General Surgery Resident and Faculty Perceptions of Autonomy: A Mixed-Methods Analysis

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Abstract
Purpose Residents consistently underestimate their level of operative autonomy compared to faculty. We sought to understand how residents and faculty conceptualize autonomy to identify sources of perceptual misalignment surrounding entrustment and feedback. Methods A mixed-methods survey was distributed through the Association for Surgical Education to General Surgery residents and attending surgeons. Respondents rated the importance of nine autonomy signals using Likert scales and provided free-text responses. Quantitative analysis included descriptive statistics, Welch’s t-tests, effect sizes (Hedges’ g), and exploratory factor analysis. Qualitative responses underwent thematic analysis to compare resident and faculty conceptualizations of operative autonomy. Results A total of 118 respondents (36 residents, 82 attendings) completed the survey. Residents rated “fraction of the operation performed” (4.0 vs 3.5, p = 0.0049, g = 0.53) and “being allowed to struggle” (4.4 vs 3.6, p < 0.0001, g = 0.84) as more important, while attendings rated “operative preparation” (3.6 vs 3.0, p = 0.0068, g=–0.58) as more important. Exploratory factor analysis identified two latent dimensions in both groups, with shared clustering around technical execution. Residents additionally linked autonomy to correction and attending presence, while attendings clustered preoperative decision-making and preparation. Qualitative analysis revealed shared definitions of autonomy as cognitive ownership rather than task completion but highlighted divergence in how autonomy loss was attributed, the role of safe struggle, and the impact on resident professional identity. These findings informed a conceptual model distinguishing faculty-granted from resident-perceived autonomy. Conclusions Residents and attendings diverge on key elements of operative autonomy, particularly independent struggle, technical execution, and cognitive readiness. A shared mental model of how autonomy is granted, communicated, and experienced may improve alignment of training expectations, feedback, and entrustment decisions.

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