Trends, Perception, and Variation in Operative Dictation Practices Among General Surgery Residents and Its...

Operative dictation is critical for accurate surgical documentation, impacting patient care, medico-legal standards, and education; however, lacking structured training causes gaps in quality and standardization. This study aims to examine the current trends and variations in dictation practices among junior (postgraduate year (PGY-1) and PGY-2) and senior (PGY-3 to PGY-5) general surgery residents.

A cross-sectional anonymous survey of junior and senior general surgery residents was conducted to explore dictation practices, preferences, and educational needs. The survey addressed demographics, dictation methods, mentorship, and perceptions of junior and senior residents.

67.2% of respondents reported dictating cases, with seniors more likely to dictate both major and minor cases (75%) compared to juniors (58.6%). Oral dictation was preferred by most residents, with 58.6% of juniors using transcription-based methods and 46.9% of seniors using voice recognition. Dictation improved operative step retention for 58.6% of juniors and 62.5% of seniors, enhancing preparedness for repeated operations. Formal mentorship was reported by 58.6% of juniors but only 43.8% of seniors, while formal orientation was not available to any juniors or seniors in this study. Early formal education in dictation was supported by 75.0% of juniors and 62.5% of seniors.

This study highlights the need for structured education in operative dictation, particularly for junior residents, to improve documentation quality and preparedness. The findings emphasize the critical gap in mentorship and formalized training, with a lack of formal orientation and inconsistent mentorship opportunities posing significant barriers to skill development.