2015 APDS SPRING MEETINGHow do Perceptions of Autonomy Differ in General Surgery Training Between Faculty, Senior Residents, Hospital Administrators, and the General Public? A Multi-Institutional Study
Introduction
Self-determination theory states that human beings have a natural tendency to develop toward autonomous behavior, 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, 15, 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 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, 18, 19, 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.
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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
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 TABLE 1, TABLE 2.
Discussion
Autonomy is defined by Merriam-Webster’s Dictionary as, “the quality or state of being independent, free, and self-directing.”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 >90% of faculty, residents, and hospital administrators recognize the importance of autonomy in
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
References (33)
- et al.
The effects of programmatic change on resident motivation
Surgery
(1998) - et al.
Entrustment of general surgery residents in the operating room: factors contributing to provision of resident autonomy
J Am Coll Surg
(2014) - et al.
Patient-care–related telephone communication between general surgery residents and attending surgeons
J Am Coll Surg
(2008) - et al.
Impact of resident participation on laparoscopic inguinal hernia repairs: are residents slowing us down?
J Surg Educ
(2012) - et al.
Resident participation does not affect surgical outcomes, despite introduction of new techniques
J Am Coll Surg
(2010) - et al.
How do supervisiong surgeons evaluate guidance in the operating room?
Am J Surg
(2012) - et al.
Resident participation in index laparoscopic general surgical cases: impact of the learning environment on surgical outcomes
J Am Coll Surg
(2013) - et al.
AM last page: education is not filling a bucket, but lighting a fire: self-determination theory and motivation in medical students
Acad Med
(2013) - et al.
Issues in general surgery residency training—2012
Ann Surg
(2012) - ACGME Program Requirements for Graduate Medical Education in General Surgery....
National efforts to reform residency education in surgery
Acad Med
Transition to practice: a bold move
General Surgery News
General surgery training and the demise of the general surgeon
Bull Am Coll Surg
A policy-based intervention for the reduction of communication breakdowns in inpatient surgical care: results from a Harvard surgical safety collaborative
Ann Surg
Commentary: watching closely at a distance: key tenstions in supervising resident physicians
Acad Med
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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.