Surgical residency training in the U.S. has evolved over the last century. The Halstedian trainee was required to reside in the hospital, which resulted in the term “resident”; however, changing sociocultural norms have altered this paradigm significantly. Anecdotally, many among us hear of attendings who essentially ran their own operating room (OR) as senior residents or had their own line clinics. Today, most cases are directly supervised by an attending surgeon, and resident-run clinics and ORs are relics of a bygone era. As a result, many senior surgeons are of the view that surgical trainees in the past had more operative autonomy than the trainees of today.
The reasons for this seismic change in autonomy are many but are largely rooted in an increased emphasis on patient outcomes, hospital policies, and public perception. Several other factors may influence a resident’s level of operative autonomy, including case complexity, postgraduate year (PGY), prior work with attending, and performance during the case. Other commonly cited reasons for the decrease in autonomy are demand for efficiency in the OR, increased complexity of surgical technique, and decreased duty hours leading to less experience.1,2
The scope of the problem may be better understood by examining the results of a recent survey of fellowship directors, in which survey participants stated that incoming fellows graduating from general surgery residencies were inadequately prepared for their fellowship. Specifically, 66 percent of fellows were unable to independently operate for 30 minutes without assistance or supervision.3 Similarly, 59 percent of the Fellows of the American College of Surgeons older than age 45 who responded to the survey indicated that surgical training provides inadequate preparation for independent practice. In stark contrast to the perceptions of older surgeons, nearly all (91 percent) of surgeons ages 45 and younger indicated that they were adequately prepared for their transition to their role as an attending surgeon.4
The objective of a surgical residency program is to provide trainees with the technical skills and knowledge they need to confidently deliver surgical care. Invariably, a limited perception of autonomy hinders this purpose. While the old model of highly autonomous senior residents produced skilled surgeons capable of operating independently right after completion of surgical residency, the current system places several limitations on trainees’ ability to achieve these goals. Although we cannot eliminate all constraints associated with the current system (reduced operative hours, increased nonphysician obligations, increased administrative tasks, and so on), we do need to adapt our training models to promote autonomy and maintain the pipeline of a skilled surgical workforce. Surgeons broadly agree that the development of surgical proficiency requires autonomy during training, yet a consensus has not been reached as to the level of autonomy that should be granted and how this autonomy should be implemented in the current health care environment. This article explores the various perceptions of autonomy, how these conflicting viewpoints may be affecting training, and steps to correct these issues.
Gaps in perceptions of autonomy
Perhaps an initial question that needs to be addressed is: What expectations do attending surgeons and trainees share about the degree of autonomy that should be afforded to trainees? Faculty and trainees seem to agree on a general lack of autonomy for residents. In a multi-institutional study by Kempenich and colleagues, 47 percent of residents (n = 32) and 38 percent of the faculty (n = 50) said that residents had too little autonomy.5 Residents and faculty also propose similar levels of expected autonomy for performing the most common surgical procedures.
One study asked 30 attending surgeons and 33 surgery residents to rate the expected degree of autonomy for six commonly performed operations. A Zwisch scale was used to compare the expected autonomy against the actual degree of observed autonomy in the OR. The study showed that attending surgeons and residents shared similar expectations for the degree of autonomy that should be allowed. For five of the six operations, faculty and residents both expected senior trainees to perform with levels of autonomy between “passive help” and “supervision only.” However, despite the concurrent views on the amount of autonomy that should be allowed, the study found that senior residents performed only 44 percent of operations within these levels of autonomy.2 Residents and faculty also describe case difficulty similarly, and these descriptions are echoed across all PGY training levels.6
Understanding the gap between expected and observed levels of autonomy is critical for improving training and aligning expectations with reality. Survey data indicate that the most important factors from the point of view of the attending are the observed clinical skills of the trainee, the surgeon’s confidence to adequately supervise and/or correct resident errors, the ease of the operation, time spent with the resident, and the PGY level of the trainee.7
Recent data also indicate that consonant personality traits shared by the attending and the resident may contribute to increased trust in the OR. In one study, the authors evaluated 63 operations and determined the personality traits of residents and attendings involved. A questionnaire designed to detect an individual’s perception of goal attainment via a promotion orientation or a prevention orientation was used. Promotion has been described as ‘‘playing to win’’ and prevention as ‘‘playing not to lose.” Promotion-oriented individuals typically are risk-takers, open to new opportunities, plan for best-case scenarios, and work quickly. In contrast, prevention-oriented individuals are considered meticulous, often risk-averse, plan for the worst, and stick with tried-and-true ways of doing things. In this study, congruent promotion or prevention-oriented resident-faculty dyads displayed the greatest operative trust.8 The authors concluded that this personality trait alignment could lead to enhanced trust in the surgical resident because both resident and faculty shared the same goals and affirmed one another’s actions. However, other investigators have shown that the level of autonomy provided is completely dependent on trainee performance during a specific case.1
Another factor that requires further investigation is related to how gender may influence the level of autonomy granted to a resident. Women have historically been underrepresented in surgical training programs. This situation has changed in recent decades, with women comprising almost 40 percent of all surgical trainees.9 In a study of thoracic surgery trainees, male respondents reported having meaningful autonomy in almost twice as many cases as their female counterparts, significantly different from attending perceptions.10 Perhaps being mindful of these possible differences and how they may be perceived could be leveraged to bridge any gaps in operative autonomy.
Of all the stakeholders in medical training, the most important and most vulnerable is the patient. In the complex physician-patient relationship, autonomy is subordinate to patient willingness to allow in-training physicians to provide care. Patients, in general, have positive attitudes toward resident involvement, and the academic context is perceived as advantageous. However, when it comes to invasive or complex procedures, patient comfort level decreases with greater resident involvement. Cowles and colleagues found that after administering surveys to 200 patients over a seven-month period, 91 percent of patients thought training future surgeons was an important undertaking, and a similar proportion felt comfortable involving residents in their care. Yet, only 68 percent answered that they would agree to residents performing a portion of their operation.11
This discrepancy may be rooted in an incomplete understanding of the complexities of medical training. A significant proportion of patients are unaware that interns and residents who participate in their care already have a medical degree.12 Therefore, it is unsurprising that patients are averse to residents performing increasingly complex procedures. In a study of 202 patients, Santen and colleagues found patients were less comfortable with having a resident performing a procedure as the invasiveness of the procedure increased.13 Only 29 percent of the respondents said they would be comfortable allowing a resident to intubate them if it was the trainee’s first time.13 Similarly, when patients were presented with different scenarios, their inclination to consent to a procedure declined as the attending’s participation decreased. Although 86 percent of the surveyed patients would allow residents to observe, only 14 percent would consent to a resident performing the procedure, even with direct supervision.14
Expectedly, patients are more likely to allow senior residents to perform routine procedures but are much less enthusiastic about junior residents being involved in their operations or for general resident involvement in complex procedures.15 One study demonstrated that 46 percent of patients would allow a senior resident to be the primary surgeon for bariatric procedures,16 but this number decreases to 14 percent if attending staff will not be scrubbed in. Patient consent rates decreased from 94 percent to 18.2 percent as the level of resident participation increased.17
Recommendations for improving resident autonomy
Closing the gap between the expected level of graduated resident autonomy and the level observed in the community at large is challenging but essential. Operative autonomy requires faculty to move from “show and tell” and “active help” toward a paradigm of “passive help” and “supervision alone.”18 Documented evidence of previous autonomy may serve as a better guide than reliance on subjective opinions. It has been demonstrated that ongoing evaluation and feedback improve faculty awareness of the teaching needs of trainees.19 Another effective tool is the provision of immediate feedback.19 To this end, attendings should be encouraged to offer more structured and routine end-of-case feedback using either smartphone applications or some form of written feedback.
Day and colleagues propose the use of autonomy scores specific to different procedures based on the inherent complexity of the operations. The authors based this recommendation on a study of the level of resident independence for the 10 most common procedures performed in their hand surgery clinic. They found increased autonomy with increasing years of training.20 This study supports providing more autonomy for residents based on milestone assessment or demonstrated proficiency in standardized operations at the junior levels. A proposal like this could encourage granting autonomy based on predefined metrics of a trainee’s achievements. This model would also have the potential to translate to the OR, granting autonomy based on previously demonstrated skill rather than using limited data points and attending preferences.
A once common model, the “chief resident service,” could address the autonomy gap as well. In this model, a resident in the final year of training would be responsible for all aspects of patient care, resembling a first year of practice. Both residents and attendings support this model.21,22 The Massachusetts General Hospital, Boston, recently tested this paradigm by designing a one-month rotation in which chief residents had their own OR block. During their block time, the residents independently started and completed both elective and emergent cases with a designated attending who would come to the OR only to supervise the critical portion of the operation. Although this was a small study over a short period of time (one academic year), it demonstrated that in an unadjusted subset analysis comparing the structured operative autonomy (n = 54) and standard resident (n = 718) services, 30-day outcomes, readmission rates, and serious adverse events were comparable for patients undergoing appendectomy and cholecystectomy.23
Continuity clinics run by residents may afford another avenue for graduated autonomy with minimal attending oversight. As an example, most ophthalmology programs have a resident continuity clinic, where the residents provide longitudinal care to patients. Although 92 percent of them had an assigned faculty member on site, their expected supervision varied. In 30 percent of the cases, faculty were required to evaluate each patient, while in 42 percent, discussion of every case with the resident was the minimum requirement.24 Resident autonomy, in this example, is determined by the policy of the specific clinic or program.
Patients deserve the best possible care and full disclosure about their treatment and the team involved in their care. Therefore, a balance between the best possible patient outcomes and training objectives for surgical residents must be achieved. A clear and straightforward conversation during the consent process goes a long way. Consents should include disclosure of the training status of the physicians performing a procedure.13,16 Disclosure of resident participation during a case and degree of attending involvement are part of our ethical duty to our patients, but also important in terms of engaging them to improve resident autonomy.25,26 As demonstrated by this one study, there was a >90 percent acceptance rate of resident participation in cataract surgery when a specifically worded discussion of resident participation was done with the patient.27
Improved resident autonomy will ensure a well-trained surgical workforce for the future. A rearrangement of the training paradigms should ensure a balance between supervision and autonomy in a fashion that maximizes patient outcomes while emphasizing training of the residents. To create better systems to support resident autonomy, steps should be taken to align differences in perception between residents and attendings and bridge expectations and reality. No single fix can accomplish all these goals, but a multitude of steps can be taken to improve this process. Standardized evaluation forms to track operative autonomy are indispensable, as is provision of autonomy based on milestone assessment or demonstrated proficiency in standardized operations and less reliance on subjective measures such as attending preference. Additionally, chief resident services and continuity clinics can promote further autonomy at the senior resident levels. Adherence to standardized training paradigms that promote operative autonomy among surgical trainees will ensure that the supply of a well-trained surgical workforce in the U.S. is maintained.
- Williams RG, George BC, Meyerson SL, et al. What factors influence attending surgeon decisions about resident autonomy in the operating room? Surg. 2017;62(6):1314-1319.
- Meyerson SL, Sternbach JM, Zwischenberger JB, Bender EM. Resident autonomy in the operating room: Expectations versus reality. Ann Thorac Surg. 2017;104(3):1062-1068.
- Mattar SG, Alseidi AA, Jones DB, et al. General surgery residency inadequately prepares trainees for fellowship: Results of a survey of fellowship program directors. Ann Surg. 2013;258(3):440-449.
- Napolitano LM, Savarise M, Paramo JC, et al. Are general surgery residents ready to practice? A survey of the American College of Surgeons Board of Governors and Young Fellows Association. J Am Coll Surg. 2014;218(5):1063-1072.e31.
- Kempenich JW, Willis RE, Rakosi R, Wiersch J, Schenarts PJ. How do perceptions of autonomy differ in general surgery training between faculty, senior residents, hospital administrators, and the general public? A multi-institutional study. J Surg Educ. 2015;72(6):e193-e201.
- Young KA, Lane SM, Widger JE, et al. Characterizing the relationship between surgical resident and faculty perceptions of autonomy in the operating room. J Surg Educ. 2017;74(6):e31-e38.
- Teman NR, Gauger PG, Mullan PB, Tarpley JL, Minter RM. Entrustment of general surgery residents in the operating room: Factors contributing to provision of resident autonomy. J Am Coll Surg. 2014;219(4):778-787.
- Sutzko DC, Boniakowski AE, Nikolian VC, et al. Alignment of personality is associated with increased intraoperative entrustment. Ann Surg. May 23, 2018 [Epub ahead or print].
- Abelson JS, Chartrand G, Moo TA, Moore M, Yeo H. The climb to break the glass ceiling in surgery: Trends in women progressing from medical school to surgical training and academic leadership from 1994 to 2015. Am J Surg. 2016;212(4):566-572.
- Meyerson SL, Sternbach JM, Zwischenberger JB, Bender EM. The effect of gender on resident autonomy in the operating room. J Surg Educ. 2017;74(6):e111-e118.
- Cowles RA, Moyer CA, Sonnad SS, et al. Doctor-patient communication in surgery: Attitudes and expectations of general surgery patients about the involvement and education of surgical residents. J Am Coll Surg. 2001;193(1):73-80.
- Unruh KP, Dhulipala SC, Holt GE. Patient understanding of the role of the orthopedic resident. J Surg Educ.2013;70(3):345-349.
- Santen SA, Hemphill RR, McDonald MF, Jo CO. Patients’ willingness to allow residents to learn to practice medical procedures. Acad Med. 2004;79(2):144-147.
- McClellan JM, Nelson D, Porta CR, Martin M. Bariatric surgery patient perceptions and willingness to consent to resident participation. Surg Obes Relat Dis. 2016;12(5):1065-1071.
- Kempenich JW, Schenarts PJ. Improving autonomy in general surgery resident training. American College of Surgeons Division of Education. Available at: facs.org/education/division-of-education/publications/rise/articles/improving-autonomy. Accessed June 26, 2018.
- Porta CR, Sebesta JA, Brown TA, Steele SR, Martin MJ. Training surgeons and the informed consent process: Routine disclosure of trainee participation and its effect on patient willingness and consent rates. Arch Surg. 2012;147(1):57-62.
- George BC, Teitelbaum EN, Meyerson SL, et al. Reliability, validity, and feasibility of the Zwisch scale for the assessment of intraoperative performance. J Surg Educ. 2014;71(6):e90-e96.
- Fryer JP, Teitelbaum EN, George BC, et al. Effect of ongoing assessment of resident operative autonomy on the operating room environment. J Surg Educ. 2018;75(2):333-343.
- Bello RJ, Sarmiento S, Meyer ML, et al. Understanding surgical resident and fellow perspectives on their operative performance feedback needs: A qualitative study. J Surg Educ. April 20, 2018 [Epub ahead of print].
- Day KM, Zoog ES, Kluemper CT, et al. Progressive surgical autonomy observed in a hand surgery resident clinic model. J Surg Educ. 2018;75(2):450-457.
- Siam B, Al-Kurd A, Simanovsky N, et al. Comparison of appendectomy outcomes between senior general surgeons and general surgery residents. JAMA Surg. 2017;52(7):679-685.
- Jarman BT, O’Heron CT, Kallies KJ, Cogbill TH. Enhancing confidence in graduating general surgery residents: Establishing a chief surgery resident service at an independent academic medical center. J Surg Educ. February 20, 2018 [Epub ahead of print].
- Wojcik BM, Fong ZV, Patel MS, et al. Structured operative autonomy: An institutional approach to enhancing surgical resident education without impacting patient outcomes. J Am Coll Surg. 2017;225(6):713-724.e2.
- Singman EL, Srikumaran D, Green L, Tian J, McDonnell P. Supervision and autonomy of ophthalmology residents in the outpatient clinic in the United States: A survey of ACGME-accredited programs. BMC Med Educ. 2017;17(1):105.
- Gallant JN, Langerman A. How should trainee autonomy and oversight be managed in the setting of overlapping surgery? AMA J Ethics. 2018;20(4):342-348.
- Jones JW, McCullough LB. Consent for residents to perform surgery. J Vasc Surg. 2002;36(3):655-656.
- Gan KD, Rudnisky CJ, Weis E. Discussing resident participation in cataract surgery. Can J Ophthalmol. 2009;44(6):651-654.