Tertiary-care university hospitals are also academic teaching hospitals. Experience in the OR influences students’ interest in a career as an anesthesiologist. Most surgical cases involve clinician training which effects both OR learning and patient care, including timings. With this in mind, it is important to consider how efforts to improve the efficiency of operating rooms may threaten clinician training.
The idea of improving operating room efficiency has led to increased interest in the time used to train residents in the operating room. Several studies have analyzed the impact of anesthetic residents on the time required for induction and emergence from anesthesia or ACT.4,5 No study analyzing the contribution of medical students to operating room performance have been published thus far.
The key finding of this study was that, during OB-GYN and general surgery, the participation of 5th -year medical students, compared with anesthetic residents and student nurse anesthetists, were associated with increased procedural durations. Our study found that a group of 5th -year medical students was involved in significantly more time-consuming procedures (ART, ACT, APpT, and APT) than anesthetic residents and/or student nurse anesthetists.
Eappen et al. 4 reported that teaching anesthesia residents was associated with a statistically significant increase in the time required for induction and emergence from anesthesia. Browne et al. 5 found anesthetic trainees in cesarean sections increased anesthesia-controlled time (ACT) by 5.2 minutes (16% increase), which was attributable to the presence of trainees. Our study found that the involvement of group of 5th -year medical students significantly increased time of ACT when compared with anesthetic residents (p < 0.001) but was not significantly different from a group of student nurse anesthetists (p = 0.159). We found prolonged ACT in a group of 5th -year medical students when compared to a group of anesthetic residents and student nurse anesthetists for approximately 11.243 (41.6% increase) and 3.27 (8.6% increase) minutes, respectively. Moreover, when comparing all anesthetic procedure times (ACT) to TCT, the group of 5th -year medical students (ACT/TCT = 26.7%) underwent more anesthetic procedures than the other groups (ACT/TCT in the group of anesthetic residents and student nurse anesthetists = 24.8% and 22.6%, respectively). The increase in procedural time in the group of 5th -year medical students is attributable to anesthetic time and was modest relative to the total procedural time. Frank et al.1 found ACT in GYN and general surgery at about 15% of the TCT available, which is similar to the range of 8%-20% found by Dexter et al.6 In our study, ACT in all groups was about 22.6–26.7% of the TCT, which is higher than that reported in previous studies. Previous studies by Mazzei7 and Dexter et al.6 suggest that reducing ACT does not decrease OR costs because the 30 minutes that can be reliably saved per day per OR is not sufficient to allow an extra revenue-producing case to be scheduled during an eight-hour shift. Certainly, the financial impact of anesthesia-controlled time secondary to teaching is minimal.
In our study, a group of 5th -year medical students had significantly prolonged ART compared to a group of anesthetic residents and student nurse anesthetists, approximately 5.486 minutes (p = 0.0015) and 4.973 minutes (p = 0.0038), respectively. This finding, similar to a previous study by Davis et al.,8 found teaching anesthesia residents accounted for a mean increase of time to incision of 4.5 ± 3.2 minutes. This increase was insignificant compared with the time required to complete the surgical procedure. The increased time of anesthetic procedure for the 5th -year medical students could be attributable to their lack of hands-on experience with patients under supervision, their lack of clinical skill experience, and the short duration of their rotation in the anesthesiology department. Considering that the other groups had more clinical skills and experience, it is unsurprising that the anesthetic procedure time in the group of 5th -year medical students would be longer than that in other groups. Irani et al. found that only 9.8% of the total case time was spent teaching pre-established learning goals that included developing clinical and communication skills as well as understanding common symptoms and diseases.9 Similarly, our study found ART about 8.4–13.3% of TCT.
Moreover, we found that for the 5th -year medical students and the anesthetic residents the proportion of ART/TCT was significantly higher than that of student nurse anesthetists. This may because the group of student nurse anesthetists had only general anesthesia procedures, while the other groups had both general anesthesia and spinal block procedures. Normally, spinal block procedures require more time to achieve an adequate level of anesthesia before surgical preparation.
On the scale of difficulty for case induction, the group of 5th -year medical students scored significantly higher than the other groups (p < 0.001). It is possible that they felt the tasks were more difficult than the other groups because they had fewer clinical skills and experiences. However, the numbers of attempted and successful procedures did not differ significantly between the groups.
For intra-op and post-op, complications were not significantly different between groups except in the case of immediate post-op complications, where the group of 5th -year medical students and nurse anesthetists had more complications than the group anesthetic residents. Airway complications (sore throat, hoarseness, and wheezing) occurred in these two groups but were not found in the group of anesthetic residents. This may be the anesthetic residents had more clinical skills and experience than the other groups.
In the subgroup analysis of a group of anesthetic residents (1st to 3rd -year anesthetic residents), we found that differences in the timings, complications, attempts, and success of the procedure were not statistically significant. Although early residency is marked by intensive teaching, as residency progresses, increased case complexity provides greater teaching opportunities and accounts for the lack of significant differences in teaching requirements based on years of experience.
Strengths and limitations
This study has strengths and limitations. First, this study is prospective observational study. And second, the OR staffs were blinded from the nature of project and instructed to perform as usual. So, the data collection was conducted with no bias in this study. Limitations are the small sample size in subgroups, and abstraction from the single center. The difference in timing in teaching from other institutions may differ with varying in clinical setting.