Bridging the autonomy gap in surgical training: An introduction

The goal of surgical training is to produce surgeons who are capable of practicing independently, delivering high-quality surgical care, and meeting the surgical needs of the community at large. This process involves building the anatomic and pathophysiologic fund of knowledge needed to understand surgical disease, acquiring and refining the cognitive and technical skills required to correct it, and developing the clinical judgment and decision making necessary to know when to exercise it. Integral to this process is the graduated independence or progressive autonomy afforded to trainees as they transition to the independent provision of safe, high-quality surgical care.

The changing landscape of surgical training

The landscape of surgical training has changed drastically in recent years. The most obvious and oft-cited change is the imposition of duty-hour restrictions. Not uncommonly, perceived deficiencies in clinical acumen, technical proficiency, and accountability or professionalism have been ascribed to duty-hour restrictions and their downstream effect on surgical culture. In reality, we have increasingly come to understand that myriad complex factors have eroded the experience of autonomy among surgical trainees.

Increasing liability concerns and external pressures aimed at protecting patient safety have resulted in limits on concurrent surgery and mandates on specific supervisory behaviors. Evolving clinical pressures include greater patient complexity, higher patient volume and turnover, and increased demand for clinical productivity. Furthermore, clinical productivity is scrutinized with public reporting of patient outcomes that are tracked to both surgeons and hospitals. The clinical environment also has been affected by increased documentation and other administrative requirements.

Increased specialization and changes in resident-faculty ratios have altered the surgical training environment. Previously common surgical interventions have been replaced with usually successful nonoperative management. Innovation in technology has expanded the skill set required of graduating chief residents to include competency in laparoscopic, robotic, and endoscopic interventions. Additional training in nontechnical skills, including communication, diversity/cultural sensitivity, professionalism, educational techniques (for example, delivering feedback, residents as teachers programs), and quality improvement have enriched the balance and versatility of trainees, but simultaneously compete with time devoted to didactic or clinical activities.

The patient experience also has evolved. Fortunately, paternalism in patient care is declining and has been replaced with an appropriate emphasis on shared decision making. Factors that continue to have a powerful influence on the patient experience include social media; headlines in the mainstream media; and portrayal of residents, surgery, and medical culture on television and in films. As a result, patients arrive at the hospital with a heightened awareness of the fallibility of physicians and often have preconceived notions about trainees and expectations for their care. Patients sometimes request that no trainees be involved in their care or specifically question the faculty to ensure that an attending will be present in the operating room and will be the primary surgeon conducting the operation.

Effects

The consequences of the changing landscape in surgical training are fairly significant. We find ourselves in an era where the literature is replete with reports from program directors and other surgical education leaders sharing concerns regarding the overall preparation of graduating residents, their ability to operate, and the quality of care delivered to patients.¹ Likewise, graduating chief residents have expressed concerns regarding their surgical skills and readiness for independent practice.² The challenge lies in defining progressive autonomy that maximizes educational value to trainees, minimizes risk to current patients, but simultaneously minimizes risk to future patients as a consequence of delayed maturation of surgical skills. Balancing the relationship between autonomy and patient risk is well conceptualized by George and colleagues.³ (See Figure 1 in Coleman et al, “The autonomy crisis: A call to action for resident advocacy.”)

Many surgical educators and trainees are invested in addressing the challenges this dilemma poses. We have become increasingly aware of the disparate perceptions of autonomy between faculty and trainees, known as the “autonomy gap.”^4,5 We have a greater understanding of the role of entrustment behaviors—those behaviors that facilitate autonomy—both on the part of the trainee and the faculty.^6-9 Models of surgical services that are resident-run or incorporate designated operative block time for residents have been implemented, engendering greater autonomy among trainees while producing similar or equivalent patient outcomes.^10,11

It is important to draw the distinction that autonomy and supervision are not mutually exclusive—that is, autonomy does not imply a lack of supervision. It is possible to have a high degree of supervision and concurrently be afforded a high level of autonomy. Facilitating a learning environment that allows the “safe struggle” to proceed is critical to building trainee confidence, problem solving, and future proficiency and mastery of surgery. However, this process must never compromise patient safety and quality.^6,9 If these efforts are to succeed, the pursuit of autonomy must be transparent, inclusive of patients, and never result in two standards of patient care.

Balancing autonomy with patient safety

What are the solutions? Should residencies be restructured—for example, using the 4 + 2 model? Should advancement be competency-based? Are entrustable professional activities the answer? Should longer rotations or more apprentice/mentor-based rotations be instituted to foster relationships and trust between trainees and faculty? Should a smaller core of faculty members be responsible for education, while other faculty focus more on clinical productivity? How can we incentivize and compensate surgical education appropriately? These important questions have no easy answers.

The issue of autonomy in surgical training is not unique to general surgery. These challenges affect all surgical specialties and training programs. As the representative of the House of Surgery, the American College of Surgeons (ACS) recently convened key stakeholders from all surgical specialties, educational societies, and governing bodies for its third Annual ACS Summit on Surgical Training, a meeting aimed at identifying and addressing the challenges in surgical training. The focus and theme of this meeting was autonomy. Through broad-based collaboration and shared goals, bodies such as the College have great potential to leverage knowledge, experience, and support to positively influence autonomy in surgical training.

During a focus group session for members of the Resident and Associate Society of the College (RAS-ACS) at Clinical Congress 2017, trainees identified erosion of autonomy as one of the greatest threats and areas of concern in surgical training. Accordingly, this year’s RAS-ACS issue of the Bulletin focuses squarely on the issue of autonomy in surgical training. In the following feature articles, RAS-ACS members explore the autonomy gap in surgical training, factors that limit autonomy, and strategies to foster autonomy or entrustment. I anticipate that surgeons at all stages of their career will find this issue of the Bulletin to be both informative and instructive.

References

1. Damewood RB, Blair PG, Park YS, Lupi LK, Newman RW, Sachdeva AK. Taking training to the next level: The American College of Surgeons Committee on Residency Training survey. J Surg Educ. 2017;74(6):e95-e105.
2. Becholz EM, Sue GR, Yeo H, Roman SA, Bell R, Sosa JA. Our trainees’ confidence: Results from a national survey of general surgery residents. Arch Surg. 2011;146(8):907-914.
3. George BC, Dunnington GL, DaRosa DA. Trainee autonomy and patient safety. Ann Surg. 2018;267(5):820-822.
4. Meyerson SL, Teitelbaum EN, George BC, Schuller MC, DaRosa DA, Fryer JP. Defining the autonomy gap: When expectations do not meet reality in the operating room. J Surg Educ. 2014;71(6):e64-e72.
5. Meyerson SL, Sterbach JM, Zwischenberger JB, Bender EM. Resident autonomy in the operating room: Expectations versus reality. Ann Thorac Surg. 2017;104(3):1062-1068.
6. 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.
7. Sandhu G, Thompson-Burdine J, Nikolian V, et al. Association of faculty entrustment with resident autonomy in the operating room. JAMA Surg. 2018;153(6):518-524.
8. Williams RG, George BC, Meyerson SL, et al. What factors influence attending surgeon decisions about resident autonomy in the operating room? Surg. 2017;162(6):1314-1319.
9. 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.
10. Kantor O, Schneider AB, Rojnica M, et al. Implementing a resident acute care surgery service: Improving resident education and patient care. Surg. 2017;161(3):876-883.
11. 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.