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Background Educating residents in the operating room requires balancing patient safety, operating room efficiency demands, and resident learning needs. This study explores 4 factors that influence the amount of autonomy supervising surgeons afford to residents. Methods We evaluated 7,297 operations performed by 487 general surgery residents and evaluated by 424 supervising surgeons from 14 training programs. The primary outcome measure was supervising surgeon autonomy granted to the resident during the operative procedure. Predictor variables included resident performance on that case, supervising surgeon history with granting autonomy, resident training level, and case difficulty. Results Resident performance was the strongest predictor of autonomy granted. Typical autonomy by supervising surgeon was the second most important predictor. Each additional factor led to a smaller but still significant improvement in ability to predict the supervising surgeon's autonomy decision. The 4 factors together accounted for 54% of decision variance (r = 0.74). Conclusion Residents' operative performance in each case was the strongest predictor of how much autonomy was allowed in that case. Typical autonomy granted by the supervising surgeon, the second most important predictor, is unrelated to resident proficiency and warrants efforts to ensure that residents perform each procedure with many different supervisors.

Background To further understand how faculty promote resident autonomy in the operating room (OR), we explored their perceptions, and those of senior residents, on the behaviors and techniques they employ to foster independence. Methods Twenty postgraduate year PGY4 and PGY5 residents were asked to list 3 general surgery faculty who give the most and least autonomy to residents in the OR. Two focus groups were conducted with residents to identify behaviors and techniques for promoting autonomy from the resident perspective. Individual semistructured interviews were conducted with top-rated and low-rated faculty to identify behaviors and techniques from the attending perspective. Results Behaviors and techniques faculty exhibit to promote increased autonomy included allowing residents time to struggle, letting residents begin case themselves, and forcing residents to think about steps of procedure before case. The main “triggers” for granting autonomy were increased familiarity and trust with resident's capabilities, how well resident comes prepared to OR, and faculty confidence that they can “fix anything.” Reasons why low-rated faculty seldom give autonomy included feeling a deep moral obligation for personally seeing patient through the operation, residents not coming fully prepared to perform case, and being young in their own maturation process. Conclusion Our results suggest that increased autonomy depends greatly on establishing a trusting relationship between faculty and resident; a partnership that can only happen when time is given for trust to mature. Program directors must work to refine the training paradigm in order to build relationships. Residents can also be coached to demonstrate increased OR preparedness.

Background We investigated attending surgeon decisions regarding resident operative autonomy, including situations where operative autonomy was discordant with performance quality. Methods Attending surgeons assessed operative performance and documented operative autonomy granted to residents from 14 general surgery residency programs. Concordance between performance and autonomy was defined as “practice ready performance/meaningfully autonomous” or “not practice ready/not meaningfully autonomous.” Discordant circumstances were practice ready/not meaningfully autonomous or not practice ready/meaningfully autonomous. Resident training level, patient-related case complexity, procedure complexity, and procedure commonality were investigated to determine impact on autonomy. Results A total of 8,798 assessments were collected from 429 unique surgeons assessing 496 unique residents. Practice-ready and exceptional performances were 20 times more likely to be performed under meaningfully autonomous conditions than were other performances. Meaningful autonomy occurred most often with high-volume, easy and common cases, and less complex procedures. Eighty percent of assessments were concordant (38% practice ready/meaningfully autonomous and 42% not practice ready/not meaningfully autonomous). Most discordant assessments (13.8%) were not practice ready/meaningfully autonomous. For fifth-year residents, practice ready/not meaningfully autonomous ratings (9.7%) were more frequent than not practice ready/meaningfully autonomous ratings (7.5%). Ten surgeons (2.3%) failed to afford residents meaningful autonomy on any occasion. Conclusion Resident operative performance quality is the most important determinant in attending surgeon decisions regarding resident autonomy.

Background Concerns exist regarding the competency of general surgery graduates with performing core general surgery procedures. Current competence assessment incorporates minimal procedural numbers requirements. Methods Based on the Zwisch scale we evaluated the level of autonomy achieved by categorical PGY1-5 general surgery residents at 14 U.S. general surgery resident training programs between September 1, 2015 and December 31, 2016. With 5 of the most commonly performed core general surgery procedures, we correlated the level of autonomy achieved by each resident with the number of procedures they had performed before the evaluation period, with the intent of identifying specific target numbers that would correlate with the achievement of meaningful autonomy for each procedure with most residents. Results Whereas a definitive target number was identified for laparoscopic appendectomy (i.e. 25), for the other 4 procedures studied (i.e. laparoscopic cholecystectomy, 52; open inguinal hernia repair, 42; ventral hernia repair, 35; and partial colectomy, 60), target numbers identified were less definitive and/or were higher than many residents will experience during their surgical residency training. Conclusions We conclude that procedural target numbers are generally not effective in predicting procedural competence and should not be used as the basis for determining residents' readiness for independent practice.

Background Guidance in the operating room impacts resident confidence and ability to function independently. The purpose of this study was to explore attending surgeon guidance practices in the operating room as reported by faculty members themselves and by junior and senior residents. Methods This was an exploratory, cross-sectional survey research study involving 91 categorical residents and 82 clinical faculty members at two academic general surgery training programs. A series of analyses of variance along with descriptive statistics were performed to understand the impact of resident training year, program, and surgeon characteristics (sex and type of surgery performed routinely) on guidance practices. Results Resident level (junior versus senior) significantly impacted the amount of guidance given as reported by faculty and as perceived by residents. Within each program, junior residents perceived less guidance than faculty reported giving. For senior guidance practices, however, the differences between faculty and resident practices varied by program. In terms of the effects of surgeon practice type (mostly general versus mostly complex cases), residents at both institutions felt they were more supervised closely by the faculty who perform mostly complex cases. Conclusion More autonomy is given to senior than to junior residents. Additionally, faculty report a greater amount of change in their guidance practices over the training period than residents perceive. Faculty and resident agreement about the need for guidance and for autonomy are important for achieving the goals of residency training.