Patient inequities in affording surgical resident operative autonomy at Veterans Affairs teaching hospitals, does it extend to female patients?

Published:September 21, 2022DOI:


      • Female veterans are less likely to have residents operate on them autonomously.
      • From 2004 to 2018, resident primary cases decreased in both the males and females, but more significantly in males.
      • For RP cases, female patients had shorter length of stay, shorter OR times, and lower mortality compared to male patients.



      Examining surgical resident operative autonomy within the Veterans Affairs (VA) System, we previously showed residents were afforded autonomy more frequently on Black patients. We hypothesized that, compared to males, female surgical patients receive less attending involvement and more resident autonomy during surgery.


      Retrospective review of all general/vascular surgeries performed at teaching VA hospitals from 2004 to 2019. Operative procedures are coded at the time of surgery as attending primary surgeon (AP), attending with resident (AR), or resident primary surgeon--attending not scrubbed (RP). The primary outcome was the difference in supervision rates between patient sexes.


      618,578 operations were examined—24.9% AP, 68.9% AR, and 6.2% RP. Overall, 5.9% of cases were performed on women. The rate of RP cases was higher in males compared to females (6.3% vs 5.3%, p < 0.001).


      Female veterans are less likely to have residents operate on them autonomously. Reasons for this require further characterization.


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        • Anjaria D.J.
        • et al.
        A 15-year analysis of surgical resident operative autonomy across all surgical specialties in veterans Affairs hospitals.
        JAMA Surg. 2022; 157: 76-78
        • Scarborough J.E.
        • Bennett K.M.
        • Pappas T.N.
        Defining the impact of resident participation on outcomes after appendectomy.
        Ann Surg. 2012; 255: 577-582
        • Krell R.W.
        • et al.
        Effects of resident involvement on complication rates after laparoscopic gastric bypass.
        J Am Coll Surg. 2014; 218: 253-260
        • Itani K.M.
        • et al.
        Surgical resident supervision in the operating room and outcomes of care in Veterans Affairs hospitals.
        Am J Surg. 2005; 190: 725-731
        • Kunac A.
        • et al.
        General surgical resident operative autonomy vs patient outcomes: are we compromising training without net benefit to hospitals or patients?.
        J Surg Educ. 2021; 78: e174-e182
        • Oliver J.B.
        • et al.
        Association between operative autonomy of surgical residents and patient outcomes.
        JAMA Surg. 2022; 157: 211-219
        • Fonseca A.L.
        • et al.
        Are graduating surgical residents confident in performing open vascular surgery? Results of a national survey.
        J Surg Educ. 2015; 72: 577-584
        • George B.C.
        • et al.
        Readiness of US general surgery residents for independent practice.
        Ann Surg. 2017; 266: 582-594
        • Glasbey J.C.
        • et al.
        Proposals for shortening UK surgical training will directly impact on patient safety.
        Ann Surg. 2017; 266: e34-e35
        • Meyerson S.L.
        • et al.
        The effect of gender on operative autonomy in general surgery residents.
        Surgery. 2019; 166: 738-743
        • Wallis C.J.D.
        • et al.
        Association of surgeon-patient sex concordance with postoperative outcomes.
        JAMA Surg. 2022; 157: 146-156
        • Vespa J.E.
        Those who served: America's veterans from world war II to the war on terror.
        US Census Bureau. 2020;
        • Massarweh N.N.
        • Kaji A.H.
        • Itani K.M.F.
        Practical guide to surgical data sets: veterans Affairs surgical quality improvement program (VASQIP).
        JAMA Surg. 2018; 153: 768-769
        • Drageset S.
        • et al.
        Being in suspense: women's experiences awaiting breast cancer surgery.
        J Adv Nurs. 2011; 67: 1941-1951
        • Dickinson K.J.
        • et al.
        Public perception of general surgery resident autonomy and supervision.
        J Am Coll Surg. 2021; 232: 8-15 e1
        • de Bourmont S.S.
        • et al.
        Resident physician experiences with and responses to biased patients.
        JAMA Netw Open. 2020; 3: e2021769
        • Tonelli C.M.
        • et al.
        Does resident autonomy in colectomy procedures result in inferior clinical outcomes?.
        Surgery. 2022; 171: 598-606
        • Lorenzo I.L.
        • et al.
        Supervised independence in elective inguinal hernia repairs performed by surgical residents is not associated with compromised short clinical outcome or rates of reoperation for recurrence.
        Am J Surg. 2022; 223: 470-474
        • Resnick E.M.
        • Mallampalli M.
        • Carter C.L.
        Current challenges in female veterans' health.
        J Womens Health (Larchmt). 2012; 21: 895-900
        • Marshall V.
        • et al.
        The focus they deserve: improving women veterans' health care access.
        Wom Health Issues. 2021; 31: 399-407
        • Whitehead A.M.
        • et al.
        Improving trends in gender disparities in the department of veterans Affairs: 2008-2013.
        Am J Publ Health. 2014; 104: S529-S531
        • Mengeling M.A.
        • et al.
        Evolving comprehensive VA women's health care: patient characteristics, needs, and preferences.
        Wom Health Issues. 2011; 21: S120-S129
        • Chrystal J.G.
        • et al.
        Women veterans' attrition from the VA health care system.
        Wom Health Issues. 2022; 32: 182-193
        • Bertakis K.D.
        The influence of gender on the doctor-patient interaction.
        Patient Educ Counsel. 2009; 76: 356-360
        • Lyons N.B.
        • et al.
        Gender disparity in surgery: an evaluation of surgical societies.
        Surg Infect. 2019; 20: 406-410
        • Fink A.S.
        • et al.
        Comparison of risk-adjusted 30-day postoperative mortality and morbidity in Department of Veterans Affairs hospitals and selected university medical centers: general surgical operations in women.
        J Am Coll Surg. 2007; 204: 1127-1136
        • Guth A.A.
        • Hiotis K.
        • Rockman C.
        Influence of gender on surgical outcomes: does gender really matter?.
        J Am Coll Surg. 2005; 200: 440-455