American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Improving Autonomy in General Surgery Resident Training

Dr. Schenarts
Dr. Kempenich

Excellence in surgical education was founded on a model of gradually giving surgical residents increasing levels of responsibility with patient care as they approach graduation in preparation for independent practice.1 There are mounting concerns regarding the lack of preparedness of general surgery graduates for independent practice due to a lack of autonomy in training.2-4 Evidence for this view is found in the number of residents seeking fellowship training after residency increasing to 80 percent,1 as well as the perceived need for and the development of the American College of Surgeons Transition to Practice Program in General Surgery. Multiple factors have been implicated as reasons for lost autonomy including the 80-hour work week,1 new and innovative applied technologies,1 financial constraints,5-6 legal limitations,7 quality of patient care,8 patient expectations,9 and public opinion.10

There are multiple stakeholders in training the future workforce of surgeons to include residents, teaching faculty, hospital administration and the public. We performed a multi-institutional study to investigate current perceptions of autonomy in general surgery residency among these groups.11 We found that there is agreement between residents, faculty, and hospital administration that residents require autonomy in training in order to graduate as competent practitioners. The vast majority of residents and faculty also believe that autonomy improves resident self-confidence and patient ownership. When graded on a scale of zero to 10, however, faculty consistently rate the level of autonomy that should be granted to residents lower than residents did. Sterkenburg et al.12 found similar results when investigating factors that influence faculty to trust residents with unsupervised tasks. They suggest that “...it may be necessary for residents to overestimate their ability from a confidence issue to stimulate learning.”

While it may be appropriate for residents to overestimate their skill to be effective learners, we did find a concerning trend in that no faculty or resident surveyed felt that residents were given too much autonomy and 38 percent to 47 percent, respectively, felt there was too little autonomy granted at their institution.11 This begs the question, have we allowed the pendulum to swing too far, thereby stunting our educational efforts? Juxtaposed to the idea that autonomy is necessary for surgical training, there is little data to support the educational benefit ascribed to autonomy. There are multiple articles that suggest that better supervision may improve not only patient outcomes but educational goals as well, however, there is still a lack of data evaluating the quality of supervision.13

While some have cited public opinion as the driving force behind reduced resident autonomy, we found they are generally welcoming to resident participation with 96 percent agreeing to resident involvement.11 Unfortunately, enthusiasm among the general public wanes when patients are confronted with having surgery, decreasing to 82 percent for routine procedures and 59 percent for complex procedures (p<0.001). In an effort to investigate if we could improve patient perspectives with regard to resident involvement in procedures, we created an informational pamphlet regarding resident roles and responsibilities and distributed it to patients being treated in outpatient general surgery clinics.14 After reading the pamphlet, patients were more receptive to a chief resident performing a routine procedure independently than if they had not read the pamphlet (64 percent vs 52 percent, respectively, p=0.02). Similar to our results when surveying the general public, we found patients were also more enthusiastic about resident involvement in their procedure if the resident was a senior level resident for routine (p<0.001) and complex (p<0.001) procedures compared with junior residents (Table).

Finally, another significant area of concern in the era of quality improvement is the effect resident education has on patient quality of care. At least in terms of perception, we found that faculty and residents believe that resident involvement improves quality of patient care more than the general public does (p<0.001). That being said , only 3 percent of the general public we surveyed did not agree with the statement that residents improve the quality of their care.11  Substantiating the general public’s concerns, there have been several retrospective studies published showing increased risk of complication and/or increased operative times with residents involved, but none have shown an increase in mortality. At least one study in oncology patients showed a decrease in mortality with resident involvement.15-20

While there seems to be agreement among faculty, residents, and hospital administrators that autonomy in training is very important, barriers still exist. Surgical education faces a unique hurdle when training residents because a large portion of resident training occurs in the operating room and patients tend to be more uncomfortable with resident involvement in this area compared to non-operative tasks. Simultaneously, 80 percent of the general public we surveyed want residents to perform procedures independently prior to completing residency.11 There seems to be a disconnect between wanting well-trained surgeons upon graduation from residency and allowing appropriate autonomy during training to achieve this goal. We found it encouraging that informing patients of residents’ roles and responsibilities during their involvement seemed to promote chief resident autonomy. Others have also found that patients are more favorable to resident involvement when they know what to expect.21, 22 Counihan et al.23 found in a survey of attending surgeons that 84 percent felt they could successfully negotiate patient concerns regarding resident involvement using multiple arguments including improved quality of care, ethical need to train future generations, and practical need for an assistant. We feel that support of resident autonomy goes hand-in-hand with purposeful disclosure to the patient of resident involvement. Without this disclosure, patients are left to their own imaginations with regard to resident involvement. Additionally, while we view autonomy as important for surgical training, the paucity of data supporting this attractive concept means we don’t know how to gauge the optimal amount to achieve the best educational objectives without sacrificing patient outcomes.

The other significant piece towards improving autonomy rests with faculty development. We found that 70 percent of faculty feel regulations regarding reimbursement are responsible for decreased resident autonomy.11 Teman et al.9 found that attending surgeons cited increased focus on patient outcomes as well as patient and hospital expectations for surgeon involvement most commonly as reasons for limiting autonomy. They also found that factors that promoted autonomy included resident operative skill and faculty comfort with the procedure. The Netherlands instituted competency-based curriculum reform for their postgraduate medical training programs in 2006, whereby residents who demonstrate mastery of all entrustable professional activities (EPAs) for a clinical task could be awarded a “statement of awarded responsibility” (STAR) allowing the trainee to act independently.24, 25 For instance, if a resident earned a STAR for inguinal hernia, they would be allowed to book this case independently without supervision. The acceptance of this model in the U.S. among the general public and patients, policy-makers, teaching faculty, hospital leadership, and residents is not clear. Certainly the current reimbursement regulations for resident work and supervision would need to be revisited and cooperation from all entities required. Regardless, defining unique methods that assist faculty in granting autonomy while still maintaining appropriate supervision in order to ensure optimal patient outcomes and achieve superior educational targets is an area for future investigation.

Table
Patients’ Willingness to Consent to a Resident Participating in Surgical Care and Assisting with a Procedure Based on Training Level and Procedure Complexity

 

Strongly Disagree & Disagree

Neutral

Strongly Agree & Agree

Senior resident
Routine procedure (n=448)

5%

13%

82%

Senior resident
Complex procedure (n=451)

7%

16%

77%

Junior resident
Routine procedure (n=446)

11%

23%

65%

Junior resident
Complex procedure (n=449)

22%

26%

52%

Dr. Kempenich is an assistant professor in the department of surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX. Dr. Schenarts is a professor in the division of surgery, University of Nebraska Medical Center, Omaha, NE.