loss of more straightforward cases to percutaneous interventions, and the pressure of public reporting. No study to date has compared the outcomes of similar cases performed entirely ("skin-to-skin") by the resident with those performed entirely by the staff to confirm the safety of this practice.
A total of 100 consecutive cardiac cases performed skin-to-skin by the resident (group R) were matched by procedure 1:1 to nonconsecutive cases performed by a single attending surgeon (group A). Patients were excluded from the analysis if there was overlap in any portion of the procedure by the trainee or the attending.
Patients in group A were similar to those in group R with respect to age, gender, body mass index, American Society of Anesthesiologists classification, left ventricular ejection fraction, and diabetes mellitus. Mean operative times were longer in group R (4.6 vs 2.7 hours, P < .001), as were cardiopulmonary bypass times (96 vs 50 minutes, P < .001) and aortic crossclamp times (78 vs 39 minutes, P < .001). There were no significant differences in red blood cell transfusions, reexplorations, stroke, length of stay, or wound infections. There were no in-hospital or 30-day deaths.
Our data indicate that trainees can be educated in operative surgery under the current paradigm, despite longer operative times, without sacrificing outcome quality. It is reasonable to expect academic programs to continue providing trainees significant experience as primary operating surgeons.
在患者合并症增多、更简单的病例通过经皮介入治疗流失以及公众报告压力不断增加的情况下，既要教授下一代心脏外科医生，又要保持最高水平的患者护理，这是一个越来越大的挑战。迄今为止，尚无研究比较完全由住院医师（“皮肤对皮肤”）完成的类似病例与完全由主治医生完成的病例的结果，以确认这种做法的安全性。
共有 100 例连续的心脏手术由住院医师（R 组）进行皮肤对皮肤手术，通过程序 1:1 与由单个主治外科医生（A 组）进行的非连续病例相匹配。如果受训者或主治医生在手术的任何部分有重叠，则将患者排除在分析之外。
A 组患者与 R 组患者在年龄、性别、体重指数、美国麻醉师协会分类、左心室射血分数和糖尿病方面相似。R 组的平均手术时间较长（4.6 小时对 2.7 小时，P<.001），体外循环时间（96 分钟对 50 分钟，P<.001）和主动脉阻断时间（78 分钟对 39 分钟，P<.001）也较长。两组间的红细胞输注、再次探查、中风、住院时间或伤口感染无显著差异。无院内或 30 天死亡。
我们的数据表明，尽管手术时间较长，但在当前模式下，培训生可以在手术操作中接受教育，而不会牺牲手术质量。可以合理地期望学术项目继续为培训生提供作为主要手术医生的大量经验。
