Impact of resident participation on morbidity and mortality in neurosurgical procedures

A resident physician or resident or resident medical officer is a person who has received the title of “physician” (usually a D.O., M.D. or MBBS, MBChB, BMed) or in some circumstances, another health sciences terminal degree (such as psychology or dentistry) who practices medicine usually in a hospital or clinic.

see residency

Working Time directive

The introduction of the European Working Time directive 2003/88/EC has led to a reduction of the working hours with distinct impact on the clinical and surgical activity of neurosurgicalresidents in training.

A survey was performed among European neurosurgical residents between 06/2014 and 03/2015. Multiple logistic regression was used to assess the relationship between responder-specific variables (e.g., age, gender, country, postgraduate year (PGY)) and outcome (e.g., working time).

A total of 652 responses were collected, of which n = 532 responses were taken into consideration. In total, 17.5, 22.1, 29.5, 19.5, 5.9, and 5.5 % of European residents indicated to work <40, 40-50, 51-60, 61-70, 71-80, or >80 h/week, respectively. Residents from France and Turkey (OR 4.72, 95 % CI 1.29-17.17, p = 0.019) and Germany (OR 2.06, 95 % CI 1.15-3.67, p = 0.014) were more likely to work >60 h/week than residents from other European countries. In total, 29 % of European residents were satisfied with their current working time, 11.3 % indicated to prefer reduced working time. More than half (55 %) would prefer to work more hours/week if this would improve their clinical education. Residents that rated their operative exposure as insufficient were 2.3 times as likely as others to be willing to work more hours (OR 2.32, 95 % CI 1.47-3.70, p < 0.001). Less than every fifth European resident spends >50 % of his/her working time in the operating room. By contrast, 77.4 % indicate to devote >25 % of their daily working time to administrative work. For every advanced PGY, the likelihood to spend >50 % of the working time in the OR increases by 19 % (OR 1.19, 95 % CI 1.02-1.40, p = 0.024) and the likelihood to spend >50 % of the working time with administrative work decreases by 18 % (OR 0.84, 95 % CI 0.76-0.94, p = 0.002).

The results of this survey on >500 European neurosurgical residents clearly prove that less than 40 % conform with the 48-h week as claimed by the WTD2003/88/EC. Still, more than half of them would chose to work even more hours/week if their clinical education were to improve; probably due to subjective impression of insufficient training 1).

Impact of resident participation on morbidity and mortality in neurosurgical procedures

In a multicenter study, Lim et al demonstrated that resident involvement in the operating room was not a significant factor for postoperative complications in neurosurgery service. This analysis also showed that much of the observed difference in postoperative complication rates was attributable to other confounding factors. This is a quality indicator for resident trainees and current medical education. Maintaining high standards in postgraduate training is imperative in enhancing patient care and reducing postoperative complications 2)


The American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients who had undergone neurosurgical procedures between 2006 and 2012. The operating surgeon(s), whether an attending only or attending plus resident, was assessed for his or her influence on morbidity and mortality. Multivariate logistic regression, was used to estimate odds ratios for 30-day postoperative morbidity and mortality outcomes for the attending-only compared with the attending plus resident cohorts (attending group and attending+resident group, respectively).

The study population consisted of 16,098 patients who had undergone elective or emergent neurosurgical procedures. The mean patient age was 56.8 ± 15.0 years, and 49.8% of patients were women. Overall, 15.8% of all patients had at least one postoperative complication. The attending+resident group demonstrated a complication rate of 20.12%, while patients with an attending-only surgeon had a statistically significantly lower complication rate at 11.70% (p < 0.001). In the total population, 263 patients (1.63%) died within 30 days of surgery. Stratified by operating surgeon status, 162 patients (2.07%) in the attending+resident group died versus 101 (1.22%) in the attending group, which was statistically significant (p < 0.001). Regression analyses compared patients who had resident participation to those with only attending surgeons, the referent group. Following adjustment for preoperative patient characteristics and comorbidities, multivariate regression analysis demonstrated that patients with resident participation in their surgery had the same odds of 30-day morbidity (OR = 1.05, 95% CI 0.94-1.17) and mortality (OR = 0.92, 95% CI 0.66-1.28) as their attending only counterparts.

Cases with resident participation had higher rates of mortality and morbidity; however, these cases also involved patients with more comorbidities initially. On multivariate analysis, resident participation was not an independent risk factor for postoperative 30-day morbidity or mortality following elective or emergent neurosurgical procedures 3).


1) Stienen MN, Netuka D, Demetriades AK, Ringel F, Gautschi OP, Gempt J, Kuhlen D, Schaller K. Working time of neurosurgical residents in Europe-results of a multinational survey. Acta Neurochir (Wien). 2015 Nov 14. [Epub ahead of print] PubMed PMID: 26566781.
2) Lim S, Parsa AT, Kim BD, Rosenow JM, Kim JY. Impact of resident involvement in neurosurgery: an analysis of 8748 patients from the 2011 American College of Surgeons National Surgical Quality Improvement Program database. J Neurosurg. 2015 Apr;122(4):962-70. doi: 10.3171/2014.11.JNS1494. Epub 2015 Jan 23. PubMed PMID: 25614947.
3) Bydon M, Abt NB, De la Garza-Ramos R, Macki M, Witham TF, Gokaslan ZL, Bydon A, Huang J. Impact of resident participation on morbidity and mortality in neurosurgical procedures: an analysis of 16,098 patients. J Neurosurg. 2015 Apr;122(4):955-61. doi: 10.3171/2014.11.JNS14890. Epub 2015 Jan 9. PubMed PMID: 25574567.

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