Kerri A. Ohman

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 “operating room set-up” (3.6 vs. 3.0, p = 0.0068, g=–0.58) as more important. Exploratory factor analysis suggested 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. 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.

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.

With increased scrutiny on the quality and cost of health care, surgeons must be mindful of their outcomes and resource use. We evaluated surgeon-specific intraoperative supply cost (ISC) for pancreaticoduodenectomy and examined whether ISC was associated with patient outcomes. Patients undergoing open pancreaticoduodenectomy between January 2012 and March 2015 were included. Outcomes were tracked prospectively through postoperative day 90, and ISC was defined as the facility cost of single-use surgical items and instruments, plus facility charges for multiuse equipment. Multivariate logistic regression was used to test associations between ISC and patient outcomes using repeated measures at the surgeon level. There were 249 patients who met inclusion criteria. Median ISC was $1,882 (interquartile range [IQR] $1,497 to $2,281). Case volume for 6 surgeons ranged from 18 to 66. Median surgeon-specific ISC ranged from $1,496 to $2,371. Greater case volume was associated with decreased ISC (p < 0.001). Overall, ISC was not predictive of postoperative complications (p = 0.702) or total hospitalization expenditures (p = 0.195). At the surgeon level, surgeon-specific ISC was not associated with the surgeon-specific incidence of severe complication or any wound infection (p > 0.227 for both), but was associated with delayed gastric emptying (p = 0.004) and postoperative pancreatic fistula (p < 0.001). In a single-institution cohort of 249 pancreaticoduodenectomies, high-volume surgeons tended to be low-cost surgeons. Across the cohort, ISC was not associated with outcomes. At the surgeon level, associations were noted between ISC and complications, but these may be attributable to unmeasured differences in the postoperative management of patients. These findings suggest that quality improvement efforts to restructure resource use toward more cost-effective practice may not affect patient outcomes, although prospective monitoring of safety and effectiveness must be of the utmost concern.