Orthopaedic Surgery Resident and Fellow Perspectives on Autonomy and Entrustment in the Operating Room


Joshua Hollman, David Flanigan, MD, Robert Duerr, MD


There is growing concern over the readiness of orthopaedic surgical residents and fellows for independent surgical practice upon completion of their training. This study evaluates orthopaedic trainee perspectives regarding barriers to autonomy, strategies for gaining autonomy, and the current state of operative autonomy at a single institution.


Semi-structured focus group interviews were conducted with residents and fellows grouped within their post-graduate year (PGY). A non-faculty facilitator led the discussions using a series of prepared questions to stimulate conversation around the theme of successfully gaining autonomy in orthopaedic training. The interviews were then transcribed and examined by three reviewers for emerging themes until thematic saturation was achieved.


A total of 16 residents and 2 fellows participated in the interviews. Themes emerged regarding trainee perceptions of: techniques for gaining operative autonomy (building rapport, preoperative planning, knowing attending preferences, and effective communication), faculty techniques to improve autonomy (setting expectations, indications conference, and providing graduated autonomy), and perceived autonomy in different clinical and operative settings (elective versus non-elective cases).


Residents should focus on building rapport with faculty, creating a strong preoperative plan for each procedure, learning attending surgeon preferences, and communicating effectively to gain attendings' trust in the operating room. While the responsibility of gaining autonomy largely falls on residents, attending surgeons should adopt strategies to help residents. They can set clear expectations for residents and fellows, hold indications conference, provide trainees with graduated autonomy, and allow for trainees to productively struggle during procedures in a safe manner. While many opportunities for surgical autonomy exist on trauma rotations and on call, attending surgeons should make more of a conscious effort to provide these opportunities during elective surgeries.



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