Surgical Trainees’ Sense of Responsibility for Patient Outcomes: A Multi-institutional Appraisal

Scoping review: exploring residents' views of supervisor entrustment and its effect on learning and professional development

This scoping review aimed to systematically explore the complex and nuanced perceptions of residents entrusted with significant responsibilities by their supervisors in the clinical context. We conducted a comprehensive search strategy targeting six major electronic databases. Data were extracted using the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist and a scoping review protocol. Resident perceptions regarding entrustment and its impact on learning and professional development were categorized. This review elucidated the role of supervisor entrustment in shaping residents' clinical performance, notably influencing autonomy, self-confidence, responsibility for patients, learning needs and goals, uncertainty management, and professional identity formation. Residents identified factors that promote and hinder performance and entrustment development resulting from supervisor entrustment and distinguished between appropriate supervision and over- or under-supervision. Our review suggests that residents' perceptions of supervisor entrustment, as bestowed by supervisors, serves as a catalyst for enhancing autonomy, thereby exerting a significant influence on clinical performance, and fostering the development of a professional identity. However, residents' views on appropriate supervision differ in some ways from supervisors' perspectives. Further research is needed to bridge the gap between residents' expectations of autonomy and what they are given, and to explore the intricate relationship between autonomy and entrustment.

General Surgery Resident Autonomy: Truth and Myth

Within general surgery education circles, the state of autonomy for residents in surgery training programs has been of growing concern. Although there is no direct evidence showing less autonomy in modern surgical training, multiple surrogates have been cited as reasons for concern. Many reasons have been given for lost autonomy including the 80-hour work week, financial constraints, concerns over quality of patient care, patient expectations, new and innovative technologies, legal limitations, and public opinion. This article discusses the current state of general surgery resident autonomy, why autonomy is important, barriers to autonomy, and ways to support autonomy.

Outcomes Following Cholecystectomy on a Service Designed to Maximize Chief Resident Entrustment

BACKGROUND

The chief resident service provides surgical trainees in their final year of training the opportunity to maximize responsibility, continuity, and decision-making. Although supervised, chief residents operate according to personal preferences instead of adapting to their attendings' preferences. We hypothesized that outcomes following cholecystectomy are equivalent between the chief resident service and standard academic services.

METHODS

We matched adults undergoing cholecystectomy from 07/2016-06/2019 on the chief resident service to two standard academic service patients based on operative indication and age. We compared demographics, operative details, and 30-d complications.

RESULTS

This study included 186 patients undergoing cholecystectomy. Body mass index (32.4 versus 32.0, P = 0.49) and Charlson comorbidity index (0.9 versus 1.4, P = 0.16) were similar between chief resident and standard academic services, respectively. Operative approach was similar (95.2% laparoscopic on chief resident service versus 94.4% on standard service), but residents on the chief resident service performed cholangiograms more often (48.4% versus 22.6%, P < 0.01) and averaged longer operative times during laparoscopic cholecystectomy with cholangiogram (146±28 versus 85±22 min, P < 0.01) and without (94±31 versus 76±35 min, P < 0.01) compared with standard academic services, respectively. 30-d complication rates were similar (5.2% chief resident versus 5.0% standard, P = 0.95). No patients suffered bile leak, bile duct injury, or reoperation. Emergency Department visits were similar (12.1% chief resident versus 7.4% standard, P = 0.32); readmissions were less frequent on the chief resident service (0.0% versus 5.0% standard, P = 0.03).

CONCLUSIONS

With appropriate supervision, chief residents provide safe care for patients undergoing cholecystectomy while directing medical decisions and practicing according to their preferences.