The American Journal of Surgery (2014) 207, 797-805

Surgical Education

Operative confidence of graduating surgery residents: a training challenge in a changing environment Annabelle L. Fonseca, M.D.*, Vikram Reddy, M.D., Ph.D., Walter E. Longo, M.D., Robert Udelsman, M.D., Richard J. Gusberg, M.D. Department of Surgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA

KEYWORDS: Operative confidence; Resident confidence; Open surgery

Abstract BACKGROUND: Given the recent changes in general surgical training, this study was undertaken to assess the confidence of graduating general surgery residents in performing open operations and to determine factors that are associated with increased confidence. METHODS: A survey was sent to the 5th-year general surgery residents in the Northeast. Respondents were queried regarding demographics, program characteristics and asked to rate their confidence in performing open operations. We compared those who indicated confidence with those who did not. RESULTS: We received 232 responses: 74% male, 70% from university programs, and 50% from programs affiliated with a Veterans Affairs Hospital. Fifty-two percent expressed confidence in their ability to practice independently after residency. Operative confidence varied with sex, type of training program, affiliation to a Veterans Affairs Hospital, and surgical volume. CONCLUSIONS: Graduating surgical residents indicated a significant lack of confidence in performing a variety of open surgical procedures. Analyzing and addressing this confidence deficit merits further study. Ó 2014 Elsevier Inc. All rights reserved.

General surgical training in the United States, which developed around the apprenticeship model introduced by Halsted with a focus on graded responsibility, has undergone a paradigm shift over the last decade.1,2 Several factors have contributed to the gradual evolution of this model. Furthermore, increasing subspecialization, the 80-hour workweek, an emphasis on operating room

The authors declare no conflicts of interest. The authors received no support from industry or organizations. * Corresponding author. Tel.: 11-862-216-9999; fax: 11-203-7375209. E-mail address: [email protected] Manuscript received August 16, 2013; revised manuscript August 29, 2013 0002-9610/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjsurg.2013.09.033

efficiency, and the increasing complexity of surgical cases have resulted in a decrease in operative opportunities for general surgery residents.1,3–5 Additionally, the nature of the operative experience of surgery residents has also been altered. The substantial increase in the number of minimally invasive, endoscopic and endovascular surgical procedures, combined with the increasing use of nonoperative strategies for solid organ trauma have resulted in a decrease in the number of open operations.6 Eckert et al7 noted a 200% to 1,000% increase in the number of percutaneous and endovascular interventions, and a simultaneous 30% to 70% decrease in the number of open gastrointestinal and vascular operations over the last 14 years. In a 10-year review of patients admitted to a Level 1 Trauma Center, Jennings et al8 noted a decrease

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from 100% and 93% to 19% and 28%, respectively, in the operative management of patients with spleen and liver injuries. Fakhry et al,9 in a large multi-institutional study of Level 1 Trauma Centers estimated that a resident would have to care for an average of 500 blunt trauma patients before performing a splenectomy or liver repair. Bulinski et al,10 in a retrospective review at 2 trauma centers, showed that their chief residents graduated with an average of 6.4 trauma cases per resident. This change in the volume and composition of operative experience will certainly have a significant impact on the training of general surgery residents. Although the number of open operations performed is decreasing, open surgery remains the most appropriate procedure in certain, select situations and is often required when less invasive modalities fail or when complications develop.6 Although many minimally invasive procedures have been demonstrated to result in decreased patient morbidity and are the standard of care for elective surgery for many surgical problems, it is imperative for surgical residents to have the confidence and competence to be able to perform open operations when the need arises. In the event of intraoperative complications arising during laparoscopic surgery that cannot be managed in a safe, minimally invasive manner, the standard of care dictates that the surgery be converted to an open procedure. Additionally, although the number of operative trauma cases is decreasing, leading to decreasing resident experience, general surgeons in practice may be called upon to perform emergency open surgery to stabilize or treat an injured patient. The decreased exposure to open operations during residency training may, in that setting, pose a challenge for both the surgeon and the patient. In view of the change in the operative experience of general surgery residents, this study was undertaken to assess the experience and confidence of graduating general surgery chief residents in the performance of open operative procedures. In this study, recognizing that there are no validated instruments that have been used to reliably evaluate technical skill in the performance of operations on patients, we used self-assessment of resident confidence as a surrogate for operative competence.

residents in their final year of residency training (PGY5 residents). The survey did not request any identifying information and complete anonymity was guaranteed. The survey was developed based on a comprehensive multistage method; the first phase utilized qualitative methods, including in-depth interviews to develop a pool of possible survey questions.11 Subsequent to this, the survey items were subjected to the 4 stages of pretesting, including review by knowledgeable colleagues, cognitive interviewing, pilot testing, and a final check, as detailed by Dillman.12 The survey queried respondents regarding demographics (age, sex, postgraduate training year), residency program characteristics (type of surgical program: University, Community, or University Affiliated; program size; affiliation to a Veterans Affairs [VA] Hospital; presence of a simulation lab), estimated number of operations performed, estimated percentage of operations performed laparoscopically, and specific resident’s professional goals (research years, future fellowship goals, future practice plans). In addition, respondents were asked to rate their confidence level in performing a number of open surgical procedures on a Likert Scale with scores ranging from 1 (not confident) to 5 (extremely confident). Survey responses to questions regarding confidence level were divided into ‘‘Not Confident’’ (Not confident, Minimally confident, Neutral) and ‘‘Confident’’ (Confident, Extremely Confident). To assess differences in confidence levels based on individual and program-specific characteristics, we compared the demographic and program-specific variables of residents who reported being confident at performing the specified procedures to those who did not. Univariate analysis was performed with the t test and one-way analysis of variance for continuous data and chi-square test for categorical data. Multivariate analysis was then performed with logistic regression to identify independently predictive factors. All variables with a P value of ,.2 on univariate analysis were entered into a backward stepwise logistic regression model. A P value of ,.05 was considered significant. This study was approved by the Yale University Institutional Review Board and Human Subjects Review Committee.

Methods

The survey was administered to and completed by residents in every year of training. For the purpose of this study, we were interested in the cumulative experience that residents gained from their training and, therefore, focused on those residents completing their final year; 232 responses were obtained from PGY5 residents (65.35% response rate). Table 1 indicates demographic and program-specific variables based on PGY5 responses. Although nearly all (96.12%) of PGY5 residents reported being confident at performing basic laparoscopy, 59% reported confidence at performing advanced laparoscopy and 84% reported confidence at performing open surgical cases. Fifty percent or less of the PGY5 residents reported being confident performing 8 of the 18 specified

A 39-question survey was developed and distributed electronically to all general surgery residents in residency programs in the Northeast (Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont). A total of 76 programs were contacted. Program Directors and Program Coordinators of all the general surgery programs in the listed states were contacted individually with a brief explanation of the study and asked to distribute the survey to their categorical and nondesignated preliminary surgery residents. All programs complied with this request. A total of 1,770 surveys were thus distributed, of which 355 were distributed to

Results

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Table 1 Demographic characteristics of graduating surgical residents (n 5 232)

Table 2 Percentage of graduating surgical residents reporting confidence in performing various surgical procedures

Variable

Surgery

PGY5

Advanced laparoscopy Open surgical cases Basic laparoscopy IVC exposure and control Supraceliac aortic exposure and control Approach to and control of great vessels in the chest Exposure and control of the visceral mid-abdominal aorta Open common bile duct exploration Control of liver injury Open low anterior resection Open groin lymph node dissection Axillary lymph node dissection Open cholecystectomy Hemorrhoidectomy Hand-sewn bowel anastomosis Open control of splenic injury Open appendectomy Vascular anastomosis Open inguinal hernia repair Open evaluation and treatment of bowel injury Simple mastectomy

59.05% 83.62% 96.12% 5.60% 8.62%

Age (y) ,35 351 Sex Male Female Program type University Program University Affiliated Program Community Program Program size Small (1–3 residents/year) Medium (4–5 residents/year) Large (61 residents/year) Veterans Administration Hospital Affiliated Programs Simulation laboratory Dedicated research years Future fellowship plans Future practice patterns Academic Private Rural Undecided

Number of responses (%) 205 (88.36%) 27 (11.64%) 172 (74.14%) 60 (25.86%) 163 (70.26%) 25 (10.77%) 44 (18.97%) 50 78 104 116

(21.55%) (33.62%) (44.83%) (50.00%)

219 (94.40%) 95 (40.95%) 184 (79.31%) 108 84 2 38

(46.55%) (36.21%) (.86%) (16.38%)

open procedures addressed in the survey (Table 2). When queried regarding their confidence in their ability to practice independently after residency training, only 51.72% of residents reported confidence. Sex, age, program type, program size, percentage of cases performed laparoscopically at current training program, presence of a simulation laboratory, VA Hospital affiliation, dedicated research time, future fellowship and practice plans, surgical volume in residency and during the final year of residency training were the variables evaluated. Sex, program type, program size, VA Hospital affiliation, and surgical volume were all associated with variations in reported confidence. Male sex and increased surgical volume were associated with increased reported confidence performing a number of open general surgery and vascular surgery cases. Residents who were trained at University Affiliated or Community Programs, residents at small- or medium-sized programs, and programs not affiliated with a VA Hospital reported increased confidence performing a number of open general surgical cases, while residents who were trained at University Programs, large programs, and programs affiliated with a VA Hospital reported increased confidence performing specific open vascular surgical procedures (Tables 3 and 4). Variables associated with increased postresidency operative confidence included male sex, training at a University Affiliated or Community Program (P 5 .05), a program not affiliated to a VA Hospital (P 5 .013), and increased surgical volume in residency (P 5 .05) and in the final year of surgical training (P 5 .024).

12.07% 18.97% 22.41% 37.93% 44.40% 50.00% 59.48% 59.48% 65.52% 69.83% 69.83% 79.31% 78.45% 90.09% 90.09% 93.53%

The data are arranged in increasing order of reported confidence. IVC 5 inferior vena cava; PGY5 5 surgical residents in their final year of training.

Multivariate analyses were then performed to identify variables that were independently predictive of increased resident confidence. Program type and surgical volume were independently associated with increased reported confidence (Tables 5 and 6). Training at a University Program or a program associated with a VA Hospital was independently associated with decreased confidence performing open general surgery cases and increased confidence performing open vascular surgery cases. Male sex and increased surgical volume were independently associated with increased reported confidence performing a number of open general and vascular surgical cases. Older age was associated with increased confidence performing a number of open operations, with the exception of exposure and control of the great vessels in the chest where younger residents expressed more confidence. Male sex (P 5 .001, odds ratio 7.30) and increased surgical volume during the final year of training (P 5 .0001, odds ratio 8.23) were independently associated with increased postresidency operative confidence on multivariate analysis.

Comments A multitude of factors are responsible for the evolution of the experience and training of surgical residents over the

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Table 3

Factors associated with reported confidence performing open general surgical cases (univariate analysis)

Variable

Sex

Open surgical cases Basic laparoscopy Advanced laparoscopy Open appendectomy Open cholecystectomy Open inguinal hernia repair Common bile duct exploration Hand-sewn bowel anastomosis Hemorrhoidectomy Low anterior resection Mastectomy Axillary lymph node dissection Groin lymph node dissection

P P P P P

5 5 5 5 5

Age .016 .05 .01 .005 .04

P P P P

5 5 5 5

Program type

Program size

VA affiliation

Surgical volume (last year)

Surgical volume (residency)

P 5 .015

P 5 .003 P 5 .001 P 5 .003

P 5 .001 P 5 .033

P 5 .06

P 5 .008

P 5 .0001

P 5 .001 P 5 .001

P P P P P P

P 5 .001

P 5 .001

P P P P P P

.01 .018 .01 .012

P 5 .04 P 5 .01 P 5 .003

5 5 5 5 5 5

.03 .021 .001 .003 .008 .01

P 5 .001 P 5 .001 P 5 .018

P P P P P

5 5 5 5 5

.06 .001 .001 .005 .001

P P P P P P P P P

5 5 5 5 5 5 5 5 5

.01 .026 .001 .001 .03 .006 .004 .036 .005

P 5 .001

5 5 5 5 5 5

.001 .01 .001 .001 .001 .001

P 5 .001 P 5 .029

Age 5 older residents; Program size 5 small- and medium-sized programs; Program type 5 University Affiliated and Community Programs; Sex 5 male; Surgical volume 5 increased surgical volume; VA affiliation 5 no VA affiliation; VA 5 Veterans Affairs.

Factors associated with reported confidence performing open surgical procedures in open vascular and trauma surgery cases (univariate analysis)

Variable

Sex

Age

Vascular anastomosis

P 5 .014

P 5 .013 (older residents)

Supraceliac aortic exposure and control Exposure and control of visceral mid-abdominal aorta Inferior vena cava exposure and control Exposure and control of great vessels in the chest Control of splenic injury Control of liver injury evaluation and treatment of bowel injury

P 5 .04

Program size

VA affiliation

Surgical volume (last year)

Surgical volume (residency)

P 5 .001

P 5 .001

P 5 .001

P 5 .001

P 5 .001

P 5 .004

P 5 .001

P 5 .001

P 5 .001

P 5 .001

P 5 .001

P 5 .001

P 5 .0001

P 5 .001 P 5 .001

P 5 .0001 P 5 .0001 P 5 .001

P 5 .010 P 5 .05

P 5 .001 P 5 .001

Program type

P 5 .001 P 5 .02 (younger residents)

P 5 .041

P 5 .05

P 5 .01

Program size 5 large programs; Program type 5 University Programs; Sex 5 male; Surgical volume 5 increased surgical volume; VA affiliation 5 VA affiliated; VA 5 Veterans Affairs.

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Table 4

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Independent predictors of increased resident confidence in open general surgical cases (multivariate logistic regression)

Variable Open surgical cases Basic laparoscopy Advanced laparoscopy Open inguinal hernia repair Open appendectomy Open cholecystectomy

Sex

Age

P 5 .017 (OR 2.22) P 5 .047 (OR 1.96) P 5 .045 (OR 3.08)

Hand-sewn bowel anastomosis Hemorrhoidectomy Low anterior resection Common bile duct exploration Mastectomy Axillary lymph node dissection Groin lymph node dissection

P 5 .01 (OR 2.63)

Program type

P 5 .01 (OR 1.99) P 5 .001 (OR 6.25) P 5 .001 (OR 2.17) P 5 .02 (OR .60) P 5 .03 (OR 2.60) P 5 .009 (OR 2.43) P 5 .023 (OR 1.38)

Program size P P P P

5 5 5 5

.017 .001 .003 .001

(OR (OR (OR (OR

1.68) 1.25) 1.33) 3.25)

P 5 .002 (OR 1.65)

VA Hospital affiliation

Surgical volume (last year)

P 5 .001 (OR 1.88) P 5 .006 (OR 2.88) P 5 .006 (OR 1.82)

P 5 .005 (OR 3.13)

Surgical volume (residency) P 5 .001 (OR 2.94)

P 5 .0001 (OR 3.27) P 5 .011 (OR 5.21)

P 5 .001 (OR 4.13)

P 5 .05 (OR 2.08)

P 5 .05 (OR 2.81)

P , .0001 (OR 8.06)

P 5 .001 (OR 5.91)

P 5 .003 (OR 2.46)

P , .0001 (OR 5.80)

P , .0001 (OR 9.92)

P 5 .003 (OR 2.42)

P 5 .001 (OR 3.19) P 5 .001 (OR 4.58)

P 5 .001 (OR 7.46)

Resident operative confidence

Table 5

P 5 .02 (OR 1.65) P 5 .016 (OR 1.33)

P 5 .02 (OR 2.53) P 5 .001 (OR 3.28)

P 5 .01 (OR 1.91)

P 5 .015 (OR 2.37)

Age 5 older residents; OR 5 odds ratio; Program size 5 small- and medium-sized programs; Program type 5 University Affiliated and Community Programs; Sex 5 male; Surgical volume 5 increased surgical volume; VA affiliation 5 no VA affiliation; VA 5 Veterans Affairs.

801

P 5 .012 (OR 1.71)

P 5 .04 (OR 1.37)

Supraceliac aortic exposure and control Exposure and control of visceral mid-abdominal aorta Inferior vena cava exposure and control Exposure and control of great vessels in the chest Control of liver injury Control of splenic injury Evaluation and treatment of bowel injury

P 5 .017 (OR 2.16)

P 5 .03 (OR 1.88)

P 5 .05 (OR 1.17)

P 5 .018 (OR 1.70) P 5 .001 (OR 4.23) P 5 .001 (OR 1.93)

P 5 .001 (OR 7.79) P 5 .042 (OR 1.60) Vascular anastomosis

Age 5 younger residents; OR 5 odds ratio; Program size 5 large programs; Program type 5 University Programs; Sex 5 male; Surgical volume 5 increased surgical volume; VA affiliation5 VA affiliated; VA 5 Veterans Affairs.

P 5 .046 (OR 4.43) P 5 .001 (OR 3.40)

P 5 .001 (OR 6.85) P 5 .001 (OR 7.10) P 5 .01 (OR 4.59)

P 5 .004 (OR 8.11)

P 5 .0001 (OR 8.09)

P 5 .012 (OR 8.00) P 5 .001 (OR 3.56)

P 5 .03 (OR 9.05)

P 5 .05 (OR 1.80) P 5 .0001 (OR 7.48)

Surgical volume (last year) VA Hospital affiliation Program size Program type Age Sex Variable

Independent predictors of increased resident confidence in open vascular and trauma surgery (multivariate logistic regression) Table 6

P 5 .001 (OR 13.39)

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Surgical volume (residency)

802

last decade. These factors, including a decrease in resident work hours, increasing use of minimally invasive methods, and a decrease in the amount of operative trauma, have led to concerns regarding the current operative experience and technical training of general surgery residents.13,14 Attempts to study the operative competence of surgical trainees have, however, been inhibited by the absence of relevant validated assessment instruments. Although validated instruments have been developed and utilized to assess competence in the performance of specific technical maneuvers in bench models15 or for central venous line insertion in patients,16 developing such an instrument to reliably assess competence in the performance of an operation, given the complexity of technical and decision-making skills involved, has been elusive. Self-reported operative confidence has been used as a substitute for assessment of competence. Although the relationship between operative confidence and operative competence is complex, confidence in one’s operative skill does develop over time, with the increasing acquisition of surgical skills and techniques. Studies have demonstrated that both surgeons17 and surgical residents18 accurately self-assess their operative competence. This ability to accurately evaluate one’s operative competence suggests that operative confidence could be used as a potential surrogate marker for competence. Operative confidence develops progressively over the course of residency training with continued exposure and experience and optimally, over time, leads to the development of surgical expertise. It entails the acquisition of surgical skills through repetitive practice and the ability to apply these skills and tailor them appropriately to a specific clinical context. It has been proposed that a common feature of experts is that they have performed years of deliberate practice, not just gained experience, and that the attained level of expertise is closely related to the time devoted to deliberate practice. Deliberate practice involves the repetitive performance of intended cognitive or psychomotor skills in a focused domain, coupled with rigorous skills assessment that provides trainees with specific, informative feedback, to enable sustained improvement in performance.19–21 Ericsson,19 through several studies of expertise in several domains, demonstrated that it takes at least 10 years or 10,000 hours of deliberate practice for someone to demonstrate expertise in a specific domain. Clearly, a basic objective of surgical training would be for the trainees to graduate from their programs, heading to fellowship or practice, with both confidence and competence in performing commonly required procedures as well as those called for in select emergencies. Several authors have attempted to study resident confidence and the factors associated with it. The National Study of Expectations and Attitudes of Residents in Surgery survey demonstrated that more than 70% of general surgery residents felt confident with their operating skills. In this study, factors that were associated with greater trainee confidence included male sex, being a more senior resident, having children, training at a Community program or at a

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program with fewer chief residents, or no fellowships.22 These results appear to differ from those of our survey in which only 51.72% of residents expressed confidence in their ability to practice independently after residency training; however, although Bucholz et al surveyed the overall operative experience of general surgery residents at all levels of training, our study focused on the reported operative confidence of graduating chief residents in performing specific open operations. We assumed that the operative confidence of residents evolves over the course of residency training with reported confidence varying with the level of training. Assessing the experience of the graduating residents should provide a more accurate view of the overall training experience. In a recent study, Fronza et al surveyed recent graduates of a surgical residency program. One year after graduation a survey was sent to the participants listing 67 operations encompassing all aspects of general surgery. All the respondents reported confidence in performing only 24% of the various operations about which they were queried. Additionally, more than 10% of the respondents reported feeling not confident performing operations that were felt to be relevant to their practice.23 In contemporary residency training, the number of hours devoted to technical skill development and deliberate practice in the operating room as well as the setting in which the operative experience occurs may limit the opportunity for the acquisition of technical facility, intraoperative decision making, and confidence. Additionally, the volume of cases needed to obtain such proficiency may not be attainable. Kairys et al3 report a decrease in the operative volume of chief surgery residents by 8.3% since the implementation of the 80-hour workweek. In a study on the operative experience of general surgery residents, Bell et al found that in over 50% of the 112 operations that general surgery residency program directors deemed residents should be competent to perform by the end of residency, the mode (most commonly reported) experience reported by graduating general surgery residents was 0. The mean reported experience for 83 of these 121 procedures was ,5, and for 31 of these it was ,1. The procedures for which the mean reported experience was ,2 cases included open common bile duct exploration, incision of a thrombosed hemorrhoid, and several traumatic repairs including the abdominal aorta, vena cava, and bladder or neck exploration.14 Given the low mean reported experience with these cases, it is understandable that a large percentage of graduating chief residents do not report confidence performing these procedures. Although one of the reasons for the change in the operative experience of general surgery residents is the development of subspecialization and the increase in the number of fellowship training programs, this may potentially be a part of a vicious circle with graduating chief residents now no longer feeling adequately prepared for independent practice after residency training and feeling the need for additional post-residency training.

803 In our study, the type of training program (specifically type of program and program size), as well as affiliation with a VA Hospital were independently predictive of reported operative confidence. Residents training at University Affiliated and Community Programs as well as those at small- and medium-sized programs and at programs not affiliated with a VA Hospital reported increased confidence in performing a number of open general surgical cases, while residents training at University Programs and at large-sized programs as well as programs affiliated with a VA Hospital reported increased confidence in performing certain open vascular operations. Although the reason for this is not completely clear, it is possible that this is because of differences in the volume and mix of cases seen at university, university affiliated, and community programs. Operative experience at community programs tends to be in more broad-based general surgery cases,24 with more extensive operative experience in the early years of residency training25 but a lesser number of complex index cases.25 This, in addition to the fact that most Level 1 Trauma Centers tend to be university programs, could potentially be one of the factors contributing to the increased operative confidence that residents training at university programs reported in performing some of the more infrequently performed open vascular surgical maneuvers. Surgical volume was strongly predictive of increased operative confidence in almost all the specific operations we addressed in the survey. This association with volume has been extensively studied in the surgical literature and has been shown to be an important determinant of outcome.26,27 Male residents also reported increased confidence performing a number of open general and vascular operations on univariate analysis. Sex was also demonstrated to be independently predictive of increased confidence in a number of operations (open appendectomy, open inguinal hernia repair, vascular anastomosis, and exposure and control of great vessels in the chest) on multivariate analysis. Bucholz et al,22 in their study, also suggest that male sex is associated with increased self-reported confidence. Although these differences in self-assessment may be because of sex differences in socialization,28 without being representative of actual competence,29 additional studies should be performed to confirm or refute this apparent sex difference. It is clear that surgical care is in a period of rapid and significant change. It is equally clear that surgical residencies need to adapt to these changes while continually monitoring the operative experiences and operative skills of their residents. The changing spectrum of trainees, the ongoing move to reduce the length of training programs, as well as the diverse and changing sites at which residents are trained will represent a continuing challenge. To meet this challenge there will be a continuing need to monitor the operative experience of our trainees and develop validated instruments to assess technical competence in the operating room. Our data suggest that the development of operative confidence and competence is most likely influenced by

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multiple factors: trainee-specific, site-specific, and program-specific. General surgery training programs have instituted many changes since the implementation of work-hour restrictions to maximize resident operative exposure within the confines of the 80-hour workweek.30,31 The results of our survey would certainly support an approach that maximizes exposure while emphasizing on the acquisition of both technical facility and independent operative judgment. It seems obvious that the simultaneous development of competence and confidence requires both. Although this may be possible for the more commonly performed operations, ‘‘essential-uncommon’’ operations such as open common bile duct exploration and repair of traumatic or iatrogenic tears of the aorta or vena cava may pose a significant educational challenge.32 These are operations that most residents will have little opportunity to perform during their training, but they may be called upon to perform at some point during their career. A general surgeon may be called upon to control bleeding from major intraabdominal or retroperitoneal vessels that are injured as a complication during an elective laparoscopic or open procedure, or may be required to stabilize a trauma patient with a liver laceration and other intra-abdominal injuries. Residency programs must continue to focus on graduating residents with the requisite operative skills needed to be effective independent surgeons in a changing healthcare environment. This may be a particular challenge in the context of the current training environment given both work-hour restrictions and the changing nature of surgical practice. The development of advanced simulation technology offers the possibility of augmenting the training of technical skills in a safe, reproducible simulated environment. The Advanced Trauma Operative Management Course33,34 is one such simulation training course that attempts to complement residents’ trauma operative experience. Simulation training could potentially be used in a program-specific, resident-specific fashion to address specific deficiencies in the operative experience of the residents. For example, university programs appear to train residents who develop increased confidence in open vascular surgery and decreased confidence in certain open general surgery procedures. It might be possible to address this perceived deficit by using simulation models to focus on those open operative procedures in which experience and confidence are lacking. Similarly, community and university affiliated programs might focus their simulation training on developing competence and confidence in relevant vascular procedures or techniques. In the paradigm of graduated responsibility that characterizes surgical residencies, the achievement of competence and confidence is a key element in attaining safe and effective operative independence. Such independence optimally requires the acquisition of both minimally invasive and open surgical skills. Competence in this context means having the skill set to deal in the operating room with a

variety of surgical problems in a safe and effective manner and the confidence to know when to proceed, when to change plans, and when to ask for help. This should be the expectation of both program directors and the public as residents complete their training and enter into a surgical practice. Meeting this expectation may be an increasing challenge in the minimally invasive culture that characterizes much of contemporary surgical practice. The responses to our survey reflect a widespread lack of confidence in performing even some basic open surgical procedures and appear to be consistent with a declining exposure to such procedures. However, when adverse events occur, either as a primary problem or as a complication of a minimally invasive operation, and cannot be safely or expeditiously dealt with using minimally invasive techniques, the standard of care dictates that an open procedure be undertaken, and graduating residents need to finish their training with the skill set to be able to perform this. This study has several limitations that are inherent in survey-based studies. Despite the fact that respondents were assured of strict anonymity and no identifying factors were elicited in the survey, it is possible that the responses were influenced by concerns about identification and possible repercussions. In addition, although the correlation between self-reported confidence and actual competence may be uncertain, there are data that indicate that operative confidence may be a reasonable surrogate for operative confidence.17,18 Trainees who lack confidence in performing a particular operation are unlikely to achieve the best and safest outcomes for their patients. It is our contention that self-reported confidence, a reflection of one’s ability to deal effectively with both the technical and judgmentrelated aspects of an operation, is a valid surrogate for competence and an important measure of one’s development as an independent surgeon. We purposely limited our analysis to graduating chief residents, whose operative confidence is likely a culmination of their years of surgical training and operative exposure. In addition, our study was limited geographically to the Northeast United States, and may not be representative of operative confidence of graduating chief residents elsewhere. Clearly, further studies need to be undertaken to better characterize both the nature and the causes of this apparent confidence deficit and to develop approaches that can ameliorate it.

Conclusions General surgery residency training has changed significantly over the last decade, leading to concerns about the operative experience of general surgery residents and the operative skills of graduating chief residents. Our study indicates that graduating chief residents lack confidence in performing a number of open surgical procedures, especially procedures that are infrequently performed. Surgical volume and type of training program are predictive of reported operative confidence. It is imperative that programs focus on

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maximizing operative volumes of their surgical residents, develop accurate assessment tools to track their technical development, and consider utilizing simulation training in a targeted fashion to address potential deficits.

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