2024 General Surgery/Global Health Engagement/Quality Improvement Presentations

Ama J Winland, MD1; Jerusalem Merkebu, PhD2; Holly Meyer, PhD2; William B Sweeney2; Mary T O'Donnell, MD1; Zachary Taylor, DO1; 1Walter Reed National Military Medical Center; 2Uniformed Services University

Objective: Operative autonomy is poorly defined, but nevertheless, it is the goal of every surgical resident before entering independent practice. In the setting of perceived decreasing operative autonomy, this qualitative study is meant to elucidate both staff and resident concerns influencing the amount of resident autonomy given intra-operatively. Additionally, we investigate the intersection of confidence of both 1) the staff to teach and 2) the resident to progress the case and how that interaction drives the ultimate autonomy of the operative resident.

Methods: Surveys were distributed to general surgery residents and active teaching staff. The survey questions were designed to determine factors that contribute to resident autonomy in the operating room as well as factors affecting both resident and staff confidence and comfort. Qualitative review was performed to identify pertinent themes and trends.

Results: 26 residents and 20 staff from a single institution responded. Both staff and residents had similar expectations for how long laparoscopic cases should take at a teaching hospital with the majority reporting an appendectomy should take 30 minutes - 1 hour, a cholecystectomy or a totally extra-peritoneal hernia repair 1-2 hours, and 2-3 hours for a right colectomy. When asked about factors leading to discomfort in the operating room, residents felt low case volume and not knowing whether a move is safe or unsafe were most unsettling. When staff were asked what contributes most to their discomfort, they reported coming across a situation they've never encountered and unfamiliarity with the operative resident. When asked their biggest intra-operative fears as a trainee or with a trainee, staff responses had themes of unrecoverable injury and trainees that are overconfident but underprepared, where resident responses had themes of not knowing whether a move is safe and fear of being judged or lack of comfort with the surgical team. Additionally, when asked about self-confidence in the operating room, staff reported experience, resident interest and engagement, and case progression as driving factors with residents also reporting repetition, feedback with a supportive environment and case progression. And finally, when staff were asked to describe a "safe" resident intra-operatively, staff underscored open communication, safety over speed, adaptability, and surgical proficiency.

Conclusion: Resident intra-operative autonomy stands at the intersection between both staff and resident competence, confidence, and comfort. Further study is needed to determine appropriate interventions, which account for the affective dimensions, necessary to improve resident autonomy and confidence in the operating room.