2015 APDS SPRING MEETING
How do Perceptions of Autonomy Differ in General Surgery Training Between Faculty, Senior Residents, Hospital Administrators, and the General Public? A Multi-Institutional Study Jason W. Kempenich, MD,* Ross E. Willis, PhD,† Robert Rakosi, MD,* John Wiersch, MD,† and Paul Joseph Schenarts, MD‡ Department of General Surgery, Keesler Medical Center, Biloxi, Mississippi; †Department of Surgery, University of Texas Health Science Center of San Antonio, San Antonio, Texas; and ‡Division of Surgery, University of Nebraska Medical Center, Omaha, Nebraska *
OBJECTIVE: Identify barriers to resident autonomy in
today’s educational environment as perceived through 4 selected groups: senior surgical residents, teaching faculty, hospital administration, and the general public. DESIGN: Anonymous surveys were created and distributed to senior residents, faculty, and hospital administrators working within 3 residency programs. The opinions of a convenience sample of the general public were also assessed using a similar survey. SETTING: Keesler Medical Center, Keesler AFB, MS; the
University of Texas Health Science of San Antonio, TX; and the University of Nebraska Medical Center, Omaha, NE. PARTICIPANTS: A total of 169 responses were collected:
32 residents, 50 faculty, 20 administrators, and 67 general public. RESULTS: Faculty and residents agree that when attending
staff grant more autonomy, residents’ self-confidence and sense of ownership improve. Faculty felt that residents should have less autonomy than residents did (p o 0.001). When asked to reflect on the current level of autonomy at their institution, 47% of residents felt that they had too little autonomy and 38% of faculty agreed.
No resident or faculty felt that residents had too much autonomy at their institution. The general public were more welcoming of resident participation than faculty (p ¼ 0.002) and administrators (p ¼ 0.02) predicted they would be. When the general public were asked regarding their opinions about resident participation with complex procedures, they were less welcoming than faculty, administrators, and residents thought (p o 0.001). The general public were less likely to think that resident involvement would improve their quality of care (p o 0.001). CONCLUSION: Faculty and senior residents both endorse resident autonomy as important for resident development. The general public are more receptive to resident participation than anticipated. However, with increasing procedural complexity and resident independence, they were less inclined to have residents involved. The general public also had more concerns regarding quality of care provided by residents than the other groups had. ( J Surg 72:e193-e201. Published by Elsevier Inc on behalf of the Association of Program Directors in Surgery) KEY WORDS: graduate surgical education ownership, patient care, autonomy COMPETENCIES: Patient Care, Professionalism, Interper-
sonal and Communication Skills Disclaimer: The views expressed in this article are those of the authors and do not reflect the official policy or position of the U.S. Government, the Department of Defense, or the Department of the Air Force. The work reported herein was performed under United States Air Force Surgeon General approved Clinical Investigation No. FKE20140018E. Correspondence: Inquiries to Jason Kempenich, MD, Department of General Surgery, Keesler Medical Center, 301 Fisher Street Keesler AFB, MS 39534; E-mail: jason. [email protected], [email protected]
INTRODUCTION Self-determination theory states that human beings have a natural tendency to develop toward autonomous behavior,
Journal of Surgical Education Published by Elsevier Inc on behalf of the Association of 1931-7204/$30.00 e193 Program Directors in Surgery http://dx.doi.org/10.1016/j.jsurg.2015.06.002
and those who are able to act autonomously learn better and achieve superior performance.1 The Halstead method2 for graduate medical education and the Accreditation Council for Graduate Medical Education Program Requirements for Graduate Medical Education in General Surgery3 both support gradually giving the surgical resident increasing levels of responsibility and autonomy as they approach graduation in preparation for independent practice. This method for resident education has been successfully producing excellent surgeons for more than 100 years.4 More recently, there have been mounting concerns regarding the preparedness of general surgery graduates for independent practice owing to a lack of autonomy in their training.5 This concern has culminated with the American College of Surgeons creating the “Transition to Practice Program in General Surgery” that was developed to “help fill the perceived gaps in training today.” The first cited goal of the experience is to “obtain enhanced autonomous experience in broad-based general surgery.”6 In addition to creating the Transition to Practice Program, over the last 3 decades, the number of residents seeking fellowship training after residency has slowly increased and exceeds 80%, causing some to attribute this trend to the lack of autonomy in residency.2 The perception of lost autonomy in surgical residency has been a mounting problem over the past 30 years. Multiple factors have been implicated and include the 80-hour work week,2 new and innovative technologies being applied to general surgery,2 financial constraints,7,8 legal limitations,9 quality of patient care,10 and public opinion.11 In a recent survey of attending surgeons by Minter et al.12 investigating autonomy given in the operating room (OR), factors that promoted autonomy included resident skill and faculty comfort with the procedure. The most commonly cited reasons for limiting autonomy included increased focus on patient outcomes and expectation of surgeon involvement by patients and hospitals. In a survey addressing barriers to resident-attending communication with the goal of improving patient safety, one barrier cited was resident fear of losing autonomy.13 Granting autonomy to a trainee is made more difficult in the medical profession by the potential for pain and suffering of the patient because of a complication. However, many studies show at least equivalent outcomes as compared with nonteaching institutions.14-16 Ten Cate17 points out that trust is developed between a resident and supervisor when a competent resident executes a task when appropriate. This not only builds trust but is also a definition for performance, i.e., not only being competent to do a task, but executing a task when it is appropriate to do so. Most supervisors can identify which residents they trust, even if they cannot identify why. Without trust, it is difficult for supervisors to extend sufficient autonomy to residents. In the current educational climate, there is increasing focus on achieving competency. This is evidenced by the e194
core competencies and milestones mandated by the Accreditation Council for Graduate Medical Education.3 There are also multiple articles in the literature attempting to evaluate entrustable professional activities.12,17-20 Both of these are attempts to measure a resident’s ability and trustworthiness for increasing levels of independence in an effort to guide faculty regarding when to grant the appropriate level of independence at the appropriate time in resident training. The issue of resident autonomy in education is multifaceted and involves not only the resident and teaching faculty but also the patient who is under the care of the surgical teaching service. Hospital administrators are also indirectly affected by standards for supervision of residents concerning reimbursement as well as quality, safety, and liability concerns. The aim of this study was to evaluate the perceptions regarding resident autonomy from the perspective of the surgical trainee, surgical instructor, hospital administrator, and the general public. We hypothesized that the perceptions of the resident and the faculty surgeon would be more closely allied than those of the hospital administration or the general public. Our second hypothesis was that residents and faculty would favor more autonomy in training when compared with hospital administration and the general public.
MATERIALS AND METHODS For this study, surgery residents, teaching faculty, and hospital administrators were surveyed at each of 3 general surgery resident training programs: Keesler Medical Center, the University of Nebraska Medical Center, and the University of Texas Health Science Center at San Antonio. Institutional review board approval was obtained at Keesler Medical Center before commencement of the study. The resident group was limited to general surgery residents in clinical postgraduate year 3 (PGY3) to PGY5. The hospital administration group surveyed was composed of the Chief Medical Officer; Chief Nurse; Chief Legal Counsel; Head of Quality; and Chief Executive Officer, President, or Vice President (or equivalent) of any hospital that was associated with training residents from 1 of the 3 participating training programs. The general public group was a convenience sample of adult (Z18 y of age) nonmedical persons encountered by the investigators through association (e.g., neighbors and community groups). There were no other exclusion criteria. Similar surveys were created for each of the 4 groups (Appendix). Each survey was specific to the appropriate group of participants, but the questions were constructed to be similar to the other groups for purposes of comparison. A 5-point Likert scale was used for all questions except 2 questions asking the participant to rate the degree of independence appropriate on a scale from 0 to 10 for a
Journal of Surgical Education Volume 72/Number 6 November/December 2015
TABLE 1. Population Characteristics: Faculty, Administrators, and Residents
Hospital work experience* University University-affiliated community hospital Non–university-affiliated community hospital Veterans affairs/military Other Years of experience working in a teaching hospital 0-5 y 6-10 y 11-15 y 16-20 y 420 y
Faculty (%) (n ¼ 50)
Administrators (%) (n ¼ 20)
70 30 20 66 0
50 20 20 60 0
34 16 20 8 22
20 35 10 10 25
Residents (n ¼ 32) 100% 53% 50% 91% 3% PGY3 31.25% PGY4 37.5% PGY5 31.25%
*Multiple items could be marked for this question.
junior resident (PGY2) and a chief resident (PGY5). The resident and faculty surveys consisted of 15 questions, and the administrator and general public surveys had 12 questions. Each survey was piloted and feedback was solicited from representative individuals of each group. The survey was then finalized after discussion and agreement among the investigators. The resident, faculty, and administrator groups were solicited by e-mail and responses were collected anonymously through the SurveyMonkey website. The general public were solicited directly in person, and no personally identifiable information was collected. There was no compensation or reward for participation. Responses were compiled for each survey group, and the median response for each question was calculated. The Kruskal-Wallis test was then used to analyze the distribution of responses between the survey groups. In cases where a significant difference was identified, the Mann-Whitney U test was used for pairwise comparisons. For the general public survey, we analyzed 3 questions regarding resident participation using the Friedman test with pairwise comparisons using the Wilcoxon signed rank test.
residents require autonomy in training to develop into an attending surgeon. Most faculty (94%) and residents (92%) agreed or strongly agreed that when attending staff grant more autonomy, self-confidence improves. Conversely, when resident independence is reduced, both faculty and residents agreed or strongly agreed that this decreases resident sense of ownership for patient care (92% and 100%, respectively). Teaching faculty, hospital administrators, and senior residents were asked to rate on a scale of 0 to 10 (0 being no independence and 10 the most) the appropriate degree of independence for a chief resident (PGY5) and a junior resident (PGY2). The medians were the same among each group surveyed for chief resident independence (i.e., all medians ¼ 10, indicating a very high level) and similar for junior resident independence (i.e., medians varied between 4 and 5, indicating a moderate level; Table 3). The KruskalWallis test was performed to evaluate the distribution of responses and were found to be significantly different among the 3 groups surveyed for chief residents (p ¼ 0.003) and junior residents (p o 0.001; Table 3). Pairwise TABLE 2. General Public Characteristics
RESULTS A total of 169 responses were collected; 32 residents, 50 faculty, 20 administrators, and 67 from the general public. Response rates for residents, faculty, and administrators were 60%, 68%, and 91%, respectively. Response rate for the general public could not be calculated. Population characteristics are displayed in Tables 1 and 2. Faculty’s, Residents’, and Hospital Administrators’ Views of Autonomy for Residents in Training Of the faculty, residents, and administrators surveyed, 98%, 97%, and 95%, respectively, agreed or strongly agreed that
General Public (%) (n ¼ 67) Age 18-30 31-40 41-50 51-60 460 Highest education level achieved High school, nongraduate High school graduate Some college Associate or tech degree Bachelor’s degree Master’s degree Doctorate or equivalent
Journal of Surgical Education Volume 72/Number 6 November/December 2015
40.3 17.9 10.5 17.9 13.4 1.5 7.5 29.9 7.5 44.8 7.5 1.5 e195
TABLE 3. Appropriate Level of Independence for a Chief (PGY5) and Junior Resident (PGY2) on a Scale of 0-10 PGY5 Median Faculty 0-10 y 11þ y Administrators Residents
PGY5 Mean Rank*
10 (4-10) 10 (7-10) 9 (4-9) 10 (0-10) 10 (5-10) Median (range)
42.02 55.50 62.36 p ¼ 0.003
n
PGY2 Median
PGY2 Mean Rank*
n
50 25 25 19 32
4 (0-6)
38.75
50
5 (0-6) 5 (2-8) Median (range)
65.84 61.33 p o 0.001
19 32
*The Kruskal-Wallis test.
comparisons using the Mann-Whitney U test revealed that faculty rated the appropriate level of autonomy for a chief resident lower than the senior residents did (p ¼ 0.001). This effect was more pronounced with greater than 10 years of experience as teaching faculty, with a median of 9 years (p ¼ 0.003; Table 3). Faculty also rated the appropriate level of autonomy for a junior resident lower than residents (p o 0.001) and administrators did (p ¼ 0.001). When asked to reflect on the current level of autonomy at their institution, 53% of residents felt it was appropriate, 41% felt they had too little autonomy, and 6% felt it was far too little. Faculty felt similarly regarding resident autonomy currently at their institution; 62% felt it was appropriate, 32% felt it was too little, and 6% felt it was far too little. There was no significant difference between residents and faculty. The effect was magnified with more experience. Those faculty with greater than 10 years of experience were more likely to think that residents have too little autonomy (p ¼ 0.05) when compared with their junior faculty counterparts. No senior resident or faculty surveyed felt that residents had too much autonomy at their institution. Perceptions of the Effect of Regulation on Reimbursement and Resident Autonomy Faculty and administrators were asked if they felt regulations regarding reimbursement were responsible for decreased resident autonomy. Overall, 70% of faculty agreed or strongly agreed, compared with 35% of administrators. Pairwise comparisons using the Mann-Whitney U test found this to be statistically significant (p ¼ 0.01). Of faculty with greater than 10 years of experience in teaching, the effect was even more pronounced with a median of “strongly agree” compared with junior faculty who had a median of “agree.” The Mann-Whitney U test was performed, and the
difference was statistically significant (p ¼ 0.04). These data indicate that faculty felt that resident autonomy was limited by reimbursement regulation more than administrators did, particularly faculty with greater than 10 years of experience in teaching. General Public’s Views on Resident Participation in Their Health Care The general public group was asked if it would welcome resident participation in their health care, and 95.5% strongly agreed or agreed. Teaching faculty, residents, and hospital administrators were asked their perception of patients’ receptiveness to resident participation in their health care. The Kruskal-Wallis test showed that there was a statistically significant difference in receptiveness or perception of receptiveness to having residents participate in patient care between the different populations (p ¼ 0.01; Table 4). Pairwise comparisons using the Mann-Whitney U test revealed that the general public had significantly higher ratings for patient involvement than administrators (p ¼ 0.02) and faculty (p ¼ 0.002) did. This indicates that the general public have more favorable views of resident participation in patient care than administrators and faculty perceive they do. There was no significant difference in responses when analyzing the general public’s responses based on having personally received care from a resident vs not. Views of Resident Autonomy in the OR Residents, faculty, administrators, and the general public were asked if a resident should perform surgical procedures independently before graduation. Residents surveyed were in the most agreement, with 96.9% that agreed or strongly agreed. The data are displayed in Table 5. The Kruskal-Wallis
TABLE 4. Patients' Welcome Resident Participation in Their Health Care
Public Faculty Residents Admin
Strongly Disagreed (%)
Disagreed (%)
Neutral (%)
Agreed (%)
Strongly Agreed (%)
n
Mean Rank*
1.5 0 0 0
0 4 0 0
3 14 12.5 10
58.2 66 62.5 80
37.3 16 25 10
67 50 32 20
97.77 73.17 83.7 73.9
*The Kruskal-Wallis test, p ¼ 0.01. e196
Journal of Surgical Education Volume 72/Number 6 November/December 2015
TABLE 5. Views of Resident Performing Surgical Procedures Independently Strongly Disagreed
Disagreed
Neutral
Agreed
Strongly Agreed
n
Should residents perform surgical procedures independently before graduation? Residents 3.1% 0% 0% 21.9% 75% 32 Faculty 0% 2% 6% 44% 48% 50 Admin 5% 0% 0% 50% 45% 20 Public 1.5% 7.5% 10.5% 44.8% 35.8% 67 If I needed a routine procedure, I would consent to a PGY5 resident performing my procedure independently. Public 1.5% 9% 16.4% 52.2% 20.9% 67 If I have surgery, I want to know how much of the procedure is going to be done by the resident. Public 1.5% 10.5% 26.9% 38.8% 22.4% 67
Mean Rank* 108.63 86.68 85.15 72.42
*The Kruskal-Wallis test, p ¼ 0.002.
test indicated a significant difference in response distribution (p ¼ 0.002; Table 5). Pairwise comparisons with the MannWhitney U test revealed that residents had significantly more positive views of the need for independent operating experience than faculty (p ¼ 0.02), administrators (p ¼ 0.04), and the general public (p o 0.001) had. These data indicate that faculty, administrators, and the general public feel less strongly about the need for residents to perform procedures independently than residents did. The general public were asked if they would consent to a resident participating in their care and assisting if they had to have routine surgical procedure, and 82.1% agreed or strongly agreed. We then asked the same question but qualified the procedure as complex, and 59.1% agreed or strongly agreed. On comparing the general public’s responses to welcoming resident participation, vs resident participation with a routine procedure, vs a complex procedure using the Friedman test, a statistically significant difference (p o 0.001) was noted. Pairwise comparisons of all 3 questions were statistically significant. This means that as we specified resident involvement from general participation to surgical procedures with increasing complexity, the general public were less willing to consent. The general public were then asked if they would agree to resident participation if they could be assured that surgical outcomes would be the same or better; 94% agreed or strongly agreed.
The general public were then asked if they would consent to a resident, in the final year of training, performing surgery independently on them if it was a routine procedure, and 73.1% agreed or strongly agreed (Table 5). We compared the general public’s opinion regarding the need for residents to perform surgical procedures independently before graduation and actually consenting for a PGY5 resident to perform a routine procedure independently. The general public were less enthusiastic for residents to perform procedures if they had to consent for it personally (p ¼ 0.05). In addition, most of the general public want to be informed regarding how much of their procedure will be done by a resident (Table 5). Perceptions of Resident Participation Effect on Quality of Patient Care Teaching faculty, residents, hospital administrators, and the general public were all queried regarding the effect of resident participation in patient care and the effect on quality of care provided (Table 6). When the general public were asked if quality of care was better with residents involved, only 3% strongly disagreed or disagreed. However, the Kruskal-Wallis test showed a statistically significant difference in quality-of-care perceptions between the different populations (p o 0.001; Table 6). Pairwise comparisons
TABLE 6. Residents’ Participation and Perceptions of Quality of Care Resident Involvement in Patient Care has Which Effect on Quality of Care Provided?
Faculty Residents Admin
Significantly Worsens (%)
Worsens (%)
No effect (%)
Improves (%)
Significantly Improves (%)
n
0 0 0
2 0 10
12 6.25 10
74 56.25 50
12 37.5 30
50 32 20
Mean Rank* 91.78 112.78 96.65
My Overall Hospital and Surgical Care is of Better Quality With Residents Involved.
Public
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
n
Mean Rank*
1.5%
1.5%
50%
40.9%
6.1%
66
61.59
*The Kruskal-Wallis test, p o 0.001. Journal of Surgical Education Volume 72/Number 6 November/December 2015
e197
using the Mann-Whitney U test revealed that with residents involved, the general public think that quality of care would be lower than what faculty (p o 0.001), residents (p o 0.001), and administrators (p ¼ 0.01) thought. Faculty also thought quality of care was lower with residents involved than residents did (p ¼ 0.01). Those in the general public who answered “yes” to having received health care from a resident were asked if they had personally received health care of lesser quality because of resident participation (n ¼ 29); 82.8% disagreed or strongly disagreed, 0% neutral, and 17.2% agreed or strongly agreed. When compared with faculty’s, residents’, and administrators’ opinions on the effect of resident involvement on quality of care vs patients reporting of health care of lesser quality received, there is a statistically significant difference between populations using the Kruskal-Wallis test (p o 0.001). Pairwise comparison using the Mann-Whitney U test also revealed that the general public believe that the quality of care they personally receive with residents involved is lower than faculty (p o 0.001), residents (p o 0.001), and administrators (p o 0.001) perceive it is. Results Summary Most of teaching faculty, administrators, and senior residents think that autonomy in resident training is important for developing attending surgeons as well as residents’ sense of patient ownership and self-confidence. Faculty rate the appropriate level of autonomy for residents lower than residents do, especially faculty with greater than 10 years of teaching experience. No teaching faculty or resident thought that residents have too much autonomy at their institution. The general public are more receptive to resident involvement than teaching faculty and administrators anticipate. Barriers to autonomy cited in our survey include regulations on reimbursement, the general public’s concerns with resident participation in complex procedures, chief residents performing procedures independently, and concerns regarding quality of care provided by residents.
DISCUSSION Autonomy is defined by Merriam-Webster’s Dictionary as, “the quality or state of being independent, free, and selfdirecting.”21 In resident training, others have defined autonomous practice as, “…both patient ownership and the active direction of one’s own learning.”22 Certainly, patient ownership and independence are important for surgical resident training, and our survey results support that 490% of faculty, residents, and hospital administrators recognize the importance of autonomy in training and that allowing for resident independence leads to residents taking greater ownership of patient care and improved selfconfidence. e198
The issue of resident autonomy or independence becomes more complicated when discussing how much autonomy should be allowed to a resident. Although residents and faculty had similar expectations for graded increases in autonomy when comparing a second-year resident and a chief resident, faculty consistently rated the appropriate level of independence lower than residents did. In a study by Sterkenburg et al.19 looking at when teaching physicians decide to entrust unsupervised tasks, teaching faculty consistently rated resident competence lower than residents did. They go on to suggest that “…it may be necessary for residents to overestimate their ability from a confidence issue to stimulate learning.” Although it may be appropriate for residents to think they are capable of functioning with more independence than those instructing them, it is worth noting that no faculty or resident in our survey felt that residents had too much autonomy at their institution, and 47% of residents and 38% of faculty felt there was not enough autonomy provided. This may suggest that the pendulum has swung definitively toward inadequate levels of autonomy for residents training in today’s educational environment. Although asking trainees to perform tasks far above their ability may set them up for failure, conversely, not challenging them with appropriate responsibility and independence can also lead to stunted learning and developement.2,7,19 Interestingly, we found that teaching faculty with greater than 10 years of experience in teaching surgery residents rated appropriate levels for chief surgery resident independence lower than their more-junior faculty counterparts did. Conversely, faculty with greater than 10 years of experience were more likely to think that residents at their institution currently have too little autonomy when compared with junior faculty. The reason for this dichotomy is unclear. More-senior teaching faculty may have a different reference point for resident independence based on a different educational environment when they trained. The grand jury recommendations from the Libby Zion case that have been the framework for many of the supervision and workhour reforms instituted for graduate medical education were released in 1986, and full implementation was not completed until 2011.11,23 Faculty with less than 10 years of teaching experience may have been residents under workhour and supervision reforms, and at a minimum, these reforms have been in place as long as they have been teaching faculty. Another possibility is that faculty with more experience have also seen more examples of resident misadventure if given too much independence. External regulations have been cited as a reason for decreasing autonomy in surgical education.2,12 Our study revealed this to be a significant concern among teaching faculty who believed regulations on reimbursement to have a negative effect on resident autonomy. In a study evaluating the amount of guidance supervising surgeons provide in the OR, it was found that faculty tend to
Journal of Surgical Education Volume 72/Number 6 November/December 2015
underestimate the amount of guidance they provide to residents.24 External regulations have necessitated increased attending surgeon presence in the OR, and this may have led to decreased resident autonomy, as the OR staff and resident naturally defer to the attending surgeon. Chalabian and Bremner7 performed a survey of surgery residents in the late 1990s, which revealed that 71% of residents felt that “…mandatory attending presence in the OR was bad.” Maintaining adequate supervision for reimbursement and patient safety is necessary, but this may be an area for future faculty development with concentration on creating a supervised OR environment where resident autonomy is still respected. We were encouraged to find that 495% of the general public group we surveyed would welcome resident participation in their care. A previous study performed in 1983 surveyed private internal medicine patients and found that 73% would allow resident participation in their care.25 They also performed a retrospective survey of patients who received care from residents and found that 70% were fully satisfied and 20% were partially satisfied. In 1996, O’Malley et al.26 surveyed patients after their visit at a general medicine clinic and found that 95% would be willing to see a resident again. Our survey results in addition to these studies support that the general public as well as those who become patients of residents are amenable to resident involvement. When we specifically asked the general public group if they welcome resident participation vs would they consent to resident participation if they had to have a routine vs complex surgical procedure, we saw a statistically significant change toward more negative responses. We anticipated that the general public would be more apprehensive regarding resident participation with complex procedures, but we would have anticipated that routine procedures would have been more closely allied with the public’s responses to resident participation in general. However, if one could ensure patients that outcomes would be the same or better with resident participation, then the general public were much more receptive to resident involvement with their procedure. In a survey of patients who underwent hysterectomy where 100% of the patients had a resident involved in their care, only 63% of the patients who responded to the survey were aware and 80% wanted to know what a resident would do during their operation and how they would be supervised.27 Overall, 61% of the general public group in our survey wanted to know what parts of the procedure would be done by a resident. We feel that the general public may be more negative toward resident participation with surgical procedures because they have not been educated regarding the residents’ role and level of participation in their procedure. Reichgott and Schwartz25 found in their survey of patients that most of the negative responses to resident participation were the result of patients not being aware that a resident was involved in their care. Attention to this issue may allow teaching faculty to assuage patient fears.
Residents we surveyed felt most strongly that performing procedures independently before graduation was important, with 496% responding “agree” or “strongly agree.” Chalabian and Bremner7 found similar results in a survey of 4 Los Angeles residencies almost 20 years ago, where 96% of chief residents felt that independent operative experience was important for surgical training. Although most of the teaching faculty, administrators, and the general public in our study felt that residents should perform procedures independently before graduation, their responses were less enthusiastic. Of the general public group, 80.6% agreed or strongly agreed that residents need to perform procedures independently before graduation. When asked if they would consent to a PGY5 resident performing a routine procedure independently on them, less agreed (73.1%; p ¼ 0.05). All 4 populations in our study were asked to rate the effect of residents on the quality of care patients receive. Residents were the most optimistic regarding the quality of care they provide patients, but even the general public group, the most pessimistic of the 4 groups, had only 3% of responses indicating that residents had a negative effect on quality of care. Overall, 50% of the general public group in our survey felt that residents had no effect on quality of care. Multiple retrospective studies have been recently published analyzing the data from the American College of Surgeons National Surgical Quality Improvement Program showing increased morbidity and complication rates when residents are involved.28-32 Castleberry et al.28 found that although there was increased morbidity with residents involved, the 30-day mortality rate was decreased and there was a lower “failure-to-rescue” (defined as mortality rate among patients having a postoperative complication) rate when residents were involved with patients undergoing oncologic surgery. Of those in the general public group of our survey who actually reported being treated by a resident as a patient, 17% endorsed receiving care of lesser quality because of resident involvement. Other studies have found no increase in complication or morbidity with residents involved.15,16 To our knowledge, there have been no prospective studies looking at the effect of resident involvement on surgical patient outcomes. Others have also pointed out that there are no studies evaluating the effect of insufficiently trained surgeons.12 In our survey, 80% or greater percentage of residents, faculty, and hospital administrators believe that residents improve the quality of patient care. Our study does have some limitations. First, response rates for residents and faculty were 60% and 68%, respectively. Although these response rates are generally considered appropriate according to published standards,33 this does open our results to a nonresponder bias. Second, the general public group was a convenience sample of nonmedical persons encountered by the investigators. Although we did not collect demographic data other than education level, this likely does not represent an ideal cross-
Journal of Surgical Education Volume 72/Number 6 November/December 2015
e199
section to represent all viewpoints. Despite this limitation, the general public sample does represent the views of a group of nonmedical persons toward surgical care involving residents. To our knowledge, this has not been attempted before. Despite these limitations, the strength of our study is that it characterizes the views of resident autonomy from the perspective of the 4 major groups who have a stake in surgical resident training.
6. ACS. Transition to practice program in general sur-
gery: American college of surgerons; division of education. Available at: 〈http://www.facs.org/ttp/index. html〉. Accessed 09.03.13. 7. Chalabian J, Bremner R. The effects of programmatic
change on resident motivation. Surgery. 1998;123 (5):511-517. 8. Santry HP, Chokshi N, Datrice N, Guitron J, Moller
MG. General surgery training and the demise of the general surgeon. Bull Am Coll Surg. 2008;93(7):32-38.
CONCLUSION Surgery residents experience less opportunity for autonomy than in the past, and this may be inadequate for appropriate training. Faculty development programs with a focus on highlighting practices that help protect resident autonomy while still maintaining patient safety and reimbursement standards are needed. Barriers to autonomy identified by our survey include reimbursement regulations, concerns regarding the effect of resident participation on quality of care, the general public’s increasing concern with resident participation with routine or complex procedures, and the general public’s willingness to consent for chief residents to perform procedures independently. Despite this, the general public was more willing to have residents involved in their care than faculty, residents, and hospital administrators thought they would be. In an effort to facilitate resident training, patient education regarding resident involvement, roles, and responsibilities may help to bridge the gap between faculty-resident views and patient expectations.
9. Arriaga AF, Elbardissi AW, Regenbogen SE, Green-
berg CC, Berry WR, Lipsitz S. A policy-based intervention for the reduction of communication breakdowns in inpatient surgical care: results from a Harvard surgical safety collaborative. Ann Surg. 2011; 253(5):849-854. 10. Babbott S. Commentary: watching closely at a dis-
tance: key tenstions in supervising resident physicians. Acad Med. 2010;85(9):1399-1400. 11. Asch DA, Parker RM. The Libby Zion case. One step
forward or two steps backward. N Engl J Med. 1988;318(12):771-775. 12. 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. 13. Phitayakorn R, Williams RG, Yudkowsky R, et al.
Patient-care–related telephone communication between general surgery residents and attending surgeons. J Am Coll Surg. 2008;206(4):742-750.
REFERENCES 1. Kusurkar R, ten Cate O. AM last page: education is
not filling a bucket, but lighting a fire: self-determination theory and motivation in medical students. Acad Med. 2013;88(6):904.
2. Lewis FR, Klingensmith ME. Issues in general surgery
residency training—2012. Ann Surg. 2012;256(4): 553-559. 3. ACGME Program Requirements for Graduate Medical
Education in General Surgery. Available at: 〈http:// www.acgme.org/acgmeweb/tabid/150/ProgramandIn stitutionalAccreditation/SurgicalSpecialties/Surgery. aspx〉; 2012 Accessed 30.2.15.
4. Sachdeva AK, Bell RH, Britt LD, Tarpley JL, Gabler
14. Raja AJ, Levin AV. Challenges of teaching surgery:
ethical framework. World J Surg. 2003;27(8):948-951. 15. Hernandez-Irizarry R, Zendejas B, Ali SM, Lohse CM,
Farley DR. Impact of resident participation on laparoscopic inguinal hernia repairs: are residents slowing us down? J Surg Educ. 2012;69(6):746-752. 16. Patel SP, Gauger PG, Brown DL, Englesbe MJ,
Cederna PS. Resident participation does not affect surgical outcomes, despite introduction of new techniques. J Am Coll Surg. 2010;211(4):540-545. 17. ten Cate O. Trust, competence, and the supervisor’s role in postgraduate training. Br Med J. 2006;333 (7571):748-751.
Blair P, Tarpley MG. National efforts to reform residency education in surgery. Acad Med. 2007;82 (12):1200-1210.
18. ten Cate O, Scheele F. Competency-based postgraduate
5. Greene FL. Transition to practice: a bold move.
19. Sterkenburg A, Barach P, Kalkman C, Gielen M, ten
General Surgery News. 2013;40(N3):1. e200
training: can we bridge the gap between theory and clinical practice? Acad Med. 2007;82(6):542-547. Cate O. When do supervising physicians decide to
Journal of Surgical Education Volume 72/Number 6 November/December 2015
entrust residents with unsupervised tasks? Acad Med. 2010;85(9):1408-1417. 20. ten Cate O, Snell L, Carraccio C. Medical compe-
tence: the interplay between individual ability and the health care environment. Med Teach. 2010;32(8): 669-675. 21. “autonomy”: Merriam-webster.com. Available at: 〈http://
www.merrriam-webster.com/dictionary/autonomy〉; 2015 Accessed 02.10.15.
27. Kim HN, Gates E, Lo B. What hysterectomy patients
want to know about the roles of residents and medical students in their care. Acad Med. 1998;73(3):339-341. 28. Castleberry AW, Clary BM, Migaly J, et al. Resident
education in the era of patient safety: a nationwide analysis of outcomes and complications in residentassisted oncologic surgery. Ann Surg Oncol. 2013;20 (12):3715-3724. 29. Schoenfeld AJ, Serrano JA, Waterman BR, Bader JO,
do patient care on my own: autonomy and the manager role. Acad Med. 2009;84(11):1516-1521.
Belmon PJ Jr. The impact of resident involvement on post-operative morbidity and mortality following orthopaedic procedures: a study of 43,343 cases. Arch Orthop Trauma Surg. 2013;133(11):1483-1491.
23. ACGME.org. Resident duty hours in the learning and
30. Jannuzzi JC, Chandra A, Rickles AS, et al. Resident
22. Hinchey KT, Iwata I, Picchioni M, McArdle PJ. I can
working environment. Comparison of 2003 and 2011. Available at: 〈https://www.acgme.org/acgmeweb/Portals/ 0/PDFs/dh-ComparisonTable2003v2011.pdf〉; Accessed 02.12.15. 24. Chen XP, Williams RG, Sanfey HA, Dunnington GL.
How do supervisiong surgeons evaluate guidance in the operating room? Am J Surg. 2012;203(1):44-48. 25. Reichgott MJ, Schwartz JS. Acceptance by private
patients of resident involvement in their outpatient care. J Med Educ. 1983;58(9):703-709. 26. O’Malley PG, Omori DM, Landry FJ, Jackson J,
Kroenke K. A prospective study to assess the effect of ambulatory teaching on patient satisfaction. Acad Med. 1997;72(11):1015-1017.
involvement is associated with worse outcomes after major lower extremity amputation. J Vasc Surg. 2013;58(3):827-831. 31. Davis SS Jr, Husain FA, Lin E, Nandipati KC, Perez S,
Sweeney JF. Resident participation in index laparoscopic general surgical cases: impact of the learning environment on surgical outcomes. J Am Coll Surg. 2013;216(1):96-104. 32. Scarborough JE, Bennett KM, Pappas TN. Defining
the impact of resident participation on outcomes after appendectomy. Ann Surg. 2012;255(3):577-582. 33. Kittleson
MJ. Determining effective follow-up of e-mail surveys. Am J Health Beh. 1997;21(3): 193-196.
SUPPLEMENTARY INFORMATION Supplementary data associated with this article can be found in the online version at http://dx.doi.org/10.1016/j.jsurg. 2015.06.002.
Journal of Surgical Education Volume 72/Number 6 November/December 2015
e201
How do Perceptions of Autonomy Differ in General Surgery Training Between Faculty, Senior Residents, Hospital Administrators, and the General Public? A Multi-Institutional Study Jason W. Kempenich, MD,* Ross E. Willis, PhD,† Robert Rakosi, MD,* John Wiersch, MD,† and Paul Joseph Schenarts, MD‡ Department of General Surgery, Keesler Medical Center, Biloxi, Mississippi; †Department of Surgery, University of Texas Health Science Center of San Antonio, San Antonio, Texas; and ‡Division of Surgery, University of Nebraska Medical Center, Omaha, Nebraska *
OBJECTIVE: Identify barriers to resident autonomy in
today’s educational environment as perceived through 4 selected groups: senior surgical residents, teaching faculty, hospital administration, and the general public. DESIGN: Anonymous surveys were created and distributed to senior residents, faculty, and hospital administrators working within 3 residency programs. The opinions of a convenience sample of the general public were also assessed using a similar survey. SETTING: Keesler Medical Center, Keesler AFB, MS; the
University of Texas Health Science of San Antonio, TX; and the University of Nebraska Medical Center, Omaha, NE. PARTICIPANTS: A total of 169 responses were collected:
32 residents, 50 faculty, 20 administrators, and 67 general public. RESULTS: Faculty and residents agree that when attending
staff grant more autonomy, residents’ self-confidence and sense of ownership improve. Faculty felt that residents should have less autonomy than residents did (p o 0.001). When asked to reflect on the current level of autonomy at their institution, 47% of residents felt that they had too little autonomy and 38% of faculty agreed.
No resident or faculty felt that residents had too much autonomy at their institution. The general public were more welcoming of resident participation than faculty (p ¼ 0.002) and administrators (p ¼ 0.02) predicted they would be. When the general public were asked regarding their opinions about resident participation with complex procedures, they were less welcoming than faculty, administrators, and residents thought (p o 0.001). The general public were less likely to think that resident involvement would improve their quality of care (p o 0.001). CONCLUSION: Faculty and senior residents both endorse resident autonomy as important for resident development. The general public are more receptive to resident participation than anticipated. However, with increasing procedural complexity and resident independence, they were less inclined to have residents involved. The general public also had more concerns regarding quality of care provided by residents than the other groups had. ( J Surg 72:e193-e201. Published by Elsevier Inc on behalf of the Association of Program Directors in Surgery) KEY WORDS: graduate surgical education ownership, patient care, autonomy COMPETENCIES: Patient Care, Professionalism, Interper-
sonal and Communication Skills Disclaimer: The views expressed in this article are those of the authors and do not reflect the official policy or position of the U.S. Government, the Department of Defense, or the Department of the Air Force. The work reported herein was performed under United States Air Force Surgeon General approved Clinical Investigation No. FKE20140018E. Correspondence: Inquiries to Jason Kempenich, MD, Department of General Surgery, Keesler Medical Center, 301 Fisher Street Keesler AFB, MS 39534; E-mail: jason. [email protected], [email protected]
INTRODUCTION Self-determination theory states that human beings have a natural tendency to develop toward autonomous behavior,
Journal of Surgical Education Published by Elsevier Inc on behalf of the Association of 1931-7204/$30.00 e193 Program Directors in Surgery http://dx.doi.org/10.1016/j.jsurg.2015.06.002
and those who are able to act autonomously learn better and achieve superior performance.1 The Halstead method2 for graduate medical education and the Accreditation Council for Graduate Medical Education Program Requirements for Graduate Medical Education in General Surgery3 both support gradually giving the surgical resident increasing levels of responsibility and autonomy as they approach graduation in preparation for independent practice. This method for resident education has been successfully producing excellent surgeons for more than 100 years.4 More recently, there have been mounting concerns regarding the preparedness of general surgery graduates for independent practice owing to a lack of autonomy in their training.5 This concern has culminated with the American College of Surgeons creating the “Transition to Practice Program in General Surgery” that was developed to “help fill the perceived gaps in training today.” The first cited goal of the experience is to “obtain enhanced autonomous experience in broad-based general surgery.”6 In addition to creating the Transition to Practice Program, over the last 3 decades, the number of residents seeking fellowship training after residency has slowly increased and exceeds 80%, causing some to attribute this trend to the lack of autonomy in residency.2 The perception of lost autonomy in surgical residency has been a mounting problem over the past 30 years. Multiple factors have been implicated and include the 80-hour work week,2 new and innovative technologies being applied to general surgery,2 financial constraints,7,8 legal limitations,9 quality of patient care,10 and public opinion.11 In a recent survey of attending surgeons by Minter et al.12 investigating autonomy given in the operating room (OR), factors that promoted autonomy included resident skill and faculty comfort with the procedure. The most commonly cited reasons for limiting autonomy included increased focus on patient outcomes and expectation of surgeon involvement by patients and hospitals. In a survey addressing barriers to resident-attending communication with the goal of improving patient safety, one barrier cited was resident fear of losing autonomy.13 Granting autonomy to a trainee is made more difficult in the medical profession by the potential for pain and suffering of the patient because of a complication. However, many studies show at least equivalent outcomes as compared with nonteaching institutions.14-16 Ten Cate17 points out that trust is developed between a resident and supervisor when a competent resident executes a task when appropriate. This not only builds trust but is also a definition for performance, i.e., not only being competent to do a task, but executing a task when it is appropriate to do so. Most supervisors can identify which residents they trust, even if they cannot identify why. Without trust, it is difficult for supervisors to extend sufficient autonomy to residents. In the current educational climate, there is increasing focus on achieving competency. This is evidenced by the e194
core competencies and milestones mandated by the Accreditation Council for Graduate Medical Education.3 There are also multiple articles in the literature attempting to evaluate entrustable professional activities.12,17-20 Both of these are attempts to measure a resident’s ability and trustworthiness for increasing levels of independence in an effort to guide faculty regarding when to grant the appropriate level of independence at the appropriate time in resident training. The issue of resident autonomy in education is multifaceted and involves not only the resident and teaching faculty but also the patient who is under the care of the surgical teaching service. Hospital administrators are also indirectly affected by standards for supervision of residents concerning reimbursement as well as quality, safety, and liability concerns. The aim of this study was to evaluate the perceptions regarding resident autonomy from the perspective of the surgical trainee, surgical instructor, hospital administrator, and the general public. We hypothesized that the perceptions of the resident and the faculty surgeon would be more closely allied than those of the hospital administration or the general public. Our second hypothesis was that residents and faculty would favor more autonomy in training when compared with hospital administration and the general public.
MATERIALS AND METHODS For this study, surgery residents, teaching faculty, and hospital administrators were surveyed at each of 3 general surgery resident training programs: Keesler Medical Center, the University of Nebraska Medical Center, and the University of Texas Health Science Center at San Antonio. Institutional review board approval was obtained at Keesler Medical Center before commencement of the study. The resident group was limited to general surgery residents in clinical postgraduate year 3 (PGY3) to PGY5. The hospital administration group surveyed was composed of the Chief Medical Officer; Chief Nurse; Chief Legal Counsel; Head of Quality; and Chief Executive Officer, President, or Vice President (or equivalent) of any hospital that was associated with training residents from 1 of the 3 participating training programs. The general public group was a convenience sample of adult (Z18 y of age) nonmedical persons encountered by the investigators through association (e.g., neighbors and community groups). There were no other exclusion criteria. Similar surveys were created for each of the 4 groups (Appendix). Each survey was specific to the appropriate group of participants, but the questions were constructed to be similar to the other groups for purposes of comparison. A 5-point Likert scale was used for all questions except 2 questions asking the participant to rate the degree of independence appropriate on a scale from 0 to 10 for a
Journal of Surgical Education Volume 72/Number 6 November/December 2015
TABLE 1. Population Characteristics: Faculty, Administrators, and Residents
Hospital work experience* University University-affiliated community hospital Non–university-affiliated community hospital Veterans affairs/military Other Years of experience working in a teaching hospital 0-5 y 6-10 y 11-15 y 16-20 y 420 y
Faculty (%) (n ¼ 50)
Administrators (%) (n ¼ 20)
70 30 20 66 0
50 20 20 60 0
34 16 20 8 22
20 35 10 10 25
Residents (n ¼ 32) 100% 53% 50% 91% 3% PGY3 31.25% PGY4 37.5% PGY5 31.25%
*Multiple items could be marked for this question.
junior resident (PGY2) and a chief resident (PGY5). The resident and faculty surveys consisted of 15 questions, and the administrator and general public surveys had 12 questions. Each survey was piloted and feedback was solicited from representative individuals of each group. The survey was then finalized after discussion and agreement among the investigators. The resident, faculty, and administrator groups were solicited by e-mail and responses were collected anonymously through the SurveyMonkey website. The general public were solicited directly in person, and no personally identifiable information was collected. There was no compensation or reward for participation. Responses were compiled for each survey group, and the median response for each question was calculated. The Kruskal-Wallis test was then used to analyze the distribution of responses between the survey groups. In cases where a significant difference was identified, the Mann-Whitney U test was used for pairwise comparisons. For the general public survey, we analyzed 3 questions regarding resident participation using the Friedman test with pairwise comparisons using the Wilcoxon signed rank test.
residents require autonomy in training to develop into an attending surgeon. Most faculty (94%) and residents (92%) agreed or strongly agreed that when attending staff grant more autonomy, self-confidence improves. Conversely, when resident independence is reduced, both faculty and residents agreed or strongly agreed that this decreases resident sense of ownership for patient care (92% and 100%, respectively). Teaching faculty, hospital administrators, and senior residents were asked to rate on a scale of 0 to 10 (0 being no independence and 10 the most) the appropriate degree of independence for a chief resident (PGY5) and a junior resident (PGY2). The medians were the same among each group surveyed for chief resident independence (i.e., all medians ¼ 10, indicating a very high level) and similar for junior resident independence (i.e., medians varied between 4 and 5, indicating a moderate level; Table 3). The KruskalWallis test was performed to evaluate the distribution of responses and were found to be significantly different among the 3 groups surveyed for chief residents (p ¼ 0.003) and junior residents (p o 0.001; Table 3). Pairwise TABLE 2. General Public Characteristics
RESULTS A total of 169 responses were collected; 32 residents, 50 faculty, 20 administrators, and 67 from the general public. Response rates for residents, faculty, and administrators were 60%, 68%, and 91%, respectively. Response rate for the general public could not be calculated. Population characteristics are displayed in Tables 1 and 2. Faculty’s, Residents’, and Hospital Administrators’ Views of Autonomy for Residents in Training Of the faculty, residents, and administrators surveyed, 98%, 97%, and 95%, respectively, agreed or strongly agreed that
General Public (%) (n ¼ 67) Age 18-30 31-40 41-50 51-60 460 Highest education level achieved High school, nongraduate High school graduate Some college Associate or tech degree Bachelor’s degree Master’s degree Doctorate or equivalent
Journal of Surgical Education Volume 72/Number 6 November/December 2015
40.3 17.9 10.5 17.9 13.4 1.5 7.5 29.9 7.5 44.8 7.5 1.5 e195
TABLE 3. Appropriate Level of Independence for a Chief (PGY5) and Junior Resident (PGY2) on a Scale of 0-10 PGY5 Median Faculty 0-10 y 11þ y Administrators Residents
PGY5 Mean Rank*
10 (4-10) 10 (7-10) 9 (4-9) 10 (0-10) 10 (5-10) Median (range)
42.02 55.50 62.36 p ¼ 0.003
n
PGY2 Median
PGY2 Mean Rank*
n
50 25 25 19 32
4 (0-6)
38.75
50
5 (0-6) 5 (2-8) Median (range)
65.84 61.33 p o 0.001
19 32
*The Kruskal-Wallis test.
comparisons using the Mann-Whitney U test revealed that faculty rated the appropriate level of autonomy for a chief resident lower than the senior residents did (p ¼ 0.001). This effect was more pronounced with greater than 10 years of experience as teaching faculty, with a median of 9 years (p ¼ 0.003; Table 3). Faculty also rated the appropriate level of autonomy for a junior resident lower than residents (p o 0.001) and administrators did (p ¼ 0.001). When asked to reflect on the current level of autonomy at their institution, 53% of residents felt it was appropriate, 41% felt they had too little autonomy, and 6% felt it was far too little. Faculty felt similarly regarding resident autonomy currently at their institution; 62% felt it was appropriate, 32% felt it was too little, and 6% felt it was far too little. There was no significant difference between residents and faculty. The effect was magnified with more experience. Those faculty with greater than 10 years of experience were more likely to think that residents have too little autonomy (p ¼ 0.05) when compared with their junior faculty counterparts. No senior resident or faculty surveyed felt that residents had too much autonomy at their institution. Perceptions of the Effect of Regulation on Reimbursement and Resident Autonomy Faculty and administrators were asked if they felt regulations regarding reimbursement were responsible for decreased resident autonomy. Overall, 70% of faculty agreed or strongly agreed, compared with 35% of administrators. Pairwise comparisons using the Mann-Whitney U test found this to be statistically significant (p ¼ 0.01). Of faculty with greater than 10 years of experience in teaching, the effect was even more pronounced with a median of “strongly agree” compared with junior faculty who had a median of “agree.” The Mann-Whitney U test was performed, and the
difference was statistically significant (p ¼ 0.04). These data indicate that faculty felt that resident autonomy was limited by reimbursement regulation more than administrators did, particularly faculty with greater than 10 years of experience in teaching. General Public’s Views on Resident Participation in Their Health Care The general public group was asked if it would welcome resident participation in their health care, and 95.5% strongly agreed or agreed. Teaching faculty, residents, and hospital administrators were asked their perception of patients’ receptiveness to resident participation in their health care. The Kruskal-Wallis test showed that there was a statistically significant difference in receptiveness or perception of receptiveness to having residents participate in patient care between the different populations (p ¼ 0.01; Table 4). Pairwise comparisons using the Mann-Whitney U test revealed that the general public had significantly higher ratings for patient involvement than administrators (p ¼ 0.02) and faculty (p ¼ 0.002) did. This indicates that the general public have more favorable views of resident participation in patient care than administrators and faculty perceive they do. There was no significant difference in responses when analyzing the general public’s responses based on having personally received care from a resident vs not. Views of Resident Autonomy in the OR Residents, faculty, administrators, and the general public were asked if a resident should perform surgical procedures independently before graduation. Residents surveyed were in the most agreement, with 96.9% that agreed or strongly agreed. The data are displayed in Table 5. The Kruskal-Wallis
TABLE 4. Patients' Welcome Resident Participation in Their Health Care
Public Faculty Residents Admin
Strongly Disagreed (%)
Disagreed (%)
Neutral (%)
Agreed (%)
Strongly Agreed (%)
n
Mean Rank*
1.5 0 0 0
0 4 0 0
3 14 12.5 10
58.2 66 62.5 80
37.3 16 25 10
67 50 32 20
97.77 73.17 83.7 73.9
*The Kruskal-Wallis test, p ¼ 0.01. e196
Journal of Surgical Education Volume 72/Number 6 November/December 2015
TABLE 5. Views of Resident Performing Surgical Procedures Independently Strongly Disagreed
Disagreed
Neutral
Agreed
Strongly Agreed
n
Should residents perform surgical procedures independently before graduation? Residents 3.1% 0% 0% 21.9% 75% 32 Faculty 0% 2% 6% 44% 48% 50 Admin 5% 0% 0% 50% 45% 20 Public 1.5% 7.5% 10.5% 44.8% 35.8% 67 If I needed a routine procedure, I would consent to a PGY5 resident performing my procedure independently. Public 1.5% 9% 16.4% 52.2% 20.9% 67 If I have surgery, I want to know how much of the procedure is going to be done by the resident. Public 1.5% 10.5% 26.9% 38.8% 22.4% 67
Mean Rank* 108.63 86.68 85.15 72.42
*The Kruskal-Wallis test, p ¼ 0.002.
test indicated a significant difference in response distribution (p ¼ 0.002; Table 5). Pairwise comparisons with the MannWhitney U test revealed that residents had significantly more positive views of the need for independent operating experience than faculty (p ¼ 0.02), administrators (p ¼ 0.04), and the general public (p o 0.001) had. These data indicate that faculty, administrators, and the general public feel less strongly about the need for residents to perform procedures independently than residents did. The general public were asked if they would consent to a resident participating in their care and assisting if they had to have routine surgical procedure, and 82.1% agreed or strongly agreed. We then asked the same question but qualified the procedure as complex, and 59.1% agreed or strongly agreed. On comparing the general public’s responses to welcoming resident participation, vs resident participation with a routine procedure, vs a complex procedure using the Friedman test, a statistically significant difference (p o 0.001) was noted. Pairwise comparisons of all 3 questions were statistically significant. This means that as we specified resident involvement from general participation to surgical procedures with increasing complexity, the general public were less willing to consent. The general public were then asked if they would agree to resident participation if they could be assured that surgical outcomes would be the same or better; 94% agreed or strongly agreed.
The general public were then asked if they would consent to a resident, in the final year of training, performing surgery independently on them if it was a routine procedure, and 73.1% agreed or strongly agreed (Table 5). We compared the general public’s opinion regarding the need for residents to perform surgical procedures independently before graduation and actually consenting for a PGY5 resident to perform a routine procedure independently. The general public were less enthusiastic for residents to perform procedures if they had to consent for it personally (p ¼ 0.05). In addition, most of the general public want to be informed regarding how much of their procedure will be done by a resident (Table 5). Perceptions of Resident Participation Effect on Quality of Patient Care Teaching faculty, residents, hospital administrators, and the general public were all queried regarding the effect of resident participation in patient care and the effect on quality of care provided (Table 6). When the general public were asked if quality of care was better with residents involved, only 3% strongly disagreed or disagreed. However, the Kruskal-Wallis test showed a statistically significant difference in quality-of-care perceptions between the different populations (p o 0.001; Table 6). Pairwise comparisons
TABLE 6. Residents’ Participation and Perceptions of Quality of Care Resident Involvement in Patient Care has Which Effect on Quality of Care Provided?
Faculty Residents Admin
Significantly Worsens (%)
Worsens (%)
No effect (%)
Improves (%)
Significantly Improves (%)
n
0 0 0
2 0 10
12 6.25 10
74 56.25 50
12 37.5 30
50 32 20
Mean Rank* 91.78 112.78 96.65
My Overall Hospital and Surgical Care is of Better Quality With Residents Involved.
Public
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
n
Mean Rank*
1.5%
1.5%
50%
40.9%
6.1%
66
61.59
*The Kruskal-Wallis test, p o 0.001. Journal of Surgical Education Volume 72/Number 6 November/December 2015
e197
using the Mann-Whitney U test revealed that with residents involved, the general public think that quality of care would be lower than what faculty (p o 0.001), residents (p o 0.001), and administrators (p ¼ 0.01) thought. Faculty also thought quality of care was lower with residents involved than residents did (p ¼ 0.01). Those in the general public who answered “yes” to having received health care from a resident were asked if they had personally received health care of lesser quality because of resident participation (n ¼ 29); 82.8% disagreed or strongly disagreed, 0% neutral, and 17.2% agreed or strongly agreed. When compared with faculty’s, residents’, and administrators’ opinions on the effect of resident involvement on quality of care vs patients reporting of health care of lesser quality received, there is a statistically significant difference between populations using the Kruskal-Wallis test (p o 0.001). Pairwise comparison using the Mann-Whitney U test also revealed that the general public believe that the quality of care they personally receive with residents involved is lower than faculty (p o 0.001), residents (p o 0.001), and administrators (p o 0.001) perceive it is. Results Summary Most of teaching faculty, administrators, and senior residents think that autonomy in resident training is important for developing attending surgeons as well as residents’ sense of patient ownership and self-confidence. Faculty rate the appropriate level of autonomy for residents lower than residents do, especially faculty with greater than 10 years of teaching experience. No teaching faculty or resident thought that residents have too much autonomy at their institution. The general public are more receptive to resident involvement than teaching faculty and administrators anticipate. Barriers to autonomy cited in our survey include regulations on reimbursement, the general public’s concerns with resident participation in complex procedures, chief residents performing procedures independently, and concerns regarding quality of care provided by residents.
DISCUSSION Autonomy is defined by Merriam-Webster’s Dictionary as, “the quality or state of being independent, free, and selfdirecting.”21 In resident training, others have defined autonomous practice as, “…both patient ownership and the active direction of one’s own learning.”22 Certainly, patient ownership and independence are important for surgical resident training, and our survey results support that 490% of faculty, residents, and hospital administrators recognize the importance of autonomy in training and that allowing for resident independence leads to residents taking greater ownership of patient care and improved selfconfidence. e198
The issue of resident autonomy or independence becomes more complicated when discussing how much autonomy should be allowed to a resident. Although residents and faculty had similar expectations for graded increases in autonomy when comparing a second-year resident and a chief resident, faculty consistently rated the appropriate level of independence lower than residents did. In a study by Sterkenburg et al.19 looking at when teaching physicians decide to entrust unsupervised tasks, teaching faculty consistently rated resident competence lower than residents did. They go on to suggest that “…it may be necessary for residents to overestimate their ability from a confidence issue to stimulate learning.” Although it may be appropriate for residents to think they are capable of functioning with more independence than those instructing them, it is worth noting that no faculty or resident in our survey felt that residents had too much autonomy at their institution, and 47% of residents and 38% of faculty felt there was not enough autonomy provided. This may suggest that the pendulum has swung definitively toward inadequate levels of autonomy for residents training in today’s educational environment. Although asking trainees to perform tasks far above their ability may set them up for failure, conversely, not challenging them with appropriate responsibility and independence can also lead to stunted learning and developement.2,7,19 Interestingly, we found that teaching faculty with greater than 10 years of experience in teaching surgery residents rated appropriate levels for chief surgery resident independence lower than their more-junior faculty counterparts did. Conversely, faculty with greater than 10 years of experience were more likely to think that residents at their institution currently have too little autonomy when compared with junior faculty. The reason for this dichotomy is unclear. More-senior teaching faculty may have a different reference point for resident independence based on a different educational environment when they trained. The grand jury recommendations from the Libby Zion case that have been the framework for many of the supervision and workhour reforms instituted for graduate medical education were released in 1986, and full implementation was not completed until 2011.11,23 Faculty with less than 10 years of teaching experience may have been residents under workhour and supervision reforms, and at a minimum, these reforms have been in place as long as they have been teaching faculty. Another possibility is that faculty with more experience have also seen more examples of resident misadventure if given too much independence. External regulations have been cited as a reason for decreasing autonomy in surgical education.2,12 Our study revealed this to be a significant concern among teaching faculty who believed regulations on reimbursement to have a negative effect on resident autonomy. In a study evaluating the amount of guidance supervising surgeons provide in the OR, it was found that faculty tend to
Journal of Surgical Education Volume 72/Number 6 November/December 2015
underestimate the amount of guidance they provide to residents.24 External regulations have necessitated increased attending surgeon presence in the OR, and this may have led to decreased resident autonomy, as the OR staff and resident naturally defer to the attending surgeon. Chalabian and Bremner7 performed a survey of surgery residents in the late 1990s, which revealed that 71% of residents felt that “…mandatory attending presence in the OR was bad.” Maintaining adequate supervision for reimbursement and patient safety is necessary, but this may be an area for future faculty development with concentration on creating a supervised OR environment where resident autonomy is still respected. We were encouraged to find that 495% of the general public group we surveyed would welcome resident participation in their care. A previous study performed in 1983 surveyed private internal medicine patients and found that 73% would allow resident participation in their care.25 They also performed a retrospective survey of patients who received care from residents and found that 70% were fully satisfied and 20% were partially satisfied. In 1996, O’Malley et al.26 surveyed patients after their visit at a general medicine clinic and found that 95% would be willing to see a resident again. Our survey results in addition to these studies support that the general public as well as those who become patients of residents are amenable to resident involvement. When we specifically asked the general public group if they welcome resident participation vs would they consent to resident participation if they had to have a routine vs complex surgical procedure, we saw a statistically significant change toward more negative responses. We anticipated that the general public would be more apprehensive regarding resident participation with complex procedures, but we would have anticipated that routine procedures would have been more closely allied with the public’s responses to resident participation in general. However, if one could ensure patients that outcomes would be the same or better with resident participation, then the general public were much more receptive to resident involvement with their procedure. In a survey of patients who underwent hysterectomy where 100% of the patients had a resident involved in their care, only 63% of the patients who responded to the survey were aware and 80% wanted to know what a resident would do during their operation and how they would be supervised.27 Overall, 61% of the general public group in our survey wanted to know what parts of the procedure would be done by a resident. We feel that the general public may be more negative toward resident participation with surgical procedures because they have not been educated regarding the residents’ role and level of participation in their procedure. Reichgott and Schwartz25 found in their survey of patients that most of the negative responses to resident participation were the result of patients not being aware that a resident was involved in their care. Attention to this issue may allow teaching faculty to assuage patient fears.
Residents we surveyed felt most strongly that performing procedures independently before graduation was important, with 496% responding “agree” or “strongly agree.” Chalabian and Bremner7 found similar results in a survey of 4 Los Angeles residencies almost 20 years ago, where 96% of chief residents felt that independent operative experience was important for surgical training. Although most of the teaching faculty, administrators, and the general public in our study felt that residents should perform procedures independently before graduation, their responses were less enthusiastic. Of the general public group, 80.6% agreed or strongly agreed that residents need to perform procedures independently before graduation. When asked if they would consent to a PGY5 resident performing a routine procedure independently on them, less agreed (73.1%; p ¼ 0.05). All 4 populations in our study were asked to rate the effect of residents on the quality of care patients receive. Residents were the most optimistic regarding the quality of care they provide patients, but even the general public group, the most pessimistic of the 4 groups, had only 3% of responses indicating that residents had a negative effect on quality of care. Overall, 50% of the general public group in our survey felt that residents had no effect on quality of care. Multiple retrospective studies have been recently published analyzing the data from the American College of Surgeons National Surgical Quality Improvement Program showing increased morbidity and complication rates when residents are involved.28-32 Castleberry et al.28 found that although there was increased morbidity with residents involved, the 30-day mortality rate was decreased and there was a lower “failure-to-rescue” (defined as mortality rate among patients having a postoperative complication) rate when residents were involved with patients undergoing oncologic surgery. Of those in the general public group of our survey who actually reported being treated by a resident as a patient, 17% endorsed receiving care of lesser quality because of resident involvement. Other studies have found no increase in complication or morbidity with residents involved.15,16 To our knowledge, there have been no prospective studies looking at the effect of resident involvement on surgical patient outcomes. Others have also pointed out that there are no studies evaluating the effect of insufficiently trained surgeons.12 In our survey, 80% or greater percentage of residents, faculty, and hospital administrators believe that residents improve the quality of patient care. Our study does have some limitations. First, response rates for residents and faculty were 60% and 68%, respectively. Although these response rates are generally considered appropriate according to published standards,33 this does open our results to a nonresponder bias. Second, the general public group was a convenience sample of nonmedical persons encountered by the investigators. Although we did not collect demographic data other than education level, this likely does not represent an ideal cross-
Journal of Surgical Education Volume 72/Number 6 November/December 2015
e199
section to represent all viewpoints. Despite this limitation, the general public sample does represent the views of a group of nonmedical persons toward surgical care involving residents. To our knowledge, this has not been attempted before. Despite these limitations, the strength of our study is that it characterizes the views of resident autonomy from the perspective of the 4 major groups who have a stake in surgical resident training.
6. ACS. Transition to practice program in general sur-
gery: American college of surgerons; division of education. Available at: 〈http://www.facs.org/ttp/index. html〉. Accessed 09.03.13. 7. Chalabian J, Bremner R. The effects of programmatic
change on resident motivation. Surgery. 1998;123 (5):511-517. 8. Santry HP, Chokshi N, Datrice N, Guitron J, Moller
MG. General surgery training and the demise of the general surgeon. Bull Am Coll Surg. 2008;93(7):32-38.
CONCLUSION Surgery residents experience less opportunity for autonomy than in the past, and this may be inadequate for appropriate training. Faculty development programs with a focus on highlighting practices that help protect resident autonomy while still maintaining patient safety and reimbursement standards are needed. Barriers to autonomy identified by our survey include reimbursement regulations, concerns regarding the effect of resident participation on quality of care, the general public’s increasing concern with resident participation with routine or complex procedures, and the general public’s willingness to consent for chief residents to perform procedures independently. Despite this, the general public was more willing to have residents involved in their care than faculty, residents, and hospital administrators thought they would be. In an effort to facilitate resident training, patient education regarding resident involvement, roles, and responsibilities may help to bridge the gap between faculty-resident views and patient expectations.
9. Arriaga AF, Elbardissi AW, Regenbogen SE, Green-
berg CC, Berry WR, Lipsitz S. A policy-based intervention for the reduction of communication breakdowns in inpatient surgical care: results from a Harvard surgical safety collaborative. Ann Surg. 2011; 253(5):849-854. 10. Babbott S. Commentary: watching closely at a dis-
tance: key tenstions in supervising resident physicians. Acad Med. 2010;85(9):1399-1400. 11. Asch DA, Parker RM. The Libby Zion case. One step
forward or two steps backward. N Engl J Med. 1988;318(12):771-775. 12. 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. 13. Phitayakorn R, Williams RG, Yudkowsky R, et al.
Patient-care–related telephone communication between general surgery residents and attending surgeons. J Am Coll Surg. 2008;206(4):742-750.
REFERENCES 1. Kusurkar R, ten Cate O. AM last page: education is
not filling a bucket, but lighting a fire: self-determination theory and motivation in medical students. Acad Med. 2013;88(6):904.
2. Lewis FR, Klingensmith ME. Issues in general surgery
residency training—2012. Ann Surg. 2012;256(4): 553-559. 3. ACGME Program Requirements for Graduate Medical
Education in General Surgery. Available at: 〈http:// www.acgme.org/acgmeweb/tabid/150/ProgramandIn stitutionalAccreditation/SurgicalSpecialties/Surgery. aspx〉; 2012 Accessed 30.2.15.
4. Sachdeva AK, Bell RH, Britt LD, Tarpley JL, Gabler
14. Raja AJ, Levin AV. Challenges of teaching surgery:
ethical framework. World J Surg. 2003;27(8):948-951. 15. Hernandez-Irizarry R, Zendejas B, Ali SM, Lohse CM,
Farley DR. Impact of resident participation on laparoscopic inguinal hernia repairs: are residents slowing us down? J Surg Educ. 2012;69(6):746-752. 16. Patel SP, Gauger PG, Brown DL, Englesbe MJ,
Cederna PS. Resident participation does not affect surgical outcomes, despite introduction of new techniques. J Am Coll Surg. 2010;211(4):540-545. 17. ten Cate O. Trust, competence, and the supervisor’s role in postgraduate training. Br Med J. 2006;333 (7571):748-751.
Blair P, Tarpley MG. National efforts to reform residency education in surgery. Acad Med. 2007;82 (12):1200-1210.
18. ten Cate O, Scheele F. Competency-based postgraduate
5. Greene FL. Transition to practice: a bold move.
19. Sterkenburg A, Barach P, Kalkman C, Gielen M, ten
General Surgery News. 2013;40(N3):1. e200
training: can we bridge the gap between theory and clinical practice? Acad Med. 2007;82(6):542-547. Cate O. When do supervising physicians decide to
Journal of Surgical Education Volume 72/Number 6 November/December 2015
entrust residents with unsupervised tasks? Acad Med. 2010;85(9):1408-1417. 20. ten Cate O, Snell L, Carraccio C. Medical compe-
tence: the interplay between individual ability and the health care environment. Med Teach. 2010;32(8): 669-675. 21. “autonomy”: Merriam-webster.com. Available at: 〈http://
www.merrriam-webster.com/dictionary/autonomy〉; 2015 Accessed 02.10.15.
27. Kim HN, Gates E, Lo B. What hysterectomy patients
want to know about the roles of residents and medical students in their care. Acad Med. 1998;73(3):339-341. 28. Castleberry AW, Clary BM, Migaly J, et al. Resident
education in the era of patient safety: a nationwide analysis of outcomes and complications in residentassisted oncologic surgery. Ann Surg Oncol. 2013;20 (12):3715-3724. 29. Schoenfeld AJ, Serrano JA, Waterman BR, Bader JO,
do patient care on my own: autonomy and the manager role. Acad Med. 2009;84(11):1516-1521.
Belmon PJ Jr. The impact of resident involvement on post-operative morbidity and mortality following orthopaedic procedures: a study of 43,343 cases. Arch Orthop Trauma Surg. 2013;133(11):1483-1491.
23. ACGME.org. Resident duty hours in the learning and
30. Jannuzzi JC, Chandra A, Rickles AS, et al. Resident
22. Hinchey KT, Iwata I, Picchioni M, McArdle PJ. I can
working environment. Comparison of 2003 and 2011. Available at: 〈https://www.acgme.org/acgmeweb/Portals/ 0/PDFs/dh-ComparisonTable2003v2011.pdf〉; Accessed 02.12.15. 24. Chen XP, Williams RG, Sanfey HA, Dunnington GL.
How do supervisiong surgeons evaluate guidance in the operating room? Am J Surg. 2012;203(1):44-48. 25. Reichgott MJ, Schwartz JS. Acceptance by private
patients of resident involvement in their outpatient care. J Med Educ. 1983;58(9):703-709. 26. O’Malley PG, Omori DM, Landry FJ, Jackson J,
Kroenke K. A prospective study to assess the effect of ambulatory teaching on patient satisfaction. Acad Med. 1997;72(11):1015-1017.
involvement is associated with worse outcomes after major lower extremity amputation. J Vasc Surg. 2013;58(3):827-831. 31. Davis SS Jr, Husain FA, Lin E, Nandipati KC, Perez S,
Sweeney JF. Resident participation in index laparoscopic general surgical cases: impact of the learning environment on surgical outcomes. J Am Coll Surg. 2013;216(1):96-104. 32. Scarborough JE, Bennett KM, Pappas TN. Defining
the impact of resident participation on outcomes after appendectomy. Ann Surg. 2012;255(3):577-582. 33. Kittleson
MJ. Determining effective follow-up of e-mail surveys. Am J Health Beh. 1997;21(3): 193-196.
SUPPLEMENTARY INFORMATION Supplementary data associated with this article can be found in the online version at http://dx.doi.org/10.1016/j.jsurg. 2015.06.002.
Journal of Surgical Education Volume 72/Number 6 November/December 2015
e201
