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BACKGROUND: Open reduction and internal fixation are the gold-standard treatment for displaced patellar fractures. The current literature remains inconclusive on the relationship between resident participation in the operating room and optimal patient outcomes. We hypothesize that surgeries performed solely by residents, without attending supervision, can provide similar outcomes to those performed by fellowship-trained orthopedic surgeons, providing new insights into the relationship between resident autonomy and surgical outcomes in the field of orthopedic trauma. METHODS: A tertiary trauma center cohort was retrospectively reviewed for all surgically treated patellar fractures between 2015 and 2020. The cohort was divided into 2 groups: patients operated by residents and patients operated by orthopedic trauma specialists. Demographics, surgical parameters, and radiographs were compared between the groups to evaluate complications and reoperation rates, radiographic outcomes (such as hardware failure, or loss of reduction), and clinical outcomes (including residual pain, painful hardware, decreased range of motion, and infections). RESULTS: A total of 129 patellar fractures were included in the study. Demographics and ASA were similar between the groups. There were no significant differences in complications (p = 0.900) or reoperation rates (p = 0.817), with an average follow-up time of 8 months (SD ± 5.3). Residents had significantly longer surgery duration (p =0.002). However, the overall length of stay was shorter in the resident group (p < 0.001). CONCLUSION: The study shows patellar fracture surgery performed by adequately trained residents can provide similar outcomes to those performed by fellowship-trained orthopaedic trauma surgeons. These findings highlight the significance of surgical autonomy in residency and its role in contemporary surgical education.

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INTRODUCTION: This retrospective study aims to analyze the impact of standardized rules for teaching in university hospitals on surgical resident autonomy and patient safety, as measured by patient outcomes, and also examines the learning curves for residents and their impact on patient outcomes in a non-teaching hospital. METHODS: The data for the study was collected retrospectively from medical records of 2000 adult patients who went through surgical procedures from January 2020 to December 2022. Participants were categorized into two groups based on the supervision level provided by attending surgeons and residents. Appropriate statistical methods were used to analyze the data. RESULTS: It was observed that operative times of cases handled by both attending and resident surgeons were less than those handled by residents alone. On the other hand, the former group had a significantly higher burden of comorbidities and higher rate of perioperative complications than the latter. These results have important implications for the training of medical residents and the overall delivery of healthcare services in university hospitals. CONCLUSION: The findings will also help towards better understanding of the effectiveness of these rules and their potential for improving the quality of care provided by residents in these settings.

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BACKGROUND: Previous work has demonstrated that residents are able to accurately perceive the intraoperative motivational style of faculty. Additionally, alignment of motivational style between residents and faculty has been demonstrated to enhance resident intraoperative autonomy. This study evaluated if faculty perception of resident behaviors aligned with resident self-perception in order to identify ways of enhancing intraoperative learning. METHODS: General surgery residents were asked to complete a self-assessment evaluating their own intraoperative behaviors. Conversely, faculty rated how strongly the residents exhibited these behaviors in the operating room. RESULTS: Of the 10 intraoperative behaviors that were evaluated, eight demonstrated no correlation between resident self-perception and faculty perception of resident behavior. Similarly, inconsistent correlations emerged when behaviors were assessed according to the self-reported gender and race of the resident. CONCLUSION: Faculty are not able to accurately perceive the motivational style of residents. Strategies to improve faculty perception of resident motivational style may enhance intraoperative learning.

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BACKGROUND: The purpose of the study was to investigate the relationship between the independent practice time of residents and the quality of care provided in the Emergency Department (ED) across three urban hospitals in Taiwan. The study focused on non-pediatric and non-obstetric complaints, aiming to provide insights into the optimal balance between resident autonomy and patient safety. METHODS: A comprehensive retrospective study was conducted using de-identified electronic health records (EHRs) from the hospital's integrated medical database (iMD) from August 2015 to July 2019. The independent practice time was defined as the duration from the first medical order by a resident to the first modifications by the attending physician. The primary outcome was revisits to the ED within 72 h following discharge. Statistical analysis was conducted using RStudio and pyGAM. RESULTS: The study identified several factors associated with shorter independent practice times (< 30 minutes), including older patient age, male sex, higher body temperature, higher heart rate, lower blood pressure, and the presence of certain comorbidities. Residents practicing independently for 30-120 minutes were associated with similar adjusted odds of patient revisits to the ED (OR 1.034, 95% CI 0.978-1.093) and no higher risk of 7-day mortality (OR 0.674, 95% CI 0.592-0.767) compared to the group with less autonomy. However, independent practice times exceeding 120 minutes were associated with higher odds of revisiting the ED within 72 h. For the group with 120-210 minutes of independent practice time, the OR was 1.113 (95% CI: 1.025-1.208, p = 0.011). For the group with > 210 minutes, the OR was 1.259 (95% CI: 1.094-1.449, p = 0.001), indicating an increased risk of adverse outcomes as the independent practice time increasing. CONCLUSIONS: The study concludes that while providing residents an independent practice time between 30 to 120 minutes may be beneficial, caution should be exercised when this time exceeds 120 minutes. The findings underscore the importance of optimal supervision in enhancing patient care quality and safety. Further research is recommended to explore the long-term effects of different levels of resident autonomy on patient outcomes and the professional development of the residents themselves.

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OBJECTIVE: To assess the educational of value of teaching assistant (TA) cases from the perspectives of attending, chief resident, and junior resident. We hypothesized the greatest educational value of TA cases would be for chief residents more so than other team members. DESIGN: A prospective survey was designed and collected for TA cases separately from attendings, chief residents, and junior residents to assess operative details and educational value. The study period ran from August 2021 through December 2022. Qualitative and quantitative analysis was undertaken to compare answers and discover themes in the free-text responses of attendings and residents. SETTING: Single center, tertiary care institution, Maine Medical Center, Department of Surgery, Portland, ME PARTICIPANTS: Sixty-nine teaching assistant cases were captured from a total of 117 completed surveys that were completed by 44 chief residents, 49 junior residents, 22 attendings (n = 22) and 2 APPs. RESULTS: A wide variety of TA cases were included in the study with the most common reason for performing a TA case being resident request 68%. Operative complexity was most commonly rated easiest third (50%) and middle third (41%) of overall cases. Both junior and chief residents felt that compared to working with an attending alone, TA cases contributed more or much more to their procedural independence >80% of the time. Attendings reported learning something about the resident's skills that they were not expecting in 59% of the cases. Thematic analysis: attendings focused on the steps of the procedure, including the technical aspects, particularly regarding opening while residents largely focused on communication and preparation. CONCLUSIONS: Teaching assistant cases seem to have more educational value for chief and junior residents than attendings. Both junior and chief residents felt that compared to working with an attending alone, TA cases contributed more or much more to their procedural independence >80% of the time.

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OBJECTIVE: Robotic-assisted surgery is an increasing part of general surgery training, but resident autonomy on the robotic platform can be hard to quantify. Robotic console time (RCT), the percentage of time the resident controls the console, may be an appropriate measure of resident operative autonomy. This study aims to characterize the correlation between objective resident RCT and subjectively scored operative autonomy. METHODS: Using a validated resident performance evaluation instrument, we collected resident operative autonomy ratings from residents and attendings performing robotic cholecystectomy (RC) and robotic inguinal hernia repair (IH) at a university-based general surgery program between 9/2020-6/2021. We then extracted RCT data from the Intuitive surgical system. Descriptive statistics, t-tests and ANOVA were performed. RESULTS: A total of 31 robotic operations (13 RC, 18 IH) performed by 4 attending surgeons and 8 residents (4 junior, 4 senior) were matched and included. 83.9% of cases were scored by both attending and resident. The average RCT per case was 35.6%(95% CI 13.0%,58.3%) for junior residents (PGY 2-3) and 59.7%(CI 51.1%,68.3%) for senior residents (PGY 4-5). The mean autonomy evaluated by residents was 3.29(CI 2.85,3.73) out of a maximum score of 5, while the mean autonomy evaluated by attendings was 4.12(CI 3.68,4.55). RCT significantly correlated with subjective evaluations of resident autonomy (r=0.61, p=0.0003). RCT also moderately correlated with resident training level (r=0.5306, p<0.0001). Neither attending robotic experience nor operation type significantly correlated with RCT or autonomy evaluation scores. CONCLUSIONS: Our study suggests that resident console time is a valid surrogate for resident operative autonomy in robotic cholecystectomy and inguinal hernia repair. RCT may be a valuable measure in objective assessment of residents' operative autonomy and training efficiency. Future investigation into how RCT correlates with subjective and objective autonomy metrics such as verbal guidance or distinguishing critical operative steps is needed to validate the study findings further.

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INTRODUCTION: There are increasing concerns regarding resident autonomy in the context of efficiency, legal ramifications, patient expectations and patient safety. However, autonomy is necessary to develop competent, independent surgeons. Therefore, educational paradigms that maximize opportunities for entrustability without sacrificing patient safety are necessary to ensure adequate training for surgeons. METHODS: This is a prospective, qualitative study of intraoperative role reversal between surgeons and residents. Using Likert scales and binary questions, preintervention and postintervention surveys were collected, evaluating variables including intraoperative learning, decision making, communication, confidence, autonomy and opportunity for safe struggle. The Mann-Whitney U test was used to analyze results and compare responses between training years. RESULTS: Thirty-six general surgery residents comprising post-graduate year 1, 2, 4, and 5 acted as primary surgeon in a total of 36 cases. Preoperative knowledge scores were significantly higher in more senior residents (P < 0.001), but all residents had significant improvement in knowledge scores postoperatively (P < 0.001). The knowledge improvement was quantitatively larger for junior versus senior residents. Intraoperative decision making significantly improved after the intervention for all training levels (P < 0.001). 25 intraoperative "rescues" were performed by faculty for failure to progress or unsafe conditions (23 for junior residents, 2 for senior residents). Residents indicated that this intraoperative role reversal improved preparation, confidence, autonomy, and intraoperative communication. CONCLUSIONS: Intraoperative role reversal between residents and surgeons provides a safe opportunity for maximizing learning and increasing entrustability under direct supervision.

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BACKGROUND: Examining surgical resident operative autonomy within the Veterans Affairs (VA) System, we previously showed residents were afforded autonomy more frequently on Black patients. We hypothesized that, compared to males, female surgical patients receive less attending involvement and more resident autonomy during surgery. METHODS: Retrospective review of all general/vascular surgeries performed at teaching VA hospitals from 2004 to 2019. Operative procedures are coded at the time of surgery as attending primary surgeon (AP), attending with resident (AR), or resident primary surgeon--attending not scrubbed (RP). The primary outcome was the difference in supervision rates between patient sexes. RESULTS: 618,578 operations were examined-24.9% AP, 68.9% AR, and 6.2% RP. Overall, 5.9% of cases were performed on women. The rate of RP cases was higher in males compared to females (6.3% vs 5.3%, p < 0.001). CONCLUSION: Female veterans are less likely to have residents operate on them autonomously. Reasons for this require further characterization.

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OBJECTIVE: We sought to use the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database to determine if there is an increase in morbidity or mortality when resident physicians independently perform laparoscopic cholecystectomy compared to when an attending surgeon is scrubbed. DESIGN: We performed a retrospective review of 54,144 cases of laparoscopic cholecystectomy performed within the Veterans Affairs (VA) Healthcare system from 2000 to 2020. Cases were divided into groups based on if the attending was scrubbed or not scrubbed. We then performed 1:1 case matching without replacement based on sex, race, and major comorbidities. PARTICIPANTS: Veterans over age 18 undergoing laparoscopic cholecystectomy within the VA healthcare system between 2000 and 2020. Cases were excluded if a resident was not involved in the surgery or if the level of autonomy was not defined. RESULTS: Significantly more operative cases were performed without the attending scrubbed before 2003 than after (14.6% vs 1.60%, p < 0.01). After matching, in 1464 (48.6%) cases the attending physician was scrubbed, and in 1549 (51.4%) the attending physician was not scrubbed. Patients were statistically similar in all measured comorbidities between the groups. Operative time was noted to be slightly longer when the attending was scrubbed (1.86 hours ± 0.79 vs 1.72 ± 0.67, p < 0.01) as well as increased complication rates (9.0% vs 6.1%, p < 0.01). No differences existed for 30-day mortality (0.8% vs 0.5%, p = 0.416), postoperative length of stay (2.7 days vs 2.96 days, p = 0.43), or superficial infection (1.9% vs 1.7%, p = 0.73). CONCLUSIONS: Our analysis of the VASQIP database indicates that decreased resident supervision during laparoscopic cholecystectomy has minimal impact on patient outcomes. Rates of resident independent operating have declined 10-fold since the early 2000's. Further research is required to better define the changes in resident surgical education and their impact on patient outcomes.

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INTRODUCTION: With improved technology and technique, laparoscopic inguinal hernia repair (LIHR) has become a valid option for repairing both initial and recurrent inguinal hernia. Surgical residents must learn both techniques to prepare for future practice. We examined resident operative autonomy between LIHR and open inguinal hernia repair (OIHR) across the Veterans Affairs (VA) system. METHODS: Utilizing the VA Surgical Quality Improvement Program database, we examined inguinal hernia repairs based on the principal procedure code at all teaching VA hospitals from July 2004 to September 2019. All VA cases are coded for level of supervision at the time of surgery: attending primary surgeon (AP); attending scrubbed but resident is a primary surgeon (AR), and resident primary with attending supervising but not scrubbed (RP). Primary outcomes were the proportion of LIHR versus OIHR and resident autonomy over time. RESULTS: A total of 127,497 hernia repair cases were examined (106,892 OIHR and 20,605 LIHR). There was a higher proportion of RP (8.7% vs 2.2%) and lower proportion of AP (23.9% vs 28.4%) within OIHR compared to LIHR (p < 0.001). The overall proportion of LIHR repairs increased from 9 to 28% (p < 0.001). RP cases decreased for LIHR from 9 to 1% and for OIHR from 17 to 4%, while AP cases increased for LIHR from 16 to 42% and for OIHR from 18 to 30% (all p < 0.001). For RP cases, mortality (0 vs 0.2%, p > 0.99) and complication rates (1.1% vs. 1.7%, p = 0.35) were no different. CONCLUSIONS: LIHR at VA hospitals has tripled over the past 15 years, now compromising nearly one-third of all inguinal hernia repairs; the majority are initial hernias. Despite this increase, resident autonomy in LIHR cases declined alarmingly. The results demonstrate an urgent need to integrate enhanced minimally invasive training into a general surgery curriculum to prepare residents for future independent practice.

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OBJECTIVE: The objective of the study is to compare faculty and resident perspectives regarding the competencies of an outstanding surgical educator in practice. DESIGN: An IRB-approved survey instrument using a five-point Likert scale assessing 50 competencies and behaviors of a surgical educator was sent to study participants. The competencies and behaviors examined were within the domains of: 1) medical knowledge 2) learner-centeredness 3) interpersonal and communication skills 4) professionalism and role-modeling, and 5) intraoperative teaching. Study participants were asked to rate their level of agreement or disagreement regarding each individual competency as being a requirement for an effective surgical educator. T-test was used to compare faculty surgeons' and residents' responses, and statistically significance was defined as p<0.05. SETTING: University Hospitals Cleveland Medical Center, a tertiary care academic institution PARTICIPANTS: Residents, fellows, and attending surgeons in surgical specialties. RESULTS: There were 115 study participants, 55 faculty and 60 residents. Twelve of 50 (24%) assessed surgical education competencies were rated significantly differently by faculty and residents, with 6 of 12 (50%) being in the category of "intraoperative teaching." There were no differences in faculty and resident responses to competencies/behaviors in the category "interpersonal and communication skills". There were differences in 2 of 7 (28.6%) competencies in the category "medical knowledge", 2 of 15 (13.3%) competencies in the category "learner centeredness", 1 of 10 (10%) in the category "professionalism and role-modeling", 1 of 9 (11.1%) in the category "professionalism and role-modeling", and 6 of 12 (50%) in the category "intraoperative teaching". CONCLUSIONS: In general, there is agreement amongst surgical faculty and residents regarding the competencies and behaviors of an effective surgical educator. The main area of difference is in the perception of educator qualities and behaviors necessary for effective intraoperative teaching.

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INTRODUCTION: Appropriate faculty supervision and conditional independence of residents during training are required for autonomous and independent postgraduate practice. However, there is a growing concern that competence for transition to independent practice is not universally met. We hypothesize that surgery residents play a significant and active role in achieving their own independent status. METHODS: Over seven academic years (July 2014 through June 2021), 46 surgeons supervised and intraoperatively assessed the performance of 51 residents using validated Objective Structured Assessment of Technical Skill (OSATS) and Zwisch Operative Autonomy (ROA) assessments. Resident readiness to perform procedures independently (RRI) was graded as yes, no, or not applicable. Data were analyzed using descriptive statistics with categorical variables reported as frequencies and percentages. RESULTS: A total of 1657 elective procedures were performed by residents supervised by faculty. Association between RRI and postgraduate year (PGY), OSATS scores, ROA, resident and faculty gender, and case complexity was analyzed. Results indicated positive correlation between RRI and summative OSATS score (r = 0.510, P < 0.001), PGY (r = 0.535, P < 0.001) and ROA (r = 0.473, P < 0.001). Percentage of overall RRI increased from 7% at PGY1 to 87.4% at PGY5. Meaningful autonomy ratings increased from 23.6% at PGY1 to 92.5% at PGY5. Variations in ratings was observed when considering case category and complexity. CONCLUSIONS: RRI increases with years of training with variation when considering the specialty/The Accreditation Council for Graduate Medical Education procedure category and the complexity of cases. Specialty fellowships are a viable option to address the gap in The Accreditation Council for Graduate Medical Education categories when residency alone cannot reach appropriate independence. Residents' technical skills play a crucial role in evaluating RRI and granting operative autonomy.

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BACKGROUND: General surgery residency graduates are expected to be proficient in straightforward endocrine operations. This study aimed to elucidate residents' self-assessment of their ability to perform common endocrine procedures. METHODS: A fourteen-question survey was emailed to general surgery residents from seven U.S. residency programs regarding their self-assessed ability to perform each step of a straightforward thyroidectomy and parathyroidectomy. Demographics and perceived ability to perform the various procedures were collected. RESULTS: A minority of respondents (17, 27.9%) agreed they could complete a straightforward thyroidectomy for benign disease, with only 11.7% (n = 7) agreeing they could complete a straightforward thyroidectomy for malignant disease. 26.2% (n = 16) of respondents agreed they could complete a straightforward parathyroidectomy. Completed number of cases was significantly associated with greater self-assessed ability to perform the endocrine operations (p = 0.02). CONCLUSIONS: Most general surgery residents surveyed did not feel capable of performing common, straightforward endocrine procedures. Although confidence in operative ability increased with PGY-level and number of cases completed, the majority of PGY-5 residents still did not feel able to perform a thyroidectomy for malignant disease unassisted.

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OBJECTIVES: This study evaluated a training program to support the delivery of consumer directed care (CDC). It was hypothesized that both interventions, compared to the control condition, would demonstrate increased levels of CDC in nursing homes, increased staff practice of CDC, and improved resident QoL. The training plus support group was expected to show greater gains, compared to the training only group. MATERIALS AND METHODS: In a cluster RCT design, 33 nursing homes were randomly allocated to one of three conditions: training plus support, training only, and care as usual. Outcome measures included level of CDC within each home, staff practice of CDC, and resident QoL. RESULTS AND DISCUSSION: Hypotheses for this study were partially supported. Nursing homes became more CDC-oriented but with minimal changes in staff practice of CDC. Resident QoL also demonstrated limited change. The findings are discussed in terms of organizational barriers to change within nursing homes.

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PURPOSE: This study investigates the role of procedure difficulty on attending ratings of supervised levels of independence and procedural performance amongst general surgery residents, while accounting for case complexity. METHODS: Attending ratings for residents were obtained from System for Improving and Measuring Procedural Learning (SIMPL) database. Current procedural terminology (CPT) codes were used to match procedures to a corresponding work relative value unit (wRVU) as a surrogate for procedure difficulty. Three categories of wRVU (<13.07, 13.07-22, >22) were identified using recursive partitioning. Procedures were also divided into 'Core' or 'Advanced' as defined by the American Board of Surgery Surgical Council on Resident Education (SCORE). Temporal advancement in resident skill was accounted for through academic quarterly analysis. A generalized estimating equations (GEE) approach was used to form separate multivariable logistic regression models for meaningful autonomy (MA) and satisfactory performance (SP) adjusted for potential clustering by program, subject, and rater. Models were further adjusted for core/advanced procedures, attending rated complexity, and academic quarter. RESULTS: A total of 33,281 ratings were analyzed. Overall, 51.6% were rated as MA and 44.4% as SP. For core procedures, surgical residents rated as MA (53.5%) and SP (45.7%), which was twice as high as those for advance procedures (MA-29.2%, SP-29.0%). MA and SP both decreased with increasing wRVU (Figure 2 &3). Using a wRVU<13.07 as a reference, the adjusted odds ratios of MA and SP were significantly lower with increasing procedure difficulty, 0.44 for wRVU 13.07-22.0 and 0.24 for wRVU >22.00 (Table 3). Post graduate year (PGY) 5 residents in the final quarter of training obtain MA in 95.5% and SP 92.9% for core procedures with wRVU <13.07 (Table 4). CONCLUSION: Increasing procedural difficulty is independently associated with decreases in meaningful autonomy and satisfactory performance. As residents approach graduation the level of meaningful autonomy and satisfactory performance both reach high levels for common core procedures but decrease as procedural difficulty increases.

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OBJECTIVE: There has been concern expressed amongst the medical educational community regarding the readiness of general surgery residents in the United States to be competent practicing attendings upon graduation and that limited autonomy may be a contributing factor to this unpreparedness. The purpose of this study was to evaluate an RRC-accredited general surgery residency chief resident acute care surgery service with indirect supervision of cases in terms of safety and outcomes compared to traditional general surgeon cases with direct supervision. The study focused on common general surgical procedures, specifically cholecystectomies, appendectomies, and inguinal and ventral hernia repairs. DESIGN: A retrospective review was conducted of patient data from August 2016 to June 2018 to review all patients 16 years old and older who had received one of the following procedures: appendectomy, cholecystectomy, inguinal hernia repair, or ventral hernia repair. Patient characteristics, procedure type, procedure time, estimated blood loss, complications, length of hospital stay, 30-day readmission, 30-day ED visit, need for reoperation, and mortality were compared between attending direct supervision and chief resident indirect supervision surgery services. SETTING: A single institution associated with a community based-university associated hybrid general surgery residency was included in this study. PARTICIPANTS: Patients aged 16 years or older who underwent one of the operations of interest and were discharged between the dates of August 2016 and June 2018. The operations were performed by, or indirectly supervised by, attendings who were both private surgeons and also covered the chief resident service. RESULTS: A total of 1000 cases were reviewed, with a total of 960 included in the final data after exclusions applied. Of the 960 cases included, 68.4% were traditional attending surgeon cases with direct supervision and 31.6% were chief resident service cases with indirect supervision. A total of 161 appendectomies, 396 cholecystectomies, 201 inguinal hernias and 202 ventral hernias were included. Overall, patients in the chief resident service were more often minorities (27.7 vs. 9.4%, p < 0.001), female (56.4 vs. 44.6%, p = 0.001), younger (40 vs. 55 years, p < 0.001), had a higher BMI (31.2 vs. 29.6, p = 0.018), and a lower ASA class (class 1+2 was 86.4 vs. 65.6%, p < 0.001). The median Charleson Comorbidity Index of the chief resident service patients was lower than that of the attending service (0 vs. 2, p < 0.001). Chief resident service cases were also more often urgent cases (40.6 vs. 22.8%, p < 0.001). Overall, the 30-day complication rate was similar between the two services (5.6 vs. 5.8%, p = 1.000). Complications observed from chief resident service and attending service supervised cases included pneumonia (0.3 vs. 0.5%, p = 1.000), surgical site infection (2.3 vs. 1.5%, p = 0.389), UTI (1.0 vs. 0.6%, p = 0.685), acute kidney injury (0.0 vs. 0.8%, p = 0.333), small bowel obstruction (0.0 vs. 0.6%, p = 0.314), cerebrovascular accident (0.0 vs. 0.2%, p = 1.000), and hematoma/seroma (2.3 vs. 1.7%, p = 0.500). There were no statistically significant differences in procedure-specific complications between services. There was one 30-day mortality in the study population, in the attending service group. CONCLUSIONS: This study's data suggest that a chief resident acute care surgery service with indirect supervision of cases is safe in this community with regards to appendectomies, cholecystectomies and hernia repairs.

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Within general surgery education circles, the state of autonomy for residents in surgery training programs has been of growing concern. Although there is no direct evidence showing less autonomy in modern surgical training, multiple surrogates have been cited as reasons for concern. Many reasons have been given for lost autonomy including the 80-hour work week, financial constraints, concerns over quality of patient care, patient expectations, new and innovative technologies, legal limitations, and public opinion. This article discusses the current state of general surgery resident autonomy, why autonomy is important, barriers to autonomy, and ways to support autonomy.

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BACKGROUND: Using the platform of morbidity and mortality conference, we developed and executed a combined faculty-resident intervention called "Education M&M" to discuss challenges faced by both parties in the operating room (OR), identify realistic solutions, and implement action plans. This study aimed to investigate the impact of this intervention on resident OR training. MATERIALS AND METHODS: Two resident case presentations were followed by audience discussion and recommendations regarding actionable solutions aimed at improving resident OR training from an expert faculty panel. Postintervention surveys were completed by participants immediately and 2 mo later to assess perceived short and long-term impact on OR teaching and/or learning and the execution of two recommended solutions. Descriptive statistical analysis was applied. RESULTS: Immediate post-intervention surveys (n = 44) indicated that 81.8% of participants enjoyed the M&M "a lot"; 90.1% said they would use some or a lot of the ideas presented. Awareness of OR teaching/learning challenges before and after the M&M improved from 3.0 to 3.7 (P = 0.00001) for faculty and 3.0 to 3.9 for trainees (P = 0.00004). Understanding of OR teaching and/or learning approaches improved from 3.1 to 3.7 for faculty (P = 0.00004) and 2.7 to 3.9 for trainees (P = 0.00001). In 2-mo post-intervention surveys, most residents had experienced two recommended solutions (71% and 88%) in the OR, but self-reported changes to faculty behavior did not reach statistical significance. CONCLUSIONS: A department-wide education M&M could be an effective approach to enhance mutual communication between faculty members and residents around OR teaching/learning by identifying program-specific challenges and potential actionable solutions.

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