Abstract
Purpose
There is growing concern over the readiness of orthopedic surgical residents and fellows for independent surgical practice upon completion of their training. This study aims to explore orthopedic surgery (OS) trainees’ experience of accessing operative autonomy by eliciting their perceptions and techniques implemented to gain autonomy.
Methods
OS residents and fellows were invited to participate in focus group interviews via a convenience sampling approach. A non-faculty facilitator led the discussions using an interview guide to prompt conversation. All interviews were recorded, de-identified, and then transcribed. Three investigators iteratively analyzed transcripts to identify emerging themes until thematic saturation was achieved. All interviews were performed at Ohio State University Wexner Medical Center, an academic medical institution, in Columbus, Ohio.
Results
A total of 16 residents and 2 fellows participated. Two themes emerged: (1) optimal setting: trainees were allowed more operative autonomy in trauma and on-call cases than elective cases, though they perceived it was their responsibility to earn autonomy; (2) techniques: two techniques promote trainees’ access to autonomy, including trainee-initiated techniques (i.e., building relationship, preoperative planning, knowing attending preferences, and effective communication); and (3) faculty-initiated techniques (i.e., setting expectations, indications conference, and providing graduated autonomy).
Conclusions
Our study findings suggest OS trainees tend to access least autonomy in elective OS cases. Although trainees perceived earning autonomy as their responsibility, faculty and resident development is recommended to enhance teaching and learning techniques to increase trainees’ practice readiness.
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Data availability
There is no associated data available for this study.
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Acknowledgements
I would like to thank the Department of Orthopaedics, including the orthopedic trainess and faculty, for making this study possible. Specifically, I would like to acknowledge Dr. Duerr, Dr. Flanigan, and Dr. Chen for providing critical guidance and support, as well as the rest of the Orthopaedic Surgery and Sports Medicine faculty. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Funding
No funding was received for conducting this study.
Author information
Authors and Affiliations
Contributions
All authors contributed to the study conception and design. Mr. Hollman completed the study design, executed the group interviews, and transcribed the interviews. Mr. Hollman drafted the manuscript and along with Dr. Duerr. Mr Hollman, Dr. Duerr, and Dr. Flanigan analyzed the transcriptions for appropriate themes. Ms. Coffey-Noriega and Dr. Chen revised the manuscript for important intellectual content. All authors read and approved the final manuscript.
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Conflict of interest
All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript.
Ethical approval
This study utilized interview procedures. The Ohio State University IRB board has confirmed that this study remains exempt from ethical approval.
Consent to participate
Informed consent was obtained from all individual participants in the study.
Consent to publish
The authors affirm that human research participants provided informed consent for publication of their statements in Tables 1, 2 and 3.
Appendix A
Appendix A
Focus group interview questions | Purpose |
|---|---|
First, I’d like to introduce the overall goal of this discussion: To help future residents and fellows gain more autonomy by demonstrating increased preparation and entrustability in the OR. We are interested in knowing your preferred techniques, decision-making, and self-improvement experience | The purpose of this section is to specify the goal of the discussion |
Notes: | |
When you hear the words “autonomy” and “entrustment” what comes to mind? Prompting questions: Q1: How do you define them? Q2: How do you show that you trust a resident or fellow? - Can you give specific examples? Does this vary by situation? How? Q3: Which case(s) do you feel a resident should be able to do completely on their own upon graduating? Is this because of the ease of the procedure, the frequency it is performed, or some other reason(s)? Is this a product of a residents having more chances to practice this procedure independently? | The purpose of this section is to start defining “autonomy” and “entrustment” to ensure our discussions are on the same page |
Notes: | |
[Trainee name] Can you tell me, what was your favorite case you did with a resident this week? What about this case did you like? What was the resident’s level of involvement/autonomy? Follow-up if high autonomy—why did you allow the resident to perform the procedure rather autonomously? Were they well prepared? Did they make a plan in advance? Prompting questions: Q4: What is your preferred technique? Q5: Does your preferred technique differ from that of other attendings? Q6: Why do you choose to perform this procedure that way? Any other comments? | The purpose of this section is to prompt their experience in preferred techniques and decision-making |
Notes: | |
Tell me about some challenges you have had with decision-making, such as deciding when to operate on patients? When not to? What to do in the OR? etc Prompting questions: Q7: Can you give me some examples? | The purpose of this section is to extract examples |
Notes: | |
We all need to do M&M Prompting questions: Q8: Is there anything that you learned that specifically has changed your practice? Q9: When you see a resident present at M&M, does this ever change how you will operate with this resident in the future? Can it have a positive or negative impact on the autonomy you are willing to give them or how much you trust them? | The purpose of this section is examining the effect of M&M and complications on trainee’s development |
Notes: | |
Let us discuss how you have seen residents gain autonomy in your time as an attending Q10: How have residents successfully gained your trust and consequently increased autonomy in the OR? Prompting questions: - What steps can they take before a procedure to gain entrustment? During? After? - If they answer with mastery of a particular skill: How do you find opportunities for residents to demonstrate mastery? - Do your strategies vary for different residents? | The purpose of this section is to gather information on trainee’s perspective for building autonomy |
Notes: | |
Lastly, is there anything that could help future chief residents learn better, but we currently lack or we are not aware of at the beginning of the chief year? Prompting question: Q11: Can you give some advice that helps our upcoming [chiefs/whatever PGY-level currently at] learn better or get more autonomy in the OR? | The purpose of this section is building on future improvement |
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Hollman, J., Coffey-Noriega, E., Chen, X. et al. Accessibility of operative autonomy from orthopedic surgery resident and fellow perspectives. Global Surg Educ 2, 72 (2023). https://doi.org/10.1007/s44186-023-00150-4
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DOI: https://doi.org/10.1007/s44186-023-00150-4