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Progressive Entrustment to Achieve Resident Autonomy in the Operating Room: A National Qualitative Study With General Surgery Faculty and Residents

Sandhu, Gurjit PhD*; Magas, Christopher P. MBS; Robinson, Adina B. PhD; Scally, Christopher P. MD; Minter, Rebecca M. MD

doi: 10.1097/SLA.0000000000001782

Objective: The purpose of this study was to identify behaviors that faculty and residents exhibit during intraoperative interactions, which support or inhibit progressive entrustment leading to operative autonomy.

Background: In the operating room, a critical balance is sought between direct faculty supervision and appropriate increase in resident autonomy with indirect faculty supervision. Little is known regarding perspectives of faculty and residents about how attendings increasingly step back and safely delegate autonomy to trainees. Understanding the context in which these decisions are made is critical to achieving a safe strategy for imparting progressive responsibility.

Methods: A qualitative study was undertaken from January 2014 to February 2015. Semistructured interviews were conducted with 37 faculty and 59 residents from 14 and 41 institutions, respectively. Participants were selected using stratified random sampling from general surgery residency programs across the United States to represent a range of university, university-affiliated, and community programs, and geographic regions. Audio recordings of interviews were transcribed, iteratively analyzed, and emergent themes identified.

Results: Six themes were identified as influencing progressive entrustment in the operating room: optimizing faculty intraoperative feedback; policies and regulations affecting role of resident in the operating room; flexible faculty teaching strategies; context-specific variables; leadership opportunities for resident in the case; and safe struggle for resident when appropriate.

Conclusions: Perspectives of faculty and residents while overlapping were different in emphasis. Better understanding faculty–resident interactions, individual behaviors, contextual influences, and national regulations that influence intraoperative education have the potential to significantly affect progressive entrustment in training paradigms.

*Department of Surgery and Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI

Department of Surgery, University of Michigan, Ann Arbor, MI

Division of Surgical Oncology, UT Southwestern Medical Center, Dallas, TX.

Reprints: Gurjit Sandhu, PhD, Assistant Professor, Departments of Surgery and Learning Health Sciences, University of Michigan, 2207 Taubman Center, 1500 E. Medical Center Drive, SPC 5346, Ann Arbor, MI. E-mail:

Funding: This project was supported by The Josiah Macy Jr. Foundation (Board Grant # B15–05) and the University of Michigan Graduate Medical Education Innovations Grant.

Previous presentations: Dr Rebecca Minter (senior author) presented a portion of this work as the Charboneau Distinguished Professor at the University of Toronto February 27, 2015.

The authors report no conflicts of interest.

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