Developing and preserving resident autonomy is a topic of intense study and discussion at recent major surgical subspecialty conferences and in academic surgical journals. Changing regulations, a hyperintense and competitive surgical environment in some locales, and evolving surgical techniques, such as robotic surgery and advanced endoscopy, can act as barriers to the development of surgical autonomy in residents. Additionally, new guidelines regarding the performance of concurrent surgery have the potential to limit resident opportunities to perform cases independently, even when appropriate for their skill level.
These challenges are on the minds of both trainees and trainers, and questions regarding the expected level of resident operative autonomy frequently arise during interviews and in reviews of training programs. This article addresses the topic of surgical autonomy and provides several strategies to develop the level of aptitude necessary for residents to transition to independent practice.
Deliberate practice: A framework for achieving autonomy
Achieving autonomy in the operating room (OR) is a critical milestone for surgical residents to measure their readiness to graduate and become independent surgeons. Currently, accrediting bodies have implemented minimum case requirements, critical assessments, milestones, and other certifications that residents must fulfill to formally and officially graduate from a surgical training program.
Surgical training programs often use the Ottawa Surgical Competency Operating Room Evaluation (O-SCORE) tool to provide residents objective and formative feedback to improve technical skills in the OR.1 The O-SCORE tool was specifically designed to assess technical competence and provides valid assessments of residents and their ability to independently perform a procedure. O-SCOREs also allow an attending physician to rate the resident’s degree of autonomy, with assessments ranging from “I had to do the case” to “I did not have to be there.” Myriad other surgical technical assessment tools are used in the U.S. and abroad, and these assessments are an area of intense study in academic surgery.
Despite these advancements in resident education evaluation, the question remains: How do trainees move through the progression from dependence and observation to independence and autonomy? Why do certain residents receive more autonomy or additional opportunities to perform teaching cases? Of course, each resident learns at a different pace, and some may need more repetition than others to obtain proficiency. The best method to ensure across-the-board competency has yet to be determined.
On a more personal level, trainees can develop surgical autonomy by exercising self-determination and resilience. In her book, Grit: The Power of Passion and Perseverance, Angela Duckworth, PhD, professor of psychology, University of Pennsylvania, Philadelphia, describes the concept of grit and offers insight on how to foster grit both internally and externally.2 One important component of fostering grit from the inside out is deliberate practice. Dr. Duckworth characterizes four basic and important requirements for deliberate practice to reach a goal:
- A clearly defined stretch goal
- Full concentration and effort
- Immediate and informative feedback
- Repetition with reflection and refinement
Writer Malcom Gladwell and some psychologists have written about the principle that suggests it takes 10,000 hours of deliberate practice to achieve expertise.3 If this theory were infallible, then residents would achieve autonomy simply based on the 80-hour workweek and the length of surgical training. However, the countless hours of surgical training do not account for the true number of hours residents spend in the OR. A single institutional survey of the general surgery residents at the Medical College of Wisconsin, Milwaukee, characterized resident time allocation and concluded surgical residents spend a large amount of time on noneducational activities, such as self-study or noneducational patient care.4 By eliminating or at least working to offset the time burden of these noneducational activities, there can be a reallocation of educationally beneficial activities, such as practicing outside of the OR or taking advantage of a simulation lab.
In a New Yorker article titled “The physical genius,” Mr. Gladwell writes about a talented neurosurgeon named Charlie Wilson, MD, FACS.5 Dr. Wilson would go to his special laboratory at the end of a busy day to simulate on rats by operating on their tiny blood vessels. His goal was to improve and perfect his surgical techniques in repairing brain aneurysms. Dr. Wilson developed a regimen of working late and getting up early to achieve expertise, making him a prime example of the gritty surgeon. He built deliberate practice into his daily routine.5 Perhaps this example provides at least one strategy that residents can adopt to build autonomy.
Returning to Dr. Duckworth’s model of deliberate practice described earlier, resident autonomy can be the clearly defined goal, or the goal can function as more specifically defined for certain cases, techniques, or portions of operations that residents want to master. O-SCOREs or similar evaluation methods can provide immediate and informative feedback from an attending. The resident can then take those assessments and focus on improving through reflection, repetition, and refinement. To achieve autonomy, residents need to exercise deliberate practice and grow grit from the inside out.
Self-efficacy: A critical habit for developing autonomy
Another important step on the road to autonomy is the realization that one has the necessary tools and resources to achieve it. Self-efficacy is one way of describing this realization, which Bandura defines as an individual’s perception of “how well one can execute courses of action required to deal with prospective situations.”6 Another way of describing self-efficacy is a belief regarding one’s ability to exert influence over events that affect his or her life. People with a high degree of self-efficacy believe that they can ultimately determine whether they succeed. On the other hand, people with low self-efficacy have a fatalistic outlook and believe that events are predetermined and that they have little to no control over what happens to them.
Self-efficacy is an important concept in the field of public health as an indicator of a community’s likelihood of success when adopting a public health initiative.7 In a community with a fatalistic outlook, it is very difficult to get buy-in for a given initiative because the members of the community have little motivation to make the changes dictated by the initiative. If people believe that their actions have little to no effect on outcomes, they will tend to go with the path of least resistance or least effort. On the other hand, in communities in which the members believe that their contributions have a direct and significant effect on a given health outcome, it is much easier to achieve participation in public health initiatives. The same can be said for surgical trainees along the path to autonomy. Residents with a fatalistic outlook are likely the slowest to achieve autonomy, while those with a high degree of self-efficacy achieve it most quickly.
Some may argue that the stereotypical surgeon is bursting at the seams with self-confidence and, therefore, has no need for a boost in self-efficacy. It is important to understand, however, that this perceived self-confidence is developed over years of training and experience. In fact, residents at early stages of training may actually struggle with a low sense of self-efficacy, especially during the first year or two of training, when an intern or junior resident is repeatedly thrown into “sink or swim” situations and often bears the brunt of criticism from senior colleagues. In high-stress environments like these, a trainee may begin to feel that circumstances are beyond his or her control. The tendency in such situations is to switch into survival mode, where one loses the capacity to behave proactively and instead acts reflexively and defensively. What is most disturbing about this phenomenon is that it occurs in the most formative years of training, when trainees should be developing the sense of self-efficacy that will allow them to operate autonomously.
The following recommendations are intended to promote self-efficacy among surgical residents:
- Create clearly defined, measurable objectives. It is important that the objectives are defined rather than amorphous so that trainees and those evaluating residents’ abilities know whether they are achieving the anticipated milestones.
- Develop a curriculum composed of the specific steps necessary to fulfill the aforementioned objectives, such as reading assignments or a set of tasks in the skills lab. Clearly defined steps allow residents to appropriately budget their time, set personal goals, and build confidence as they complete the assigned tasks.
- Provide timely and specific feedback.8 One of the most critical aspects of residency is the opportunity to receive real-time feedback from experts in the field.9 Residents come to know whether their current training regimens are working by the feedback they receive from their instructors. When negative feedback is given, it is important that clear and specific steps for remediation are defined.10
- Ensure access to mentors. Mentors can guide residents when they are uncertain about what questions to ask, let alone the answers to those questions. A mentor can help residents to develop a framework for achieving their goals and, by virtue of experience, can enable trainees to avoid pitfalls that are not readily apparent to the inexperienced eye. Perhaps most importantly, mentors can embody the confidence and grit that are the hallmark characteristics of seasoned surgeons.11
Residents can only achieve true autonomy through careful development of self-efficacy. We must continue to design robust systems that identify at-risk trainees in order to intervene early in their formative years.
Grit: The characteristic that paves the way to autonomy
For some surgeons, surgical residency may be the hardest challenge they will ever face; yet, training has the potential to be the most rewarding and character-building time of a surgical career. In residency, trainees develop not only clinical skills, but also character traits and life skills that pay dividends in surgical practice, including the ability to manage one’s time, effectively communicate, and lead the patient care team, as well as character traits like perseverance, empathy, and collegiality. These competencies, in turn, help trainees develop grit—that intangible element of courage and resolve that enables people to transform the most difficult challenges into opportunities for growth and success.
Although surgical residents may strive for grit, self-efficacy, confidence, and autonomy, progression through surgical training does not always occur in a linear fashion. The high attrition from surgical training is usually multifactorial, more often related to a personal decision to leave a training program rather than dismissal for incompetence.12 A demanding surgical training program, lifestyle choices, burnout, and factors related to family/personal life often are correlated with higher attrition; managing these factors has a direct impact on performance. It is important for any lapse in morale or performance to be recognized early by the trainee or attending to decrease the likelihood of having to remediate.
A problem can be brought to light by any individual, including the program director, attending physicians, co-residents, staff, family, and even patients. A complaint or red flag of any kind should alert the program director and prompt discussion. If signs of underperformance are not readily discernable or the specific problem is difficult to pinpoint, tools such as the Accreditation Council for Graduate Medical Education core competencies can be used to identify areas of concern. These core competencies are patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. The development of surgical skills, which is often grouped into the patient care category, adds an additional layer to the training of a surgical resident. Autonomy is typically graduated through training as intended improvement in core competencies and surgical skills is achieved.
Identification of a deficiency through close observation with proper documentation is important because the area of deficiency is highly related to the likelihood of successful remediation. The most common areas of deficiency are patient care, medical knowledge, and communication.13 Professionalism is less likely to be remediated than a deficiency in medical knowledge as the steps to correct unprofessional behavior often are unclear.13 Dishonesty, poor medical knowledge, and poor technical skills are independently associated with departure from surgical training.14 Remediation is most effectively carried out in a stepwise fashion, starting with a face-to-face conversation and dedicated meetings and progressing to counseling and a formal remediation plan.14 Autonomy, competence building, social support, sleep, and time away from work are important to long-term well-being and performance; therefore, it is prudent for the program director to include these restorative features into a remediation plan.15
Creating a clear remediation plan using the previously described tenets outlined by Dr. Duckworth with documented acknowledgment from the resident ensures the goals and consequences are clear. Although dismissal from residency is uncommon, remediation is not always successful. Once adequate documentation has been obtained and the just cause threshold has been met, it is unnecessary to wait until a patient is harmed and, in general, legal precedent consistently supports faculty in the decision.16
During surgical training, residents often encounter barriers to autonomy and self-efficacy. If underperformance is identified, rehabilitation and restoration are typically part of the plan developed by the resident and the faculty. Based on introspection or being made aware of a problem, residents with grit will acknowledge a deficiency, dig their feet in, and regain autonomy. Failure to develop this type of grit has consequences for more than the practitioner and can extend beyond the training years, potentially placing patients at risk as well.
Surgical trainees navigate the pathway to surgical autonomy via different routes. Characteristics that contribute to acquisition of crucial operative skills include introspection, resilience and grit, deliberate practice targeting deficiencies, and self-efficacy. Training programs that implement systems that ensure the development of these traits will continue to produce autonomous graduates. Curricula also must include protocols for identifying residents who may be at risk of falling short of important milestones and goals that lead to autonomy and should consider factors outside of the workplace in developing a plan for remediation. Medicine and surgery continue to benefit from a high degree of self-regulation, and we owe it to our patients to continue to train the highest caliber surgeons to continue to meet the growing demands of independent surgical practice.
- Gofton WT, Dudek, NL, Wood TJ, Balaa F, Hamstra SJ. The Ottawa Surgical Competency Operating Room Evaluation (O-SCORE): A tool to assess the surgical competence. Acad Med. 2012;87(10):1401-1407.
- Duckworth A. Grit: The Power of Passion and Perseverance. Toronto, Canada: Harper Collins Publishers Ltd; 2016.
- Gladwell M. Outliers: The Story of Success. New York; Back Bay Books; 2011.
- Brasel KJ, Pierre Al, Weigelt JA. Resident work hours: What they are really doing. Arch Surg. 2004;139(5):490-493.
- Gladwell M. The physical genius. The New Yorker. August 2, 1999. Available at: www.newyorker.com/magazine/1999/08/02/the-physical-genius. Accessed June 13, 2018.
- Bandura A. Self-efficacy mechanism in human agency. American Psychologist. 1982;37(2):122-147.
- O’Leary A. Self-efficacy and health. Behav Res Ther. 1985;23(4):437-451.
- Bello RJ, Meyer M, Cooney D, Rosson G, Lifchez S, Cooney CM. Reliability of operative skill evaluations: How late is too late to give feedback? Plast Reconst Surg Glob Open. September 25, 2017 [Epub ahead of print].
- Burlew C. Surgical education: Lessons from parenthood. Am J Surg. 2017;214(6):983-992.
- Williamson K, Quattromani E, Aldeen A. The problem resident behavior guide: Strategies for remediation. Intern Emerg Med; 2016;11(3):437-449.
- Kamali D, Illing J. How can positive and negative trainer feedback in the operating theatre impact a surgical trainee’s confidence and well-being: A qualitative study in the North of England. BMJ Open. June 2018. Available at: http://bmjopen.bmj.com/content/bmjopen/8/2/e017935.full.pdf. Accessed June 13, 2018.
- Khoushhal Z, Hussain M, Greco E. Prevalence and causes of attrition among surgical residents: A systematic review and meta-analysis. JAMA Surg. 2017;152(3):265-272.
- Dupras D, Edson R, Halvorsen M, Hopkins R, McDonald F. Problem residents: Prevalence, problems and remediation in the era of core competencies. Am J Med. 2012;125(4):421-425.
- Raman H, Limbrick D, Ray W, et al. Prevalence, management, and outcome of problem residents among neurosurgical training programs in the United States. J Neurosurg. March 2, 2018 [Epub ahead of print].
- Raj K. Well-being in residency: A systematic review. J Grad Med Educ. 2016;8(5):674-684.
- Schenarts P, Langenfeld S. The fundamentals of resident dismissal. Am Surg. 2017;83(2):119-126.