Factors Influencing the Entrustment of Resident Operative Autonomy: Comparing Perceptions of General Surgery Residents and Attending Surgeons

Abstract

Background General surgery residents may be underprepared for practice, due in part to declining operative autonomy during training. The factors that influence entrustment of autonomy in the operating room are unclear. Objective To identify and compare the factors that residents and faculty consider influential in entrustment of operative autonomy. Methods An anonymous survey of 29-item Likert-type scale (1–7, 1 = strongly disagree, 7 = strongly agree), 9 multiple-choice, and 4 open-ended questions was sent to 70 faculty and 45 residents in a large ACGME-approved general surgery residency program comprised of university, county, and VA hospitals in 2018. Results Sixty (86%) faculty and 38 (84%) residents responded. Faculty were more likely to identify resident-specific factors such as better resident reputation and higher skill level as important in fostering entrustment. Residents were more likely to identify environmental factors such as a focus on efficiency and a litigious malpractice environment as impeding entrustment. Both groups agreed that work hour restrictions do not decrease autonomy and entrustment does not increase risk to patients. More residents considered low faculty confidence level as a barrier to operative autonomy, while more faculty considered lower resident clinical skill as a barrier. Improvement in resident preparation for cases was cited as an important intervention that could enhance entrustment. Conclusions Differences in perspectives exist between general surgery residents and faculty regarding entrustment of autonomy. Residents cite environmental and attending-related factors, while faculty cite resident-specific factors as most influential. Residents and faculty both agree that entrustment is integral to surgical training.

Behind the pattern: General surgery resident autonomy in robotic surgery

“…In the operating room, attending surgeons' expert subjective judgment guides their intraoperative teaching actions, and the objective patterns of resident ICT are a result of attending surgeons’ subjective assessment and judgement. Our study suggests that resident opportunities for autonomy in RC, RIH, and RVH are influenced by resident seniority level, surgeon work experience, and procedure type, which is consist with literature [ [14] , [15] , [16] , [17] ] and supported by the situated learning theory. Interviews with surgeons revealed that resident training year and experience, and the attending surgeons perceived operative time pressure, are the major influences on granting resident ICT; these are similar factors to those found in non-RAS operations reported in literature [ 14 , 16 , 23 ].…”

“…Our study suggests that resident opportunities for autonomy in RC, RIH, and RVH are influenced by resident seniority level, surgeon work experience, and procedure type, which is consist with literature [ [14] , [15] , [16] , [17] ] and supported by the situated learning theory. Interviews with surgeons revealed that resident training year and experience, and the attending surgeons perceived operative time pressure, are the major influences on granting resident ICT; these are similar factors to those found in non-RAS operations reported in literature [ 14 , 16 , 23 ]. We thus encourage residency programs to provide faculty development for attending surgeons to improve their intraoperative teaching and performance evaluation skills for working with residents performing RAS in aid of robotic surgical workforce training and patient safety.…”

“…Although additional factors influencing resident autonomy and entrustment are not yet well investigated in robotic-assisted surgery, many studies have identified these in traditional laparoscopic and open surgery. Autonomy and entrustment have been correlated with resident postgraduate year (PGY), resident skill, and attending surgeon experience, as well as possible interventions for improvement [ [14] , [15] , [16] , [17] , [18] , [19] ]. As expected, surgical residents’ self-reported intraoperative autonomy tends to increase with PGY level, especially in laparoscopic and open index surgical procedures [ 20 ].…”

The Evolving Role of Postgraduate Year 7 in Neurological Surgery Residency

“…In general surgery and in many other surgical specialties, there is a high level of concern that duty-hour restrictions, the proliferation of subspecialty fellowships at institutions (which are perceived to crowd out residents from the operating room), and an increased focus on nonclinical electives and research time has resulted in decreased resident autonomy and decreased preparedness for independent practice as graduating residents. [11][12][13][14][15][16][17] One solution to this problem in these specialties has been the institution of formal resident-run clinics that focus on minor procedures. 18,19 Studies show that these clinics are safe for patients and effective as training tools for residents.…”

Longitudinal assessment of competency development at The Ohio State University using the competency-based veterinary education (CBVE) model

“…Convincing evidence for student learning in all domains of competence is being increasingly demanded by educators, accrediting bodies, and stakeholders alike ( 10 ). In medical education, a recent study compared competencies measured using Likert type scales to those using entrustment scales ( 11 ) and national studies are being conducted to compare milestone ratings in resident training programs with national licensing examination scoring ( 12 ). Veterinary specific examples are more limited to date however there has been demonstration of strong validity evidence for a programmatic assessment approach ( 13 ).…”