General Surgery Faculty Research Articles

Can grit predict well-being?

BackgroundBurnout affects over 50% of surgical residents, and efforts focused on well-being during training are needed. Grit, defined as perseverance toward achieving long-term goals, is a measure of mental fortitude and may be protective against burnout and predictive of well-being.MethodsAn anonymous electronic survey was distributed to surgical and non-surgical resident trainees as well as general surgery faculty. Grit was measured using a 12-question validated Grit Scale and well-being was measured using a 5-question validated WHO-5 Well-Being Index. Linear regression was used to identify associations between post-graduate year (PGY), grit, and well-being. Student’s t-test was used to compare grit and well-being scores among male and female trainees.Results23/38 (60.5%) surgical residents completed the survey. Grit scores ranged from 3 to 4.67 (scale of 1–5) and well-being scores from 24 to 84 (scale of 0–100). There was no correlation between grit and well-being (R2 = 0.01, p < 0.63) or between PGY class and grit (R2 = 0.06, p < 0.27). However, there was a positive correlation between PGY class and well-being (R2 = 0.18, p < 0.05). Female residents trended towards higher grit (4.12 female vs 3.76 male, p < 0.07) and lower well-being (53 vs 60, p < 0.18). Compared with non-surgical residents, there were no significant differences in mean grit or well-being. The pooled trainee group demonstrated a positive correlation between PGY class and well-being (R2 = 0.09). Faculty reported higher grit (4, p < 0.03) and well-being (68.8, p < 0.002) than residents.ConclusionDespite high overall grit, trainees experience relatively low well-being; this effect is exaggerated in females. Grit and well-being trend to increase with PGY years and as faculty. The lack of association between grit and well-being in trainees suggests that intrinsic grit is not enough; well-being is impacted by external factors and encourages future work to identify and modify these factors for a positive impact on trainees.

Assessing the prevalence of workplace telepressure on resident and attending physicians: A validated scale

BackgroundPhysician wellbeing and burnout are significant threats to the healthcare workforce. Mobile electronic medical record access and smartphones allow for efficient communication in healthcare but may lead to workplace telepressure (WPT). MethodsAn IRB-approved survey related to five domains of burnout [WPT, smartphone usage, boundary control, and psychologic detachment] was circulated. Internal medicine and general surgery faculty and residents were surveyed between 3/2021 and 6/2021. Survey results were analyzed for internal consistency with a Cronbach alpha coefficient and validation against a known physician burnout scale. ResultsThe domains were internally valid with a Cronbach alpha of 0.888. Validation against the physician burnout scale was significantly correlated with WPT domains but was overall positively correlated across domains. Surgical trainees reported the highest burnout rate related to every domain. ConclusionSurvey-based WPT burnout scales provide insight into the daily pressures on physicians. Targeted interventions to limit WPT are needed to improve physician wellbeing.

General Surgery Faculty Knowledge and Perceptions of Breast Pumping Amongst Postpartum Surgical Residents

BackgroundThere is a lack of data regarding the knowledge and perceptions teaching faculty possess about breast pumping among general surgery residents despite breast pumping becoming more common during training. This study aimed to examine faculty knowledge and perceptions of breast pumping amongst general surgery residents.MethodsA 29-question survey measuring knowledge and perceptions about breast pumping was administered online to United States teaching faculty from March–April 2022. Descriptive statistics were used to characterize responses, Fisher’s exact test was used to report differences in responses by surgeon sex and age, and qualitative analysis identified recurrent themes.Results156 responses were analyzed; 58.6% were male and 41.4% were female, and the majority (63.5%) were less than 50 years old. Nearly all (97.7%) women with children breast pumped, while 75.3% of men with children had partners who pumped. Men more often than women indicated “I don’t know” when asked about frequency (24.7 vs. 7.9%, p = 0.041) and duration (25.0 vs. 9.5%, p = 0.007) of pumping. Nearly all surgeons are comfortable (97.4%) discussing lactation needs and support (98.1%) breast pumping, yet only two-thirds feel their institutions are supportive. Almost half (41.0%) of surgeons agreed that breast pumping does not impact operating room workflow. Recurring themes included normalizing breast pumping, creating change to better support residents, and communicating needs between all parties.ConclusionsTeaching faculty may have supportive perceptions about breast pumping, but knowledge gaps may hinder greater levels of support. Opportunities exist for increased faculty education, communication, and policies to better support breast pumping residents.

Use and Perceptions of Shared Decision-Making by General Surgery Faculty and Trainees.

The purpose of this study was to assess the practice and perceptions of shared decision-making (SDM) by both faculty and residents at Boston Medical Center and explore barriers and facilitators to implementing SDM at our institution. We created and distributed an online survey assessing provider demographic and training characteristics, experiences with the informed consent process, practices in SDM, and perceptions about SDM. We used descriptive statistics to summarize provider characteristics and survey responses and univariate analysis to determine associations between them. Fifteen surgeons and 19 surgical residents completed the survey (49% response rate). Most respondents were aware of and had a positive attitude toward SDM (91% and 76%, respectively); 35% reported having SDM training. Providers had varying levels of engagement with different SDM practices, and there were inconsistent associations between provider characteristics and the use of SDM. Often providers thought the patient's health literacy, foreign primary language, clinical condition, and socioeconomic factors were barriers to the SDM process. Although most general surgery faculty and residents at our institution had a positive view of SDM, they engaged in SDM behaviors inconsistently, with no clear association between clinician characteristics and specific behaviors. We identified several barriers to SDM consistent with those identified by providers in other specialties. This highlights the need for further research to study live general surgery provider-patient interactions, as well as structured SDM education to train general surgery providers to reliably engage their patients in effective SDM.

How We Do It: An Innovative General Surgery Mentoring Program

The taxing nature of surgery residency is well-documented in the literature, with residents demonstrating high rates of burnout, depression, suicidal thoughts, sexual harassment, and racial discrimination. Mentoring has been shown to improve camaraderie, address challenges of underrepresentation in medicine, and be associated with lower burnout. However, existing formal mentoring programs tend to be career-focused and hierarchal without opportunity to discuss important sociocultural issues. An innovative approach is needed to address these cultural and anthropological issues in surgery residencies while creating camaraderie and learning alternative perspectives across different levels of training. We sought to describe the framework we used to fill these needs by creating and implementing a novel mentoring program. A vertical, near-peer mentoring system of 7 groups was created consisting of the following members: 1 to 2 medical students, a PGY-1 general surgery resident, a PGY-4 research resident, and a faculty member. Meetings occur every 3 to 4 months in a casual setting with the first half of the meeting dedicated to intentional reflection and the second half focused on an evidence-based discussion regarding a specific topic in the context of surgery (i.e., burnout, discrimination, allyship, and finding purpose). Program implementation took place at the University of Michigan in Ann Arbor, MI. Medical students, general surgery residents, and general surgery faculty were recruited. We have successfully launched the pilot year of a cross-spectrum formal mentoring program in general surgery. This program emphasizes camaraderie throughout training while providing opportunities for evidence-based discussion regarding sociocultural topics. We have included increased opportunities for community inclusivity and mentoring while allowing trainees and faculty members to discuss sensitive topics in a supportive environment. We plan to continue developing the program with robust evaluation and to expand the program to other surgical specialties and to other institutions.

Qualitative perspectives on shared decision-making from general surgery faculty and trainees

PurposeDespite the merits of shared decision making (SDM), it remains underused in surgical fields. Through individual semi-structured interviews with general surgery providers, we explored how surgeons and surgeons-in-training perceive and engage in SDM at our academic safety-net hospital and investigated ways to increase SDM use within our surgical department.MethodsWe developed and administered individual semi-structured interviews to general surgery faculty and residents at our institution to explore their SDM knowledge and attitudes and identify actionable ways to promote SDM in surgery. Their responses were analyzed using inductive content analysis.ResultsProviders expressed positive opinions of SDM, though they also described ambivalence regarding how patients perceive SDM and the role of patients’ families in SDM. Providers identified various barriers to SDM, including time limitations, specific clinical scenarios, and patient-specific factors such as language barriers and socioeconomic status. Providers further elaborated that difficulty communicating their medical knowledge to patients also posed a barrier to SDM.ConclusionsGeneral surgery faculty and residents at our institution have a positive view of SDM. Our findings demonstrated opportunities for provider education on involving patients’ families in SDM and utilizing decision aids, as well as institutional interventions to mitigate barriers posed by language differences, socioeconomic status, and time limitations. Participant responses also suggested areas for further research on the impact of SDM on the patient-provider relationship and adaptation of SDM to patients who prefer greater physician involvement in decision-making.

A multi-institutional study assessing general surgery faculty teaching evaluations

BackgroundResident evaluation of faculty teaching is an important metric in general surgery training, however considerable variability in faculty teaching evaluation (FE) instruments exists. Study designTwenty-two general surgery programs provided their FE and program demographics. Three clinical education experts performed blinded assessment of FEs, assessing adherence 2018 ACGME common program standards and if the FE was meaningful. ResultsNumber of questions per FE ranged from 1 to 29. The expert assessments demonstrated that no evaluation addressed all 5 ACGME standards. There were significant differences in the FEs effectiveness of assessing the 5 ACGME standards (p < 0.001), with teaching abilities and professionalism rated the highest and scholarly activities the lowest. ConclusionThere was wide variation between programs regarding FEs development and adhered to ACGME standards. Faculty evaluation tools consistently built around all suggested ACGME standards may allow for a more accurate and useful assessment of faculty teaching abilities to target professional development.

The Need for Nutritional Education Reform in US Medical Education System.

To compare the setting, quality, and utility of nutritional education received by general surgery residents and faculty surgeons and their perceptions and challenges in managing patient nutritional needs. Cross-sectional analysis utilizing anonymous survey data distributed by the Association of Program Directors in Surgery (APDS) to its affiliated general surgery residency programs. 90.2% (n = 65) of residents and 85.7% (n = 24) of faculty surgeons reported having received nutritional education. The majority (78%) of respondents utilize patient nutrition on a regular basis (monthly or more often), with 54% reporting utilization daily or weekly. Overall, 65% of respondents reported experiencing challenges in managing patient nutritional needs, and 86% agreed that additional nutritional education during training would assist with patient care. Residents and faculty surgeons both significantly reported challenges in determining which specific nutritional formula to use (X2 = 22.414, P = .049). Residents were associated with reporting challenges in successfully managing oral, enteral, and parenteral routes of nutrition (X2 = 16.241, P = .023). Despite receiving nutritional education, the majority of surgery residents and faculty surgeons report difficulty in managing their patients nutritional needs. Surgery residents report difficulties with all delivery modes of nutrition, including oral, parenteral, and enteral. Revising medical school nutritional education competencies to focus on more practical aspects of nutrition, reform of formal course format, greater interprofessional collaboration with dieticians starting at the student level, and enforcement of nutritional education requirements by medical school and residency program accrediting bodies can serve to advance physicians' nutritional knowledge and improve patient outcomes.

Surgical Faculty Perception of Service-Based Advanced Practice Provider Impact: A Southwestern Surgical Congress Multicenter Survey.

A previous single-center survey of trauma and general surgery faculty demonstrated perceived positive impact of trauma and surgical subspecialty service-based advanced practice providers (SB APPs). The aim of this multicenter survey was to further validate these findings. Faculty surgeons on teams that employ SB APPs at 8 academic centers completed an electronic survey querying perception about advanced practice provider (APP) competency and impact. Respondents agreed that SB APPs decrease workload (88%), length of stay (72%), contribute to continuity (92%), facilitate care coordination (87%), enhance patient satisfaction (88%), and contribute to best practice/safe patient care (83%). Fewer agreed that APPs contribute to resident education (50%) and quality improvement (QI)/research (36%). Although 93% acknowledged variability in the APP level of function, 91% reported trusting their clinical judgment. This study supports the perception that SB APPs have a positive impact on patient care and quality indicators. Areas for potential improvement include APP contribution to resident education and research/QI initiatives.

Increased Intraoperative Faculty Entrustment and Resident Entrustability Does Not Compromise Patient Outcomes After General Surgery Procedures.

Intraoperative resident autonomy has been compromised secondary to expectations for increased supervision without defined parameters for safe progressive independence, diffusion of training experience, and more to learn with less time. Surgical residents who are insufficiently entrusted during training attain less autonomy, confidence, and even clinical competency, potentially affecting future patient outcomes. To determine if OpTrust, an educational intervention for increasing intraoperative faculty entrustment and resident entrustability, negatively impacts patient outcomes after general surgery procedures. Surgical faculty and residents received OpTrust training and instruction to promote intraoperative faculty entrustment and resident entrustability. A post-intervention OpTrust cohort was compared to historical and pre-intervention OpTrust cohorts. Multivariable logistic and negative binomial regression was used to evaluate the impact of the OpTrust intervention and time on patient outcomes. Single tertiary academic center. General surgery faculty and residents. Thirty-day postoperative outcomes, including mortality, any complication, reoperation, readmission, and length of stay. A total of 8890 surgical procedures were included. After risk adjustment, overall patient outcomes were similar. Multivariable regression estimating the effect of the OpTrust intervention and time revealed similar patient outcomes with no increased risk (P > 0.05) of mortality {odds ratio (OR), 2.23 [95% confidence interval (CI), 0.87-5.6]}, any complication [OR, 0.98 (95% CI, 0.76-1.3)], reoperation [OR, 0.65 (95% CI, 0.42-1.0)], readmission [OR, 0.82 (95% CI, 0.57-1.2)], and length of stay [OR, 0.99 (95% CI, 0.86-1.1)] compared to the historic and pre-intervention OpTrust cohorts. OpTrust, an educational intervention to increase faculty entrustment and resident entrustability, does not compromise postoperative patient outcomes. Integrating faculty and resident development to further enhance entrustment and entrustability through OpTrust may help facilitate increased resident autonomy within the safety net of surgical training without negatively impacting clinical outcomes.

The Perioperative Services Response at a Major Children's Hospital During the Peak of the COVID-19 Pandemic in New York City.

The Perioperative Services Response at a Major Children's Hospital During the Peak of the COVID-19 Pandemic in New York City.

Documentation Burden on General Surgery Faculty

Cox, Morgan L. MD, MHS; Risoli, Thomas MS; Peskoe, Sarah PhD; Turner, David A. MD; Migaly, John MD, FACS, FASCRS Author Information

Validation of the Omni: A Novel, Multimodality, and Longitudinal Surgical Skills Assessment

The breadth of technical skills included in general surgery training continues to expand. The current competency-based training model requires assessment tools to measure acquisition, learning, and mastery of technical skill longitudinally in a reliable and valid manner. This study describes a novel skills assessment tool, the Omni, which evaluates performance in a broad range of skills over time. The 5 Omni tasks, consisting of open bowel anastomosis, knot tying, laparoscopic clover pattern cut, robotic needle drive, and endoscopic bubble pop, were developed by general surgery faculty. Component performance metrics assessed speed, accuracy, and quality, which were scaled into an overall score ranging from 0 to 10 for each task. For each task, ANOVAs with Scheffé's post hoc comparisons and Pearson's chi-squared tests compared performance between 6 resident cohorts (clinical years (CY1-5) and research fellows (RF)). Paired samples t-tests evaluated changes in performance across academic years. Cronbach's alpha coefficient determined the internal consistency of the Omni as an overall assessment. The Omni was developed by the Department of Surgery at Duke University. Annual assessment and this research study took place in the Surgical Education and Activities Lab. All active general surgery residents in 2 consecutive academic years spanning 2015 to 2017. A total of 62 general surgery residents completed the Omni and 39 (67.2%) of those residents completed the assessment in 2 consecutive years. Based on data from all residents' first assessment, statistically significant differences (p < 0.05) were observed among CY cohorts for bowel anastomosis, robotic, and laparoscopic task metrics. By pair-wise comparisons, mean bowel anastomosis scores distinguished CY1 from CY3-5 and CY2 from CY5. Mean robotic scores distinguished CY1 from RF, and mean laparoscopic scores distinguished CY1 from RF, CY3, and CY5 in addition to CY2 from CY3. Mean scores in performance on the knot tying and endoscopic tasks were not significantly different. Statistically significant improvement in mean scores was observed for all tasks from year 1 to year 2 (all p < 0.02). The internal consistency analysis revealed an alpha coefficient of 0.656. The Omni is a novel composite assessment tool for surgical technical skill that utilizes objective measures and scoring algorithms to evaluate performance. In this pilot study, 3 tasks demonstrated discriminative ability of performance by CY, and all 5 tasks demonstrated construct validity by showing longitudinal improvement in performance. Additionally, the Omni has adequate internal consistency for a formative assessment. These results suggest the Omni holds promise for the evaluation of resident technical skill and early identification of outliers requiring intervention.

Impostor Phenomenon and Burnout in General Surgeons and General Surgery Residents

Impostor phenomenon (IP) characterizes feelings of self-doubt coupled with feelings that achievements were based on luck and a fear of being discovered as an intellectual fraud. Recently, studies have focused on IP in medical trainees and its association with burnout; however, this research has not yet been conducted on surgeons. This study addresses that gap by investigating the prevalence of IP and burnout in general surgeons and surgery residents. Participants completed two unlinked, blinded surveys. The first survey included demographics and scholarly activity, while the second included the Clance Impostor Phenomenon Scale (CIPS) and a validated, single-item burnout score. Hennepin County Medical Center and University of Minnesota, Minneapolis, MN. General surgeons and general surgery residents at two teaching hospitals, one community-based (N = 46) and one university-based (N = 42). The majority of both surgeons and residents were male, Caucasian, and married. Residents scored significantly higher compared to faculty in nearly half of CIPS questions. The overall CIPS score was significantly higher in trainees as well (61 vs 51, p = 0.017). Burnout did not differ significantly between trainees (30%) and faculty (41%) (p = 0.545). We found no significant differences in gender or years of practice in those with clinical IP (CIPS >62), and logistic regression analysis showed burnout as the only significant association for clinical IP symptoms (OR 3.95, p = 0.017). Contrary to studies in other medical fields, female general surgery faculty and trainees were no more likely than males to display characteristics of IP. Residents did; however, score higher than faculty on overall CIPS score. While we cannot determine how burnout and IP directly impact each other, our study shows that both faculty and trainees experiencing burnout are more likely to report symptoms of IP.

Surgical residents and palliative care, hospice care, advance care planning, and end-of-life ethics: An analysis of baseline knowledge and educational session to improve competence

Introduction: The American Board of Surgery expects competence in interdisciplinary palliative care, and dealing with advancing chronic conditions and end-of-life scenarios are part of Accreditation Council for Graduate Medical Education general surgery milestones. Despite established standards, surgical trainees receive limited amounts of formal palliative care training, if any. Objective: The study purpose was to evaluate baseline knowledge and test effectiveness of an educational session for surgical residents focused on palliative care, hospice care, advance care planning (ACP), and related topics. Methods: The study was completed at Northeast Ohio Medical University with participation from general surgery residents, students, and faculty at Northside Regional Medical Center in Youngstown, Ohio. Participation involved a pretest, lecture, and posttest surrounding palliative and hospice care, ACP, and related topics to teach and assess baseline knowledge and usefulness of an educational session based on test comparison. Mean group scores for pre/post-tests were calculated. A paired one-tailed t-test was used to assess effective change in mean scores. Results: Twenty participants completed the session. The mean pretest score for the group was 60%. The mean posttest score for the group was 75%. Results show that, after the 30-min presentation, there was statistically significant improvement between means (P = 0.00002). Conclusions: Palliative care, hospice care, and ACP are not utilized to potential due to poor residency education as indicated by low mean pretest score. Statistically significant improvement between tests indicates that education focused on these topics can remedy the knowledge gap and presumably improve patient care involving these topics. The following core competencies are addressed in this article: Practice-based learning and improvement, Interpersonal and communication skills, Professionalism.

Effect of Ongoing Assessment of Resident Operative Autonomy on the Operating Room Environment

We have previously demonstrated the feasibility and validity of a smartphone-based system called Procedural Autonomy and Supervision System (PASS), which uses the Zwisch autonomy scale to facilitate assessment of the operative performances of surgical residents and promote progressive autonomy. To determine whether the use of PASS in a general surgery residency program is associated with any negative consequences, we tested the null hypothesis that PASS implementation at our institution would not negatively affect resident or faculty satisfaction in the operating room (OR) nor increase mean OR times for cases performed together by residents and faculty. Mean OR times were obtained from the electronic medical record at Northwestern Memorial Hospital for the 20 procedures most commonly performed by faculty members with residents before and after PASS implementation. OR times were compared via two-sample t-test. The OR Educational Environment Measure tool was used to assess OR satisfaction with all clinically active general surgery residents (n = 31) and full-time general surgery faculty members (n = 27) before and after PASS implementation. Results were compared using the Mann-Whitney rank sum test. A significant prolongation in mean OR time between control and study period was found for only 1 of the 20 operative procedures performed at least 20 times by participating faculty members with residents. Based on the overall survey score, no significant differences were found between resident and faculty responses to the OR Educational Environment Measure survey before and after PASS implementation. When individual survey items were compared, while no differences were found with resident responses, differences were noted with faculty responses for 7 of the 35 items addressed although after Bonferroni correction none of these differences remained significant. Our data suggest that PASS does not increase mean OR times for the most commonly performed procedures. Resident OR satisfaction did not significantly change during PASS implementation, whereas some changes in faculty satisfaction were noted suggesting that PASS implementation may have had some negative effect with them. Although the effect on faculty satisfaction clearly requires further investigation, our findings support that use of an autonomy-based OR performance assessment system such as PASS does not appear to have a major negative influence on OR times nor OR satisfaction.

Evaluating Surgical Residents Quickly and Easily Against the Milestones Using Electronic Formative Feedback

This study was conducted to assess the effectiveness of a newly implemented electronic web-based review system created at our institution for evaluating resident performance relative to established milestones. Retrospective review of data collected from a survey of general surgery faculty and residents. Tertiary care teaching hospital system and independent academic medical center. A total of 12 general surgery faculty and 17 general surgery residents participated in this study. The survey queried the level of satisfaction before and after the adoption of QuickNotes using several statements scored on a 5-point scale, with 1 being the lowest rating as "not satisfied," and 5 being the highest rating as "completely satisfied." The weighted average improvements from pre- to post-QuickNotes implementation for the faculty responding to the survey ranged from 10% to 40%; weighted average improvements for the residents responding to the survey ranged from 5% to 73%. For the survey of faculty, both sets of weighted averages tended to be higher than the weighted average for the resident's survey responses. The highest rated topic was the faculty's level of satisfaction with the "frequency to provide feedback" with a post-QuickNotes implementation weighted average of 4.25, closely followed by the residents' level of satisfaction with the "evaluation includes positive feedback" with a post-QuickNotes implementation weighted average of 4.24. The most notable increases in weighted averages from preimplementation to postimplementation were noted for "overall satisfaction" (20% increase for faculty, 37% for residents), "reflects actual criteria that matter" (36% increase for faculty, 73% for residents), faculty "opportunity for follow-up" (increase of 40%), resident "reflects overall trends" (increase of 37%), and resident "provides new information about my performance" (increase of 37%). Our institutional adoption of QuickNotes into the resident evaluation process has been associated with an overall increased level of satisfaction in the evaluation process by both faculty and residents. The design of QuickNotes facilitates its integration into the resident training environment, as it is web based, easy to use, and has no additional cost over the standard New Innovations subscription. Although it is designed to capture snapshots of trainee behavior and performance, monthly reports through QuickNotes can be used effectively in conjunction with the more traditional end-of-rotation evaluations to show trends, identify areas of strength that should be reinforced, demonstrate areas needing improvement, allow for a more tailored individual education plan to be developed, and permit a more accurate determination of milestone progression.

The positive association of Association for Academic Surgery membership with academic productivity

BackgroundTo evaluate the academic productivity and National Institutes of Health (NIH) funding of members of the Association for Academic Surgery (AAS). MethodsAcademic metrics including, numbers of publications, citations, and NIH funding history were determined for 4015 surgical faculty at the top 55 NIH-funded departments of surgery, using Scopus, NIH RePORT, and the Grantome online databases. ResultsAAS membership included 20.5% (824) of all 4015 surgical faculty in this database. For members of the AAS, publications (P) ± standard deviation and citations (C) ± SD were P: 54 ± 96 and C: 985 ± 3321, compared with P: 31 ± 92, C: 528 ± 3001 for nonmembers, P < 0.001. Higher academic productivity among AAS members was observed across all subspecialty types and was especially pronounced for assistant and associate professors. AAS membership was also associated with increased rates of NIH funding and better productivity for equally funded surgical faculty compared with nonmembers. Analysis of AAS membership by subspecialty revealed that AAS members were most commonly general surgery faculty (57.8%); however, only 7.4% of the faculty was affiliated with cardiothoracic surgery. There was also a lack of dedicated science and/or research faculty (0.6% versus 3.4%) among the members of the AAS. ConclusionsAAS membership appears to be correlated with greater academic performance among junior and midlevel surgical faculty. This improvement is observed regardless of subspecialty. Increased participation of faculty within subspecialties such as cardiothoracic surgery and, a greater focus on increasing the numbers of dedicated research faculty within the AAS may help increase the scientific impact and productivity among members of the society.

Identification of behaviors and techniques for promoting autonomy in the operating room

To further understand how faculty promote resident autonomy in the operating room (OR), we explored their perceptions, and those of senior residents, on the behaviors and techniques they employ to foster independence. Twenty postgraduate year PGY4 and PGY5 residents were asked to list 3 general surgery faculty who give the most and least autonomy to residents in the OR. Two focus groups were conducted with residents to identify behaviors and techniques for promoting autonomy from the resident perspective. Individual semistructured interviews were conducted with top-rated and low-rated faculty to identify behaviors and techniques from the attending perspective. Behaviors and techniques faculty exhibit to promote increased autonomy included allowing residents time to struggle, letting residents begin case themselves, and forcing residents to think about steps of procedure before case. The main "triggers" for granting autonomy were increased familiarity and trust with resident's capabilities, how well resident comes prepared to OR, and faculty confidence that they can "fix anything." Reasons why low-rated faculty seldom give autonomy included feeling a deep moral obligation for personally seeing patient through the operation, residents not coming fully prepared to perform case, and being young in their own maturation process. Our results suggest that increased autonomy depends greatly on establishing a trusting relationship between faculty and resident; a partnership that can only happen when time is given for trust to mature. Program directors must work to refine the training paradigm in order to build relationships. Residents can also be coached to demonstrate increased OR preparedness.

Attending Feedback After Surgery

Attending Feedback After Surgery