Structured Operative Autonomy: An Institutional Approach to Enhancing Surgical Resident Education Without Impacting Patient Outcomes

J Am Coll Surg. 2017 Dec;225(6):713-724.e2. doi: 10.1016/j.jamcollsurg.2017.08.015. Epub 2017 Sep 5.


Background: Although barriers to granting surgical residents autonomy in the operating room are well described, few have proposed practical strategies to overcome these barriers. Our department adopted a multidisciplinary approach to develop a rotation that aimed to grant chief residents structured operative autonomy. In this study, we assess the feasibility of implementation, impact on patient safety, and educational benefit to residents after the program's pilot year.

Study design: During a 1-month rotation, chief residents began cases alone using their own operative block time. The attending surgeon was notified when the critical portion of the operation was reached and supervised its completion. Postoperative complications, intraoperative adverse events, readmissions, operation duration, and length of stay in a subset of patients that underwent a cholecystectomy or appendectomy were compared with patients operated on by standard resident services. Follow-up surveys were administered to residents 1 year after graduation.

Results: One hundred and twenty-four operations, which ranged in complexity, were performed by chief residents. Unadjusted subset analysis comparing the structured operative autonomy (n = 54) and standard resident (n = 718) services outcomes for appendectomies and cholecystectomies revealed no significant differences in 30-day postoperative complications (5.6% vs 4.0%; p = 0.59), major intraoperative adverse events, or readmissions (3.7% vs 3.8%; p = 1.00), respectively. Multivariate analysis performed for 30-day complications (odds ratio 0.8; 95% CI 0.2 to 3.2; p = 0.76) and readmissions (odds ratio 0.4; 95% CI 0.1 to 2.1; p = 0.3) corroborated unadjusted findings. All participants (n = 8) strongly agreed that the rotation eased their transition to fellowship or independent practice.

Conclusions: Structured operative autonomy overcomes known barriers to granting chief residents autonomy in the operating room. When used for select general surgery cases, resident education is enhanced without impacting patient outcomes. This training model has the potential to improve the surgical independence of graduating residents.

MeSH terms

  • Adult
  • Aged
  • Female
  • Humans
  • Internship and Residency* / standards
  • Male
  • Middle Aged
  • Professional Autonomy
  • Specialties, Surgical / education*
  • Treatment Outcome