Doing Less Later: Seniorization of General Surgery Resident Operative Experience in the Entrustable Professional Activities at Veterans Affairs Hospitals.

Objective: Identify changes in general surgery resident autonomy and resident postgraduate year (PGY) level in Entrustable Professional Activity (EPA) cases over time.

Design: Retrospective cohort study.

Setting: United States Veterans Affairs (VA) hospital system, 2004 to 2020.

Participants: 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.

Results: 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.

Conclusions: 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.