Comparison of Internal Medicine and General Surgery Residents' Assessments of Risk of Postsurgical Complications in Surgically Complex Patients

Abstract

Importance: Anticipating postsurgical complications is a vital physician skill, particularly when counseling surgically complex patients on their risks of intervention. Although internists and surgeons both counsel patients on surgical risks, it is uncertain who is better equipped to accurately anticipate surgical complications.

Objective: To examine how internal medicine and general surgery trainees compare in their assessment of risk of surgically complex patients.

Design, Setting, and Participants: General surgery and internal medicine residents (urban, tertiary, and academic medical center) answered an anonymous, online assessment of 7 real-life, complex clinical scenarios. Participants estimated the chance of any morbidity, mortality, surgical site infection, pneumonia, and cardiac complications. Scenarios represented a diverse general surgery practice, including colectomy, duodenal ulcer repair, inguinal hernia repair, perforated viscus exploration, small-bowel resection, cholecystectomy, and mastectomy in surgically complex patients likely to be comanaged by surgical and internal medicine services.

Main Outcomes and Measures: Responses were compared with risk-adjusted outcomes reported by the American College of Surgeons’ National Surgical Quality Improvement Project (NSQIP) online calculator.

Results: A total of 76 general surgery residents (50 [65.8%] male and 26 [34.2%] female) and 76 internal medicine residents (36 [47.4%] male and 40 [52.6%] female) participated (64% overall response rate). General surgery residents were significantly more confident with their responses (general surgery residents’ mean response, 3.6 [95% CI, 3.4-2.8]; internal medicine residents’ mean response, 2.8 [95% CI, 2.6-3.0]; P < .001) and with not offering operations (general surgery residents’ mean response, 4.3 [95% CI, 4.1-4.4]; internal medicine residents’ mean response, 3.7 [95% CI, 3.4-3.9]; P = .006) but less likely to discuss code status (general surgery residents’ mean response, 3.2 [95% CI, 2.9-3.4]; internal medicine residents’ mean response, 3.8 [95% CI, 3.5-4.1]; P < .001) or consult risk-adjusted models, such as NSQIP (general surgery residents’ mean response, 2.9 [95% CI, 2.7-3.1]; internal medicine residents’ mean response, 3.7 [95% CI, 3.4-4.0]; P < .001). For 91% of clinical estimates, both groups similarly overestimated every type of risk; in 9% of estimates, internal medicine residents had higher overestimates. Estimates varied significantly, with wide 95% CIs; however, only 11% of the NSQIP estimates fell within the 95% CIs. Overall, the mean percentages of the estimates ranged from 26% to 33% over NSQIP estimates for all complications.

Conclusions and Relevance: General surgery and internal medicine residents demonstrated similar estimates of postoperative complications and death. Both groups overestimated risks in surgically complex patient scenarios compared with NSQIP risk calculator estimates. This near-universal overestimation of risk underscores the importance of developing risk-estimation resources for internists and surgeons.

Figure.. Mean Difference in Estimates Between General Surgery and Internal Medicine Trainees and American College of Surgeons’ National Surgical Quality Improvement Project (NSQIP) Estimates of Surgical Risk

The degree of overestimation by both groups (in absolute percentage) was compared with the NSQIP estimates of risk for the scenarios. The internal medical and general surgery trainees overestimated risk in every category by a mean of 30%. Error bars indicate SD.