The autonomy crisis: A call to action for resident advocacy

The graduate medical education system faces mounting challenges in training competent, autonomous health care providers, balanced with the delivery of high-quality, safe, efficient care. This conundrum poses a significant dilemma for general surgery programs charged with training the next generation of surgeons in a dynamic health care atmosphere. Most attending surgeons agree that a core objective of surgical training is autonomy; however, reaching a consensus on how to practically and effectively achieve this goal continues to be a work in progress.

In a time-constrained, accelerated training environment defined by duty-hour restrictions, the Halstedian model of graduated autonomy has become more difficult to follow. Evidence from national surveys suggests residents are graduating from programs with less autonomy than in the past.¹ Faculty members seem to agree with this claim, and thus it is not surprising that an increasing number of young attending surgeons report going into fellowship programs or pursuing another transitional approach because they don’t feel ready to practice.²

Autonomy is crucial, not only because it prepares a surgery resident for future success in independent practice, but it also increases a sense of ownership in patient care, enhances confidence, and ultimately fosters clinical competence during training.³ The unintended consequences of decreased resident autonomy extend into professional development and personal well-being and may eventually lead to decreased development of leadership and teaching skills. For example, despite relative case volumes remaining the same for several years among chief residents, the number of reported teaching assistant cases—in which residents are able to practice leadership and teaching in the operating room (OR)—has declined steadily.⁴ As for a diminished level of independence affecting well-being, when trainees were surveyed about the contributing factors leading to burnout, most residents cited decreased autonomy.⁵

The answer to this dilemma may seem simple: give residents more autonomy. Unfortunately, strategies for achieving resident autonomy, particularly given myriad barriers, spanning from medicolegal issues to financial stresses, have yet to be determined. This generation of surgical residents is facing an autonomy crisis, which presents a notable opportunity for resident advocacy.

A delicate balance

Although most surgical educators agree that autonomy is essential to resident learning, they also are concerned that too much autonomy may result in medical errors and poor patient outcomes. In 2000, the Institute of Medicine (now the National Academies of Science, Engineering, and Medicine) released To Err Is Human: Building a Safer Health System, a landmark report asserting that 44,000 to 98,000 hospital patients die annually as a result of preventable medical errors.⁶ Although subsequent research has suggested that this number was inflated, the report did trigger a renewed focus on decreasing medical and surgical errors.^7-9

The widely publicized death of Libby Zion in March 1984 highlights the connection between resident supervision and autonomy and medical errors. The unfortunate death of the 18-year-old patient while under the care of two emergency medicine residents incited a robust debate and serious evaluation of residency structure on a national scale.¹⁰ In addition, these reports and events have contributed to the development of regulations affecting medical training, including resident work-hour restrictions, billing restrictions on the use of medical students and residents as assistants at surgery, and specific billing requirements for faculty involvement in procedures and operations (see Table 1).

Table 1. Examples of legislative and regulatory policies with implications for surgical resident autonomy

Interestingly, many of these regulations appear to purport the assumption that less oversight, or high levels of trainee autonomy, leads to medical errors and poor patient outcomes. On a basic level, this assertion makes sense. If trainees are left alone to make decisions or perform procedures without adequate training or guidance, the outcome is likely to be negative. Conversely, if trainees are not allowed to independently make medical decisions and perform procedures, they will not acquire the necessary experience or the hands-on skills required to independently practice in the future.

The solution to the potentially competing goals of patient safety and resident autonomy seems clear—trainees should be given only as much autonomy as they can handle.¹¹ However, determining which resident is sufficiently ready to independently manage a complex service or solely perform an intricate oncological resection is a daunting task. What is known is that nearly half of the thousands of preventable adverse patient events that occur annually follow a surgical procedure.¹² Patients and administrators often blame resident inexperience for these adverse events and feel that patient care and outcomes are improved with less resident autonomy, despite insufficient evidence to support this argument.¹¹

Because patient safety is of paramount importance, the concern related to the fact that resident-performed procedures are more likely to end with complications or errors than those performed solely by attending surgeons must be examined. Interestingly, much of the published literature on this topic indicates little to no difference in complications or errors. Furthermore, when comparing operations with resident involvement versus procedures without, multiple studies across several surgical specialties demonstrate either similar or slightly prolonged operative times, but none indicate a difference in major complications or mortality.^13-17 One Canadian study demonstrated no significant difference in complications for 399 minor clinic procedures performed by 10 mid-level residents compared with those performed by attendings.¹⁸ In another notable example, a pilot program at Massachusetts General Hospital, Boston—in which eight chief residents scheduled and performed their own general surgery cases (124 operations) until the “critical portion” of a case—found no difference in postoperative complications, readmission, or major intraoperative adverse events compared with rates in more than 700 traditional resident autonomy services.¹⁹

In contrast to these studies, however, Aminian and colleagues found that fellow involvement in cases was associated with worse patient outcomes for laparoscopic Roux-en-Y gastric bypasses.²⁰ Notably, in this study and many others in which worse outcomes are attributed to trainee involvement, researchers do not examine or describe the extent of the operation that the trainee performs, a crucial detail to assess the relationship between degree of autonomy and adverse outcomes.

Tracing adverse patient outcomes back to a single individual, let alone a surgical trainee, is challenging. A retrospective review of 444 closed liability claims resulting from an alleged surgical error showed that in 62 percent of the cases, more than one clinician played a significant role, and 82 percent of errors were due to systems-related factors. Although lack of competence in a surgical trainee was implicated in some cases, 58 percent of cases that involved lack of technical skill or knowledge were actually because of an attending surgeon practicing without sufficient experience with the respective operation.³

Expanding on this work, Regenbogen and colleagues concluded that stricter supervision (that is, less autonomy) of a trainee is likely to address only a minority of technical errors.²¹ Some data even show equivalent outcomes when trainees are present, such as in laparoscopic operations for inflammatory bowel disease in which surgery was found to be equally safe when performed by supervised trainees and by individual trainers with no difference in mortality, 30-day morbidity, reoperation, or rehospitalization.²²

The role of resident supervision was further evaluated in a meta-analysis by Snowdon and colleagues, who concluded that the relative risk of patient mortality was reduced by a third when inexperienced surgeons (that is, residents) were clinically supervised.²³ These researchers concluded that a “supervisor must consider (1) the level of skill the trainee possesses in the particular surgical technique, (2) the complexity of the patient’s condition and surgical technique, (3) the level of insight that the trainee has into their own ability, and (4) the trainee’s belief in their own ability and their comfort with performing the surgery independently.”²³ Ultimately, the breadth of literature highlights the complexity of evaluating resident autonomy’s role in adverse events and the lack of agreement about what autonomy should look like.

Despite the equivocal data, George and colleagues suggest that the relationship between autonomy and patient safety is nonlinear. They posit that limiting autonomy can reduce the immediate risk of complications, yet in the future may result in more risk and harm to patients because of the trainee’s previous learning and experiential deficits (see Figure 1).¹¹

Figure 1. Trainee autonomy and the risk to patient safety

Current fellowship program directors echo this theory. When surveyed, these program directors report that 21 percent of fellows were unprepared for the OR, 30 percent could not perform a laparoscopic cholecystectomy, and 66 percent were unable to perform a major procedure without supervision for more than 30 minutes.¹ Furthermore, general surgery residents feel they lack a clear understanding of how prepared they are for the OR, as defined by their surgical educators.²⁴ Without being able to accurately describe preparedness, trainees will never realize autonomy, and patient safety will suffer in the long run.

The dilemma surrounding resident autonomy lies in achieving balance between requiring residents to operate with supervision until they prove they are capable of independently performing operations safely and effectively and ensuring that graduating surgical residents have enough experience to practice independently. The ideal we ought to strive for, then, is a model in which trainees are given graduated autonomy, such that they are as prepared as possible to perform operations safely through ongoing simulation and self-study, but acknowledging that there is no substitute for hands-on operating.

Barriers to autonomy and a call to action

The barriers that hamper appropriate and necessary autonomy range from systems-related issues to attending-specific issues and include work-hour restrictions, discrepancies between resident and attending surgeon views of autonomy, financial pressures, legal concerns, and patient perceptions.

In 2003, the Accreditation Council for Graduate Medical Education (ACGME) mandated that resident work hours be restricted to an average of 80 hours per week in a given month. In 2011, the ACGME further created the restriction of 16-hour duty maximums for interns or first-year residents.²⁵ Despite the noble intent of improving resident well-being, among other motives, a casualty of these restrictions was resident experience. Research following these restrictions indicated a 20 percent reduction in patient exposure. The consequent lack of experience has obvious implications for autonomy.²⁶

In a recent study, Williams and colleagues examined predictors of resident autonomy and concluded that residents’ operative performance in each case was the strongest predictor of how much autonomy was allowed in the subsequent case, followed by typical autonomy granted by the supervising surgeon.²⁷ Trainee experience, which is gained through repetitive presence in the OR, also was one of the four factors predicting autonomy.²⁷ Consequently, in the advent of work-hour restrictions, residents see and do less, then struggle more to perform well or enforce repetitive presence in the OR, and ultimately are afforded less autonomy as a result. To complicate matters, within the restricted time frame available for residents to operate, research has demonstrated a discrepancy between attending and resident views of autonomy during an operation, highlighting the lack of clarity regarding the “optimal” quality and quantity of resident autonomy in the OR.

In a recent study on resident and faculty estimates of resident autonomy, 47 percent of resident respondents felt they had too little autonomy and 38 percent of faculty respondents agreed.² However, when residents and attendings are asked to grade the degree of autonomy of a resident during an operation, attendings often report significant autonomy granted, whereas residents report a paucity.^28,29 The lack of agreement on what autonomy looks like serves as a barrier for residents. Compounding this problem is the reality of a training system in which residents frequently change services and receive less feedback than desired. A recent national qualitative study on progressive entrustment found that direct observation of trainee competency and the opportunity to operate with the same attending over an extended period facilitated autonomy.³⁰

Financial pressures related to reimbursement and relative value units (RVUs) for attending surgeons also create an environment in which resident autonomy often competes with other interests. A series of measures issued by the Centers for Medicare & Medicaid Services (CMS) requires the attending surgeon be present in the OR. In 2002, CMS mandated that attending surgeons be present and scrubbed for all “critical” portions of a procedure and that they provide supervision appropriate to the skill levels of the operating residents.³¹ These guidelines, which determine reimbursement for attending surgeons, have created challenges for residents to assert more autonomy in the OR and during critical portions of cases that only can be learned through hands-on engagement.

In addition to requirements of attending presence and involvement in cases is the considerable focus on RVUs, spawned from the Omnibus Budget Reconciliation Act of 1989, which created the Medicare physician fee schedule.³² RVUs created pressures for attending surgeons to expedite operative time and increase their operative load. Shortened periods of time in the OR and demands for high patient turnover can be incompatible with resident involvement, given the literature has consistently demonstrated a link between resident involvement in cases and degree of autonomy and longer operative times.^13,16

Any discussion of barriers to resident autonomy must acknowledge the litigious nature of medical practice. Unfortunately, liability occupies a large space in the minds of practicing surgeons, and teaching faculty must find the delicate balance between learner autonomy and patient safety. Some attending surgeons may feel that trainee autonomy may lead to greater liability; however, the evidence to support this inference is insufficient, as noted previously.

In 1996, in the case of Johnson v. Kokemoor, a patient was injured after a neurosurgical procedure, which involved inadvertent clipping of a cerebral aneurysm. The patient sued, arguing that the surgeon’s lack of experience in performing the operation was not fully disclosed.³³ The Supreme Court of Wisconsin ruled in favor of the plaintiff, and although this case did not involve a surgical resident, it highlighted the medical liability attending physicians assume when supervising less-experienced physicians. The hospital assumes liability as well, and there are several examples in which institutions have been found liable for errors that took place when a patient was in the care of a resident.³⁴

Another barrier to appropriate resident autonomy is patient perceptions regarding the role of trainees in surgical care. It is not uncommon for patients at university hospitals to express negative sentiments regarding resident involvement in their care. In these scenarios, attending surgeons and academic institutions must weigh the competing obligations to both residents and patients. However, recent studies seem to suggest public sentiments regarding trainees may be more favorable than previously believed. For example, a multi-institutional study by Kempenich and colleagues evaluated perceptions of resident autonomy among residents, faculty, administrators, and the public. The authors found that the public was more welcoming of resident involvement than faculty and administrators anticipated.² This finding suggests that perceived pressure from faculty surgeons to minimize resident involvement and autonomy because of patient preference is inflated. Rather, appropriate disclosure and public and patient education are necessary.

The common barriers to autonomy can be challenged by novel training tools in surgery, advocacy for legislation that creates a medicolegal structure conducive to resident autonomy, and patient education. Residents can encourage the use of innovative educational tools to structure the focus on resident autonomy. This concept has been successfully demonstrated at Northwestern University, Chicago, IL, by using the Zwisch scale, which is now the mobile application SIMPL (System for Improving and Measuring Procedural Learning).³⁵ SIMPL incorporates three basic quality indicators that assess (1) intraoperative autonomy, graded as show and tell, active help, passive help, and supervision only; (2) performance, graded as unprepared, inexperienced, intermediate, practice-ready, and exceptional; and (3) case complexity, rated as easiest, average, hardest.³⁶ Of the ratings, passive help and supervision only are considered synonymous with “significant autonomy” for surgery residency training.

A recent study using this scale showed that general surgery residents gain graded autonomy with advancing years of training, but also that these residents were not universally ready to perform core procedures independently.²⁸ These data also revealed that resident performance and autonomy closely parallel each other. Innovative tools similar to SIMPL have been adopted, which provide a forum for attendings to give feedback, facilitate resident reflection on performance, and discuss autonomy goals.³⁷

In addition to advocacy within one’s own residency program and patients, there is a greater call for action within the surgical community to create a medicolegal legislation conducive to and even rewarding of responsible resident autonomy. The type of legislation needed can address seeking and protecting reimbursement incentives for resident-led patient care from executive branch agencies, such as CMS (as discussed in this article and outlined in Table 1) and lobbying for liability protection when resident care is involved. Surgeon-driven policy advocacy can address gray areas in legislation, such as what defines “critical” portions of operations and how to incentivize third-party payors to reimburse for resident-administered services. Further, the surgical community can advocate for more education about billing requirements during surgical residency in order to streamline billing for surgical attendings, thus discouraging minimizing resident involvement for billing reasons and creating better-prepared future providers.

Growing avenues are available to residents to become involved in legislation advocacy, specifically through the American College of Surgeons (ACS). The ACS has been instrumental in grassroots movements among surgeons to create a formal voice influential in shaping policies that ultimately affect surgeons and their patients. The Resident and Associate Society of the ACS, the national organization of surgical trainees and young surgeons affiliated with the College, has several committees for residents eager to become involved, including the Advocacy and Issues Committee, which addresses current issues in resident training, medical care, and health policy. This committee also works collaboratively with several other organizations that have a legacy of strong resident involvement in advocacy efforts, including the ACS Professional Association Political Action Committee (ACSPA-SurgeonsPAC), the Health Policy Advisory Council (HPAC), and the Health Policy and Advocacy Group (HPAG). SurgeonsPAC supports an advocacy agenda for surgeons and their patients through an interactive, grassroots, educational, and political investment program, including advocacy in action on Capitol Hill. HPAC nurtures a grassroots advocacy network that develops expertise on legislative, political, and regulatory issues relevant to surgeons and their patients. HPAG identifies significant public policy issues and concerns of surgeons and their patients and then creates ACS action plans to increase awareness and guide initiatives to address them.

Conclusion

The importance of resident autonomy in surgical training is clear. Granting autonomy to trainees not only benefits residents by fostering clinical competence and independence as a future provider, but also benefits patients by creating a surgical workforce best equipped to care for patients in the future. Obviously, resident autonomy must be skillfully balanced with attending supervision to ensure optimal patient safety and resident learning. Barriers to this equilibrium relate to work-hour restrictions, discrepancies between resident and faculty views of autonomy, frequent resident turnover, financial pressures, litigation concerns, and patient perception. Addressing these hurdles—while formidable to overcome in the face of historical context and legislative change—remains a call to action for the surgical community and demands a resident voice.

Residents will be crucial agents of change in the movement to reclaim resident autonomy in surgical training, whether through driving the adoption of innovative surgical educational tools, working with Congress to develop sensible policies that are sensitive to resident autonomy, or standing alongside patients and their families to demonstrate the value of residents in their care. The need for resident voices to lead this issue is paramount; the time to speak and be heard is now.

References

1. 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.
2. 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.
3. Rogers SO Jr, Gawande AA, Kwaan M, et al. Analysis of surgical errors in closed malpractice claims at 4 liability insurers. Surgery. 2006;140(1):25-33.
4. Patel M, Bhullar JS, Subhas G, Mittal V. Present status of autonomy in surgical residency—a program director’s perspective. Am Surg. 2015;81(8):786-790.
5. Zubairi AJ, Noordin S. Factors associated with burnout among residents in a developing country. Ann Med Surg (Lond). 2016;6:60-63.
6. Kohn L, Corrigan J, Donaldson M, eds. To Err Is Human: Building a Safer Health System. Washington, DC: Committee on Quality of Health Care in America, Institute of Medicine. National Academies Press; 1999.
7. McDonald CJ, Weiner M, Hui SL. Deaths due to medical errors are exaggerated in the Institute of Medicine report. JAMA. 2000;284(1):93-95.
8. McDonald CJ, Weiner M, Hui SL. How many deaths are due to medical errors? JAMA. 2000;284(17):2817.
9. Hayward RA, Hofer TP. Estimating hospital deaths due to medical errors: Preventability is in the eye of the reviewer. JAMA. 2001;286(4):415-420.
10. Patel N, Popp RL. Learning lessons: The Libby Zion case revisited. J Am Coll Cardiol. 2014;64(25):2802-2804.
11. George BC, Dunnington GL, DaRosa DA. Trainee autonomy and patient safety. Ann Surg. 2018;267(5):820-822.
12. Putnam LR, Levy SM, Kellagher CM. Surgical resident education in patient safety: Where can we improve? J Surg Res. 2015;199(2):308-313.
13. Seicean A, Kumar P, Seicean S, Neuhauser D, Selman WR, Bambakidis NC. Impact of resident involvement in neurosurgery: An American College of Surgeons’ National Surgical Quality Improvement Program database analysis of 33,977 patients. Neurospine. 2018;15(1):54-65.
14. Bao MH, Keeney BJ, Moschetti WE, Paddock NG, Jevsevar DS. Resident participation is not associated with worse outcomes after TKA. Clin Orthop Relat Res. February 14, 2018 [Epub ahead of print].
15. Uecker J, Luftman K, Ali S, Brown C. Comparable operative times with and without surgery resident participation. J Surg Educ. 2013;70(6):696-699.
16. Igwe E, Hernandez E, Rose S, Uppal S. Resident participation in laparoscopic hysterectomy: Impact of trainee involvement on operative times and surgical outcomes. Am J Obstet Gynecol. 2014;211(5):484.e1-7.
17. Kulaylat AS, Hollenbeak CS, Stewart DB Sr. Increased postoperative morbidity associated with prolonged laparoscopic colorectal resections is not increased by resident involvement. Dis Colon Rectum. 2018;61(5):579-585.
18. Wojcik BM, Fong ZV, Patel MS, et al. The resident-run minor surgery clinic: A pilot study to safely increase operative autonomy. J Surg Educ. 2016;73(6):e142-e149.
19. 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.
20. Aminian A, Chaudhry RM, Khorgami Z, et al. A challenge between trainee education and patient safety: Does fellow participation impact postoperative outcomes following bariatric surgery? Obes Surg. 2016;26(9):1999-2005.
21. Regenbogen SE, Greenberg CC, Studdert DM, Lipsitz SR, Zinner MJ, Gawande AA. Patterns of technical error among surgical malpractice claims: An analysis of strategies to prevent injury to surgical patients. Ann Surg. 2007;246(5):705-711.
22. Celentano V, Finch D, Forster L, Robinson JM, Griffith JP. Safety of supervised trainee-performed laparoscopic surgery for inflammatory bowel disease. Int J Colorectal Dis. 2015;30(5):639-644.
23. Snowdon DA, Hau R, Leggat SG, Taylor NF. Does clinical supervision of health professionals improve patient safety? A systematic review and meta-analysis. Int J Qual Health Care. 2016;28(4):447-455.
24. Mundschenk MB, Odom EB, Ghosh TD, et al. Are residents prepared for surgical cases? Implications in patient safety and education. J Surg Educ. 2018;75(2):403-408.
25. Ahmed N, Devitt KS, Keshet I, et al. A systematic review of the effects of resident duty hour restrictions in surgery: Impact on resident wellness, training, and patient outcomes. Ann Surg. 2014;259(6):1041-1053.
26. Bell RH Jr, Banker MB, Rhodes RS, Biester TW, Lewis FR. Graduate medical education in surgery in the United States. Surg Clin North Am. 2007;87(4):811-823.
27. Williams RG, George BC, Meyerson SL, et al. What factors influence attending surgeon decisions about resident autonomy in the operating room? Surgery. 2017;162(6):1314-1319.
28. George BC, Bohnen JD, Williams RG, et al. Readiness of U.S. general surgery residents for independent practice. Ann Surg. 2017;266(4):582-594.
29. Torbeck L, Williams RG, Choi J, Schmitz CC, Chipman JG, Dunnington GL. How much guidance is given in the operating room? Factors influencing faculty self-reports, resident perceptions, and faculty/resident agreement. Surgery. 2014;9156(4):797-803.
30. Sandhu G, Magas CP, Robinson AB, Scally CP, Minter RM. Progressive entrustment to achieve resident autonomy in the operating room: A national qualitative study with general surgery faculty and residents. Ann Surg. 2017;265(6):1134-1140.
31. Department of Health & Human Services. Centers for Medicare & Medicaid Services. CMS Manual System. Available at: www.cms.gov/regulations-and-guidance/guidance/transmittals/downloads/R37SOMA.pdf. Accessed May 15, 2018.
32. 101st Congress. H.R. 3299 Omnibus Budget Reconciliation Act of 1989. Available at: www.congress.gov/bill/101st-congress/house-bill/3299. Accessed May 15, 2018.
33. Johnson v. Kokemoor. 545 N.W.2d 495 (Supreme Court of Wisconsin 1996).
34. Wegman B, Stannard JP, Bal S. Medical liability of the physician in training. Clin Orthop Relat Res. 2012;470(5):1379-1985.
35. DaRosa DA, Zwischenberger JB, Meyerson SL, et al. A theory-based model for teaching and assessing residents in the operating room. J Surg Educ. 2013;70(1):24-30.
36. Bohnen JD, George BC, Williams RG, et al. The feasibility of real-time intraoperative performance assessment with SIMPL (System for Improving and Measuring Procedural Learning): Early experience from a multi-institutional trial. J Surg Educ. 2016;73(6):e118-e130.
37. Sanfey H, Dunnington G. Verification of proficiency: A prerequisite for clinical experience. Surg Clin North Am. 2010;90(3):559-567.