Autonomy, entrustment, self-efficacy, and decision-making: The current state of training independent surgeons

Operative autonomy, entrustment, self-efficacy, and decision-making are fundamental aspects of surgical resident education. Over the past few decades, trainee operative autonomy in surgical subspecialties has been declining. Most retrospective studies evaluating clinical outcomes with increasing levels of trainee independence have found no significant rise in patient morbidity and mortality. To provide more autonomy, attendings assess their relationship with the trainee, along with the trainee's skill level, the complexity of the case, and their own confidence. Identified barriers include a desire for efficiency and expectations from patients and the hospital that the procedure be performed by the attending. Consequently, trainees can enhance their self-efficacy by fostering a relationship with the attending, demonstrating clinical competence to encourage the delegation of clinical responsibilities, and adapting to the attending's teaching style. Techniques to improve autonomy include longitudinal evaluations of trainee independence with a variety of teaching applications and role reversal. It is essential for patients, hospital administrators, and legislators to recognize the significance of demonstrating operative independence during training to cultivate competent, self-sufficient surgeons.