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In the operating room (OR), the familiarity between the anesthesiologist-surgeon dyad is significant in determining the quality of perioperative care, as well as for optimal resource utilization and safe patient outcomes.1 A recent study evaluated this familiarity (defined as the number of times the dyad worked together annually) and found it to be independently associated with lower 90-day morbidity in complex gastrointestinal surgeries.2 However, an additional complexity in this relation is the discordance in seniority of the dyad partners. This kind of dyad discordance, based on seniority, is more relevant in the OR where strong hierarchical systems exist and recommendations by a junior may not be well received by a senior.3 We hypothesized that a concordant dyad would take shorter OR time without an increased incidence of adverse events compared to a discordant dyad. This study, therefore, aimed to evaluate the association of seniority in the anesthesiologist-surgeon dyad on timing and intraoperative outcomes.

METHODS

A cross-sectional exploratory study of secondary data was conducted in St. John’s Medical College Hospital, India for 1 year (June 2021 to June 2022). Approval was obtained from the St. John’s Medical College Institutional Ethics Review Board (IEC No: 97/2023) with a waiver of written informed consent for this study. Data were collected retrospectively from medical records of Obstetrics and Gynecology patients admitted for surgery and included demography, clinical history, and operative details. Surgeries were divided into major and minor based on complexity. Procedures such as open/laparoscopic hysterectomy, laparoscopic cystectomy and salpingo-oophorectomy, lower segment cesarean section, vaginal hysterectomy, and myomectomy were considered major. Dilation and curettage, endometrial/cone biopsy, cervical encirclage, hysteroscopic procedures, scar resection, suction/evacuation, local excision, and vaginal septal resection were considered minor procedures. Procedures performed under local anesthesia were excluded.

Clinical experience (10 years after certification) was used to distinguish a “junior” anesthesiologist (JA) or surgeon (JS) from a “senior” anesthesiologist (SA) or surgeon (SS), yielding 4 possible dyad combinations: JA-JS (junior), JA-SS (mixed), SA-JS (mixed), SA-SS (senior). The primary outcome measure used was Anesthesia Time, determined as the time from anesthesia induction to the time of shift to postanesthesia care. Secondary outcomes were anesthesia induction time (time from anesthesia induction to incision time), operative time (time between incision to the last suture), and incidence of intraoperative complications. Intraoperative adverse events were defined as per Grade II and above of ClassIntra classification and included bowel/bladder injury, conversion from laparoscopy to open, blood transfused for intraoperative bleeding, and arrhythmias secondary to anesthesia drugs.4 Outcome distributions were compared across dyad combinations and analyzed by the Kruskal-Wallis, Mann-Whitney U test, and post hoc analysis. A value of P < .05 was considered statistically significant. The analysis was performed using R, version 4.1.2 (R Core Team, 2023).

RESULTS

Data from 531 patients were available for analysis. The anesthesia time and operative time were observed to be lower for JA-JS (P < .001) compared to SA-SS. As the complexity of surgery can be a major confounder of operative outcomes, the analysis was repeated on major surgeries alone (n = 455) which yielded similar results (Table and Figure). Minor surgeries (n = 76) constituted only 14% of the total surgeries performed and the sample size was deemed insufficient to perform a comparative analysis within this subgroup.

DISCUSSION

This study demonstrates that when the anesthesiologist-surgeon dyad consisted of 2 junior physicians, there was a significantly shorter operative time, anesthesia time, and induction of anesthesia time, without any significant difference in adverse events when compared to mixed or senior dyads. It is possible that similar results with a concordant senior dyad were not seen because of confounding by the complexity of cases managed by this dyad.

Similar studies examining dyads based on seniority would be valuable. As the majority of cases involved at least 1 senior physician in the dyad, it is important to explore whether the incidence of adverse events might increase if junior dyads conducted cases of similar volume and complexity as senior dyads. Other outcomes that were not assessed include whether mixed seniority in the dyad could be a source of conflict through communication errors and near misses.5,6

The exclusive focus on ObGyn cases in this study was deliberate, as the variety of cases (range of morbidity) in this specialty is comparatively restricted. Limitations of the study include confounding by case complexity, presence of trainees and other OR team members as well as the assumption of accuracy of the chart-recorded timings used for data collection.

ACKNOWLEDGMENTS

We gratefully acknowledge Anura Kurpad, Professor, Department of Physiology, St. John’s Medical College, as a Mentor and Santu Ghosh and Rajesh Majumder, Department of Biostatistics, St John’s Medical College, for their valuable contributions toward the data analysis.