Trainee Autonomy and Patient Safety

T he ultimate goal of surgical residency must be to train surgeons who are safe and independent. There is accumulating evidence that many graduating residents have not achieved that goal. Although the precise reasons for these findings remain unknown, elements such as the 80-hour work-week, increased faculty-to-resident ratios, and reduced experience with open operations have all been hypothesized to play a role. Recently, the erosion in resident autonomy has received increased attention. Patient expectations and the health care system have both undergone dramatic change over the past 30 years, change that has put pressure on the traditional Halstedian model of progressive resident independence. For example, graduated independence has been diminished by changes designed to enhance patient safety, including limits on concurrent surgery and rules mandating specific supervisory behaviors by attendings. These rules are often made because patients, administrators, and payers assume that patient outcomes are universally improved with less resident autonomy, despite the lack of any evidence that appropriately supervised residents are unsafe. The impact of these changes is compounded by growing clinical productivity expectations for academic surgeons. If a supervising surgeon must increase their productivity but is not permitted to delegate responsibility, the expected outcome is less resident autonomy. As a result, senior residents today usually perform the critical portion of procedures with the attending scrubbed and guiding the operation. The potential long-term consequences of these changes are troubling. Patient safety is a genuinely vital concern of the present, but new policies must also account for the role that graduated responsibility plays in achieving that same goal in the future. A myopic pursuit of safety at the expense of learning threatens to produce future surgeons who are less competent. While the shortterm priorities of our current health care system are important, if they undermine the training process, then these priorities are unsustainable. To realize these goals over the long-term, we must critically assess the amount and impact of progressive autonomy granted to