As societal and legal expectations of modern medical care evolve, the graduate medical education (GME) system is tasked with training competent and autonomous health care providers while also improving patient safety, delivering more efficient care, and cutting costs. As GME programs pursue these dynamic and sometimes disparate goals, concerns about resident autonomy and preparation for independent and safe practice appear to be growing. Procedural specialties, such as surgery, face unique challenges in preparing graduates for independent practice.
The Halsted model of surgical education, featuring progressive responsibility and autonomy over the five years of clinical training, has been used to train generations of excellent surgeons. However, this model has come under scrutiny as changes in disease management, duty hours regulations, economic pressures, and the medical-legal environment have resulted in reduced operative experiences and clinical interactions for residents. These threats to the current system of surgical training are negatively impacting the outcome it seeks to achieve: competent trainees who successfully transition to independent practice. In this Commentary, we highlight the problem of decreasing autonomy in surgical residency, outline specific threats to resident autonomy, and discuss potential solutions to mitigate the impact of these threats on trainees’ successful transition to independent practice.
The Growing Problem of Decreasing Autonomy
Evidence is mounting that resident autonomy in surgery is under attack. Yeo and colleagues1 demonstrated that 27.5% of surgical residents were concerned about developing confidence to perform procedures independently. Furthermore, 23% of graduating surgical residents felt that residency did not fully prepare them for practice as an attending surgeon,2 and there has even been concern that the current environment of surgical education has left graduates unprepared for fellowship.3
This lack of confidence is not surprising when considering data on the numbers and types of key cases performed by residents. A review of operative logs of general surgery residents in 2005 demonstrated that 34% of procedures considered essential by program directors were performed at a median of less than five times during residency.4 Malangoni and colleagues compared resident operative logs in 2010 and 2011 with those from 2005; although the overall numbers of cases performed increased, the difference was driven by higher numbers of laparoscopic cases and lower numbers of open operations.5
The number of operations a resident performs in training is not the sole determinant of competence and readiness for independent practice, but it is certainly an important factor. The development of cognitive and technical skills occurs with exposure to a wide spectrum of general surgical disease and with practice. Residents exposed to fewer cases have fewer opportunities to learn and practice the skills necessary to develop autonomy and competence. Thus, the adage “practice makes perfect” might be best modified to “practice makes competent”—a tenet that is being eroded in the current GME environment. Multiple barriers exist that contribute to this erosion of resident autonomy and decreased operative experience, including differing views of autonomy, financial forces, duty hours regulations, and diverse community health care needs. Identifying these barriers and developing solutions to overcome them are vital first steps in reversing the trend of diminishing autonomy in residency training.
Barriers to Resident Autonomy
A recent survey showed a disconnect between faculty and residents’ perceptions about the level of autonomy granted during a procedure, with faculty believing they were providing more autonomy during a case than that perceived by residents.6 The intended learning objectives also differed whereby residents hoped to learn more about the technical aspects of an operation (use of instruments, operative field exposure, etc.) while faculty focused more on teaching decision making.7 Confusion about the learning objectives of a case may hinder the resident’s ability to begin thinking and functioning independently and consequently affects the level of autonomy granted by the supervising attending.
External regulations and financial pressures also contribute to the erosion of resident autonomy in training. The Health Care Financing Administration and Centers for Medicare and Medicaid Services reimbursement guidelines mandate that attending faculty be present and scrubbed for all “critical” portions of a procedure and that they provide a degree of supervision commensurate with the skill level of the operating resident.8 To provide successful supervision and assign an appropriate level of autonomy, faculty must be able to accurately assess the level of skill at which the resident is performing. This difficult task is complicated by the subjective nature of this assessment and the variability in how different faculty provide supervision, both of which may lead to inconsistency in the level of autonomy given to an individual resident over time.
The need for faculty members to generate sufficient relative value units creates external pressure on them to complete cases and turn over operating rooms as expediently as possible. The pressure on faculty to meet financial targets is also influenced by the growing reliance of academic centers on clinical revenue to fund vital missions, including resident training. These financially driven goals are often at odds with the goals of offering residents requisite experiences through competency-based training models.
Accreditation Council for Graduate Medical Education (ACGME) duty hours regulations represent another barrier to resident autonomy and have had a major effect on the time that residents spend in the actual practice of surgery. The limit of an 80-hour workweek has led to an estimated 20% reduction in hours of patient exposure for surgical residents.9 Decreased time in the hospital has led to a decrease in junior resident experience as first assistant and operating surgeon.10 Residents are losing exposure to emergency cases, traditionally the cases that allowed for greater autonomy, in night float systems made necessary by the most recent duty hours restrictions. The impact of these losses is exacerbated in our time-based (rather than competency-based) GME system, in which educators must now develop autonomous residents in the same number of years but with fewer hours per year.
Diverse community needs add a layer of complexity to the issue of autonomy. Many communities in the United States rely heavily on newly graduated resident physicians to enter the workforce immediately and to be competent at a broad array of skills, many of which are underrepresented in residency training. For example, surgeons in rural communities face a scope of practice that can be difficult to replicate in residency training, especially in nonrural programs. These communities have constant and immediate needs that cannot wait for residents to attain additional fellowship training before they can be met. Thus, surgical training faces the challenge of developing residents who are prepared to practice independently in settings that may differ significantly from those in which they are trained.
Overall, these obstacles have contributed to the erosion of resident autonomy and quality faculty supervision that are necessary to allow trainees to hone their abilities, develop confidence, and make decisions on the types of procedures they will perform in independent practice. Potential strategies exist to overcome each of these barriers and to promote greater resident autonomy and preparation for independent practice.
Strategies to Preserve and Promote Autonomy
The American College of Surgeons (ACS), in conjunction with the American Board of Surgery (ABS), the Residency Review Committee for Surgery, and the Association of Program Directors in Surgery, has launched a “Fix the Five” initiative to review training in general surgery and make recommendations for substantive change. Leaders from these groups have defined seven focus areas: organizational commitment; transitions during surgery residency; structured curricula, assessment, proficiency-based training, and advancement; sufficient autonomy for residents; environment of residency education, including duty hours, fiscal resources, and support systems; faculty development and support; and end product of surgical training.11 Many, if not all, of the seven focus areas outlined in this initiative are relevant to the issue of shrinking autonomy, highlighting the issue’s prominent stature at strategic levels. This collaborative effort at the national level reflects the importance of ensuring quality training for our next generation of surgeons.
In an effort to improve resident and faculty congruence about intraoperative autonomy, researchers at Northwestern University have developed the Zwisch scale, a four-step scale designed to document the amount of assistance a resident requires to complete an operation.12 In the first step, “show and tell,” the supervising attending demonstrates all steps of the operation to the trainee. This is followed by the “active help” phase in which the attending provides guidance of each step of the operation to the trainee, and the “passive help” phase, in which the resident sets the pace and leads the operation. During these three phases the attending is still required to optimize the progression of the case. Finally, in the “supervision only” phase, the resident is able to perform the case with only minimal oversight from the attending.
The Zwisch scale creates a common taxonomy that residents and faculty can use to better understand where residents stand in the progression to autonomous practice. A smartphone-based, multi-institutional project led by the Massachusetts General Hospital and Northwestern University is currently under way to test the ability of the Zwisch scale to assess and document trainees’ intraoperative performance and level of autonomy across the continuum of surgical training. Such initiatives will play an important role in advancing a national conversation on resident autonomy by use of clear terms and a mutually agreed-on progression matrix.
A trainee’s technical proficiency in operative skills significantly influences the level of autonomy he or she experiences in the operating room; accordingly, faculty must be able to accurately assess level of proficiency in order to assign appropriate autonomy. The ACS/Association of Program Directors in Surgery Skills Curriculum includes verification of proficiency (VOP) tools for trainees learning basic surgical skills.13 VOP tools include checklists to help provide specific feedback on performance as well as global rating scales for summative assessment and provide objective data to faculty about a trainee’s surgical abilities, making them useful at all levels of proficiency.
Ultimately, VOP determines a resident’s qualification to progress to independent practice at the end of training, and recent changes have incorporated elements of VOP throughout residency. The ACGME and ABS Milestones project provides a standardized assessment of resident performance to be used by program directors during semiannual performance meetings with residents. The milestones are meant to assess development in key domains such as Care for Diseases and Conditions and Performance of Operations and Procedures.14 Furthermore, the ABS now requires graduating surgical residents to have written evaluations of six cases performed during the course of their training to be able to sit for the qualifying examination for board certification in general surgery. Simulation has also been included as a requirement, and surgeons must now pass the Fundamentals of Laparoscopic Surgery and Fundamentals of Endoscopic Surgery examinations for certification.
With the major accrediting bodies in surgery moving toward VOP, some programs are developing unique curricula to address training to autonomy in the context of reduced hours of practice. The University of Toronto has been evaluating a competency-based, modular curriculum with VOP for orthopedic surgery designed to reduce the inefficiencies of a traditional, time-based training model.15 Residents are frequently assessed and provided feedback that helps in tailoring their learning and addresses deficiencies in their clinical skills, eliminating many of the inefficiencies of a traditional, time-based curriculum. This curriculum has led to some trainees graduating sooner, when they meet the requirements for VOP. Although not directly translatable to general surgery training, similar principles underlying competency-based training should be considered to enhance general surgery training in the United States.
Given current threats to autonomy and the proclivity of trainees to pursue subspecialty training, there is increasing interest in the role of a year of mentored general surgery practice after residency for those who wish to head straight into surgical practice.16 The Transition to Practice program developed by the ACS is one such program that promotes postresidency autonomy through a mentorship experience with a seasoned general surgeon.17 The program also offers participants the opportunity to gain practice management experience and advanced learning tailored to specific needs encountered in practice that were not adequately addressed during residency.
Resident autonomy remains under scrutiny, and identifying and addressing the threats to resident autonomy is a critical step in ensuring the safe transition to independent practice. Academic physicians ensure patient care and safety in clinical practice through supervision of trainees and must also ensure that the next generation of physicians is trained to practice safely and independently. Graduated responsibility and supervision commensurate with residents’ ability advance the confidence required for learners to safely transition to autonomous practice. Educators, administrators, and the general public should consider carefully ways to address the current barriers to autonomy while maintaining appropriate levels of trainee supervision. In moving beyond the “see one, do one, teach one” model, the goal of GME should be to have our next generation of physicians see more, do more, and teach more to enable them to provide the best care to patients, now and in the future.
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11. Sachdeva AK, director, Division of Education, American College of Surgeons. Personal communication with D. Hashimoto, June 19, 2015.
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17. Richardson JD. ACS transition to practice program offers residents additional opportunities to hone skills. Bull Am Coll Surg. 2013;98:23–27.