Are Urology Residents Losing Autonomy? A National Analysis of ACGME Case Log Data from 2013 to 2023.

OBJECTIVE: To examine national trends in urology resident surgical autonomy using Accreditation Council for Graduate Medical Education (ACGME) case log data. DESIGN: A retrospective cohort analysis of ACGME case logs for all graduating urology residents from 2013 to 2023. Resident-defined operative role ("assistant," "surgeon," or "teaching assistant") was used as a proxy for surgical autonomy, and an autonomy score was calculated for each resident. Trends over time were evaluated using mixed-effects regression, and differences by procedure subtype, ERAS geographic region, and sex were assessed using analysis of variance. SETTING: A novel national database encompassing all urology residency programs across the United States. PARTICIPANTS: Graduating urology residents who completed ACGME-accredited urology residency programs between 2013 and 2023. A total of 3391 residents across 145 programs met inclusion criteria. RESULTS: Mean case number per resident increased from 1243 in 2013 to 1404.6 in 2023 (p < 0.001). Mean autonomy score declined significantly over the study period from 92% in 2013 to 85% in 2023 (p < 0.001). Autonomy varied significantly according to procedure subtype, with oncology demonstrating the lowest autonomy at 78%, and endourology and general urology demonstrating the highest autonomy at 94% and 93%, respectively (p < 0.001). Autonomy varied significantly by ERAS geographic region (p < 0.001) and sex, with males reporting higher autonomy scores than females (p < 0.001). CONCLUSIONS: This national cohort analysis demonstrates a significant and sustained decline in urology resident self-reported surgical autonomy, with variation according to procedure subtype, geographic region, and sex. These findings are concerning and highlight the importance of re-evaluating and prioritizing autonomy within urology residencies.