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Original Investigation
June 2018

Association of Faculty Entrustment With Resident Autonomy in the Operating Room

Author Affiliations
  • 1Department of Surgery, University of Michigan, Ann Arbor
  • 2Medical student at University of Michigan Medical School, Ann Arbor
  • 3Department of Surgery, The University of Texas Southwestern Medical Center, Dallas
  • 4Currently with Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison
JAMA Surg. 2018;153(6):518-524. doi:10.1001/jamasurg.2017.6117
Key Points

Question  Do faculty behaviors drive resident entrustability in the operating room?

Findings  In this study that used the OpTrust tool to assess 117 direct intraoperative observations involving 35 residents and 28 faculty, surgical faculty entrustment behaviors were significantly associated with resident entrustability behaviors. Neither case difficulty nor faculty years of experience was significantly associated with faculty entrustment or the level of resident entrustability demonstrated.

Meaning  Faculty entrustment is a critical and teachable component for advancing resident autonomy in the operating room.


Importance  A critical balance is sought between faculty supervision, appropriate resident autonomy, and patient safety in the operating room. Variability in the release of supervision during surgery represents a potential safety hazard to patients. A better understanding of intraoperative faculty-resident interactions is needed to determine what factors influence entrustment.

Objective  To assess faculty and resident intraoperative entrustment behaviors and to determine whether faculty behaviors drive resident entrustability in the operating room.

Design, Setting, and Participants  This observational study was conducted from September 1, 2015, to August 31, 2016, at Michigan Medicine, the University of Michigan’s health care system. Two surgical residents, 1 medical student, 2 behavioral research scientists, and 1 surgical faculty member observed surgical intraoperative interactions between faculty and residents in 117 cases involving 28 faculty and 35 residents and rated entrustment behaviors. Without intervening in the interaction, 1 or 2 researchers observed each case and noted behaviors, verbal and nonverbal communication, and interaction processes. Immediately after the case, observers completed an assessment using OpTrust, a validated tool designed to assess progressive entrustment in the operating room. Purposeful sampling was used to generate variation in type of operation, case difficulty, faculty-resident pairings, faculty experience, and resident training level.

Main Outcomes and Measures  Observer results in the form of entrustability scores (range, 1-4, with 4 indicating full entrustability) were compared with resident- and faculty-reported measures. Difficulty of operation was rated on a scale of 1 to 3 (higher scores indicate greater difficulty). Path analysis was used to explore direct and indirect effects of the predictors. Associations between resident entrustability and observation duration, observation month, and faculty entrustment scores were assessed by pairwise Pearson correlation coefficients.

Results  Twenty-eight faculty and 35 residents were observed across 117 surgical cases from 4 surgical specialties. Cases observed by postgraduate year (PGY) of residents were distributed as follows: PGY-1, 21 (18%); 2, 15 (13%); 3, 17 (15%); 4, 27 (23%); 5, 28 (24%); and 6, 9 (8%). Case difficulty was evenly distributed: 36 (33%) were rated easy/straightforward; 43 (40%), moderately difficult; and 29 (27%), very difficult by attending physicians. Path analysis showed that the association of PGY with resident entrustability was mediated by faculty entrustment (0.23 [.03]; P < .001). At the univariate level, case difficulty (mean [SD] resident entrustability score range, 1.97 [0.75] for easy/straightforward cases to 2.59 [0.82] for very difficult cases; F = 6.69; P = .01), PGY (range, 1.31 [0.28] for PGY-1 to 3.16 [0.54] for PGY-6; F = 22.85; P < .001), and faculty entrustment (2.27 [0.79]; R2 = 0.91; P < .001) were significantly associated with resident entrustability. Mean (SD) resident entrustability scores were highest for very difficult cases (2.59 [0.82]) and PGY-6 (3.16 [0.54]).

Conclusions and Relevance  Faculty entrustment behaviors may be the primary drivers of resident entrustability. Faculty entrustment is a feature of faculty surgeons’ teaching style and could be amenable to faculty development efforts.