Meyerson Shari L, Teitelbaum Ezra N, George Brian C, Schuller Mary C, DaRosa Debra A, Fryer Jonathan P
Department of Surgery, Northwestern University, Chicago, Illinois.
Department of Surgery, Northwestern University, Chicago, Illinois.
J Surg Educ. 2014 Nov-Dec;71(6):e64-72. doi: 10.1016/j.jsurg.2014.05.002. Epub 2014 Jun 10.
To develop operative independence with essential procedures by the end of their training, residents need graded autonomy as they progress through training. This study compares autonomy expectations, as defined by faculty and residents, with autonomy measured in the operating room.
Operative procedures performed by general surgery residents between November 2012 and June 2013 were each assigned an autonomy score by the operating attending physician using a previously described rating scale (Zwisch). Scores range from minimum autonomy, "show and tell," to maximum autonomy, "supervision only." Autonomy expectations were defined by a survey asking faculty and residents what autonomy-level residents should achieve during each year of training for each of the 10 most commonly performed procedures. Faculty expectations, resident expectations, and actual operating room autonomy data were compared using analysis of variance with post hoc analysis by Tukey honestly significant difference test.
A total of 1467 operative cases were scored using the Zwisch scale over the period of the study. The 10 most common procedures accounted for 56.3% (827) of the cases. Resident and faculty expectations of resident operative autonomy were similar. For only laparoscopic cholecystectomy, residents expected significantly more autonomy than the faculty did during the junior years but they agreed with the faculty for the chief year. When expectations were compared with actual performance, the resident autonomy level achieved was significantly less than that expected by residents or faculty or both for all 10 procedures in at least one postgraduate level. For every procedure performed more than 5 times during the study period by postgraduate years 3 to 5 residents, autonomy was significantly less than expected.
Surgical faculty and residents had similar expectations for resident operative autonomy, yet actual resident performance failed to achieve those shared expectations for even the most common procedures. This autonomy gap provides more evidence for concerns about the preparedness of graduating residents for independent practice.
为使住院医师在培训结束时能独立完成基本手术操作，他们在培训过程中需要逐步获得不同程度的自主权。本研究比较了教员和住院医师所定义的自主权期望与在手术室中实际测量的自主权。
对2012年11月至2013年6月期间普通外科住院医师所进行的手术操作，由主刀医师使用先前描述的评分量表（Zwisch）为每个操作分配一个自主权分数。分数范围从最低自主权的“示范讲解”到最高自主权的“仅监督”。通过一项调查来定义自主权期望，该调查询问教员和住院医师对于10种最常进行的手术操作，住院医师在培训的每年应达到何种自主权水平。使用方差分析及Tukey真实显著性差异检验进行事后分析，比较教员期望、住院医师期望和实际手术室自主权数据。
在研究期间，共使用Zwisch量表对1467例手术病例进行了评分。10种最常见的手术占病例总数的56.3%（827例）。住院医师和教员对住院医师手术自主权的期望相似。仅在腹腔镜胆囊切除术方面，住院医师在低年级时期望的自主权显著高于教员，但在高年级时他们与教员的期望一致。当将期望与实际表现进行比较时，在至少一个研究生阶段，对于所有10种手术操作，住院医师实际达到的自主权水平显著低于住院医师或教员或双方的期望。对于研究生3至5年级住院医师在研究期间进行超过5次的每种手术操作，自主权均显著低于预期。
外科教员和住院医师对住院医师手术自主权有相似的期望，但即使是最常见的手术操作，住院医师的实际表现也未能达到这些共同的期望。这种自主权差距为对即将毕业的住院医师独立执业准备情况的担忧提供了更多证据。
