Department of Surgery, Indiana University, Indianapolis, IN, USA.
Department of Surgery, University of Michigan, Ann Arbor, MI, USA.
Surgery. 2018 Sep;164(3):566-570. doi: 10.1016/j.surg.2018.04.034. Epub 2018 Jun 19.
We investigated attending surgeon decisions regarding resident operative autonomy, including situations where operative autonomy was discordant with performance quality.
Attending surgeons assessed operative performance and documented operative autonomy granted to residents from 14 general surgery residency programs. Concordance between performance and autonomy was defined as "practice ready performance/meaningfully autonomous" or "not practice ready/not meaningfully autonomous." Discordant circumstances were practice ready/not meaningfully autonomous or not practice ready/meaningfully autonomous. Resident training level, patient-related case complexity, procedure complexity, and procedure commonality were investigated to determine impact on autonomy.
A total of 8,798 assessments were collected from 429 unique surgeons assessing 496 unique residents. Practice-ready and exceptional performances were 20 times more likely to be performed under meaningfully autonomous conditions than were other performances. Meaningful autonomy occurred most often with high-volume, easy and common cases, and less complex procedures. Eighty percent of assessments were concordant (38% practice ready/meaningfully autonomous and 42% not practice ready/not meaningfully autonomous). Most discordant assessments (13.8%) were not practice ready/meaningfully autonomous. For fifth-year residents, practice ready/not meaningfully autonomous ratings (9.7%) were more frequent than not practice ready/meaningfully autonomous ratings (7.5%). Ten surgeons (2.3%) failed to afford residents meaningful autonomy on any occasion.
Resident operative performance quality is the most important determinant in attending surgeon decisions regarding resident autonomy.
我们研究了主治医生对住院医师手术自主性的决策，包括手术自主性与手术质量不相符的情况。
主治医生评估手术表现，并从 14 个普通外科住院医师培训项目中记录主治医生授予住院医师的手术自主性。表现和自主性的一致性定义为“准备实践/有意义的自主”或“未准备实践/无意义的自主”。不一致的情况是准备实践/无意义的自主或未准备实践/有意义的自主。调查住院医师培训水平、患者相关病例复杂性、手术复杂性和手术常见性，以确定对自主性的影响。
从 429 名独特的外科医生对 496 名独特的住院医师收集了 8798 次评估。准备实践和卓越表现更有可能在有意义的自主条件下进行，而不是其他表现。有意义的自主最常发生在高容量、简单和常见的病例，以及不太复杂的手术。80%的评估是一致的（38%准备实践/有意义的自主，42%未准备实践/无意义的自主）。大多数不一致的评估（13.8%）是未准备实践/有意义的自主。对于五年级住院医师，准备实践/无意义自主评估（9.7%）比未准备实践/有意义自主评估（7.5%）更为频繁。10 名外科医生（2.3%）在任何情况下都未能给予住院医师有意义的自主权。
住院医师手术表现质量是主治医生决定住院医师自主性的最重要决定因素。
