Trainee Operative Autonomy in Plastic Surgery
Christina R. Vargas, Tobias Long, MD, Anand R. Kumar, MD.
University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
Appropriate, progressive trainee autonomy is critical for training competent plastic surgeons who are adequately prepared to enter independent practice. The degree of meaningful operative autonomy trainees currently achieve in plastic surgery is unknown. Procedural logs are utilized by training programs and accrediting organizations to assess trainee progression and eligibility for certification, however their correlation with competence is unclear. This study aims to investigate the current state of trainee operative autonomy in plastic surgery and to explore associated implications for achieving and assessing preparedness to enter practice.
Parallel survey instruments were developed using the Zwisch metric for progressive operative autonomy and distributed to trainees and faculty in accredited training programs. Trainees were queried about their operative autonomy with respect to 17 core plastic surgery procedures, associated approach to logging cases, and perceived readiness to enter practice. Faculty provided assessment of their final-year trainees using the same metrics.
Trainees in 28 programs and faculty in 35 programs participated. Final-year trainees reported the most operative independence with breast tissue expander reconstruction and carpal tunnel release, and the least with facelift and rhinoplasty. A mean 40% of final-year trainees reached "supervision only" autonomy in the procedures queried; notably, none achieved this with rhinoplasty (Figure 1). Faculty identified the most final-year trainee operative autonomy with botulinum toxin injection and burn excision and grafting; the least trainee independence was reported with rhinoplasty, cleft lip repair, and facelift (Figure 2). Faculty perception of final-year trainee autonomy was higher than that of trainees for 82% of procedures queried. Faculty believed cases should be logged at all levels of autonomy, though they expected more cases at each level to be logged as "assistant" rather than "surgeon" relative to trainees. 16% of trainees expected not to log cases with "show and tell" level participation; 26% felt they should log these as "assistant" (Figure 3). 95% of trainees and 98% of faculty surveyed believed that trainees will be adequately prepared to enter independent practice upon graduation from their current programs; 69% of trainees planned to pursue additional fellowship-level training.
While plastic surgery trainees endorse gradual operative autonomy overall, a majority of final-year trainees do not report "supervision only" independence in the majority of core procedures queried. Faculty perceive higher trainee operative autonomy than trainees for most procedures. Trainees and faculty view the relationship between trainee autonomy and expected case logging practices differently, however, both groups are optimistic about trainee preparedness to enter independent practice. This study identifies opportunities for improvement in the assessment and progression of operative autonomy during plastic surgery training.
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