Brocke Tiffany K, Eaton Daniel B, Johnson Cali E, Klos Coen, Awad Michael M, Ohman Kerri A
Department of Surgery, Washington University School of Medicine, St. Louis, Missouri.
John Cochran VA Medical Center, St. Louis, Missouri.
J Surg Educ. 2025 Mar;82(3):103403. doi: 10.1016/j.jsurg.2024.103403. Epub 2025 Jan 11.
Identify changes in general surgery resident autonomy and resident postgraduate year (PGY) level in Entrustable Professional Activity (EPA) cases over time.
Retrospective cohort study.
United States Veterans Affairs (VA) hospital system, 2004 to 2020.
All patients undergoing operations in any of the 12 general surgery EPAs with identifiable operative components captured by the VA Surgical Quality Improvement Project database from 2004 to 2020.
452,549 cases were identified. Between 2004 and 2020, there was a 61.4% decrease in resident-performed cases and a 14.3% decrease in attending-assisted cases, with a concomitant 51.8% increase in attending-performed cases. All EPAs experienced a statistically significant decrease in resident autonomy over the study period, and a net transfer of cases from resident-performed to attending-performed. About 7 of 12 EPAs had significant increases in the resident PGY level of attending-assisted cases over the study period: abdominal wall hernia, benign/malignant breast, benign/malignant colon, cutaneous/subcutaneous neoplasm, gallbladder disease, inguinal hernia, and soft tissue infection. About 3 EPAs had significant increases in the resident PGY of resident-performed cases: abdominal wall hernia, benign/malignant breast, and inguinal hernia. Many of these changes represented seniorization of the operative experience by 3 to 12 months.
There has been a continual decrease in resident operative autonomy across all general surgery EPAs at the VA. Furthermore, many EPA cases have shifted to more senior residents over time, delaying or deferring autonomous completion of these cases during training. Although these data were drawn from the VA system, the results likely reflect a continued decrease in autonomy for resident surgeons in other settings as well. As general surgery adapts to a competency-based educational model, action is needed to stabilize these changes for sustainable graduate surgical education.
确定随着时间推移，普通外科住院医师在可托付专业活动（EPA）病例中的自主性变化以及住院医师的研究生年级（PGY）水平。
回顾性队列研究。
美国退伍军人事务部（VA）医院系统，2004年至2020年。
2004年至2020年期间，在VA手术质量改进项目数据库中记录的12项普通外科EPA中，所有进行了具有可识别手术组成部分手术的患者。
共识别出452,549例病例。2004年至2020年期间，住院医师完成的病例数减少了61.4%，主治医生协助的病例数减少了14.3%，同时主治医生完成的病例数增加了51.8%。在研究期间，所有EPA中住院医师的自主性均有统计学显著下降，且病例从住院医师完成向主治医生完成出现净转移。在研究期间，12项EPA中约有7项主治医生协助病例的住院医师PGY水平有显著提高：腹壁疝、良性/恶性乳腺疾病、良性/恶性结肠疾病、皮肤/皮下肿瘤、胆囊疾病、腹股沟疝和软组织感染。约有3项EPA中住院医师完成病例的住院医师PGY有显著提高：腹壁疝、良性/恶性乳腺疾病和腹股沟疝。这些变化中的许多代表手术经验的高级化提前了3至12个月。
VA所有普通外科EPA中住院医师的手术自主性持续下降。此外，随着时间推移，许多EPA病例已转向更高级别的住院医师，从而延迟了培训期间这些病例的自主完成。尽管这些数据来自VA系统，但结果可能也反映了其他环境中住院外科医生的自主性持续下降。随着普通外科适应基于能力的教育模式，需要采取行动稳定这些变化，以实现可持续的毕业后外科教育。
