J. P. Fryer1, J. Bohnen2, B. George3, M. Schuller1, D. DaRosa1, L. Torbeck4, J. Mullen2, S. Meyerson1, E. Auyang5, J. Chipman6, J. Choi4, M. Choti14, E. Endean7, C. Foley8, S. Mandell9, A. Meier10, D. Smink11, K. Terhune12, P. Wise13, N. Soper1, J. Zwischenberger7, K. Lillemoe2, R. Williams4 1Northwestern University,Surgery,Chicago, IL, USA 2Massachusetts General Hospital,Surgery,Boston, MA, USA 3University Of Michigan,Surgery,Ann Arbor, MI, USA 4Indiana University,Surgery,Indianapolis, IN, USA 5University Of New Mexico,Surgery,Albuquerque, NM, USA 6University Of Minnesota,Surgery,Minneapolis, MN, USA 7University Of Kentucky,Surgery,Lexington, KY, USA 8University Of Wisconsin,Surgery,Madison, WI, USA 9University Of Washington,Surgery,Seattle, WA, USA 10State University Of New York,Surgery,Syracuse, NY, USA 11Brigham And Womens,Surgery,Boston, MA, USA 12Vanderbilt,Surgery,Nashville, TN, USA 13Washington University,Surgery,Saint Louis, MO, USA 14University Of Texas Southwestern,Surgery,Dallas, TX, USA
Introduction: Supervising residents performing operative procedures requires balancing patient safety and resident learning needs. Little is known about how faculty decide the appropriate amount of guidance to provide to a resident. This study explores the contributions of 4 possible influencing factors: resident preparedness/performance in current case, case complexity, resident level of training (post-graduate year, PGY), and prior faculty guidance behavior.
Methods: Attending surgeon guidance patterns were captured across 15 general surgery residency programs over a 9 month period (10/15- 6/16). Attending surgeons rated the following for each operation: a) guidance level provided to residents, b) resident preparedness/performance (Table 1), and c) relative case complexity (easiest 1/3, median 1/3, hardest 1/3). Prior faculty guidance behavior was calculated as the average of guidance ratings on all PGY4 resident operations in the study period. Faculty who had performed ? 3 procedures with PGY4 residents were excluded from analysis. Descriptive statistics, correlational analyses, and multiple regression analyses were performed to explore the relative contribution of each factor.
Results: Attending surgeon assessments were completed for 7,297 resident operative performances. In univariate analyses, faculty evaluation of resident preparedness/performance in the current case was the strongest determinant of how much guidance they felt the need to provide (r=0.69, 47.7% of decision variance). Each additional factor led to a smaller but still significant improvement in predictability of faculty guidance decisions. The 4 factors together accounted for 54.5% of decision variance (r = 0.74). Semi-partial correlations revealed that the factors each accounted for the following amounts of decision variance: resident’s operative performance 21.8%, attending surgeon prior guidance habits 4.5%, case complexity 2.0% and resident PGY level 0.9% of variance. Overall, 29.3% of resident performances deemed “practice ready” occurred with “supervision only”. This increased to 75.7% when resident performances were rated “exceptional”. Surprisingly, just 38.5% of senior resident cases rated as easiest 1/3 occurred with “supervision Only”.
Conclusion: A resident’s real-time performance during an individual operation is the most important factor used by faculty to determine how much guidance is needed, outweighing PGY level, prior faculty guidance behavior, and case complexity. Strategies are needed to improve resident preparedness/performance on a daily basis so faculty can feel comfortable using guidance strategies that allow more operative autonomy while preserving patient safety.
