On Surgical Resident Readiness Level, Program Directors, Resident Agree

SAVANNAH, Ga.—Many graduating general surgery residents’ assessments of their own self-efficacy—an individual’s belief in their ability to achieve a specific goal, in this case, to operate independently—are less than stellar. New research shows program directors tend to agree with residents’ assessments, suggesting more work needs to be done to ensure new surgeons are prepared for the challenges ahead.

In previous research, while an education research fellow at Stanford University, LaDonna Kearse, MD, now a general surgery resident at Howard University Hospital, in Washington, D.C., and her colleagues found that fewer than 8% of PGY-5 residents halfway through their chief year reported self-efficacy in all 10 of a selection of common operations. They also reported significant variability by case type: While 90% reported self-efficacy in wide local excision, only 20% held the belief they could perform an open thyroidectomy.

Not to be confused with self-confidence, self-efficacy is rooted in theory, pertains to the belief that one can attain a certain level of competence and can be measured, Dr. Kearse said.

“When we think about those who have achieved high self-efficacy, these are people who work to master challenges, are able to work through their failures and look inward when these failures occur. These are traits that we want not only in our trainees but also in our practicing surgeons.”

While the perception of residents’ self-efficacy has been studied, little is known about program directors’ perceptions of residents’ operative self-efficacy. Hypothesizing that program directors would report higher self-efficacy among residents than the residents did of themselves, Dr. Kearse and her colleagues surveyed program directors about their PGY-5 residents’ abilities to perform the same 10 operations the residents reported on and compared the two surveys.

Both surveys used a Likert scale to query perceptions of self-efficacy, with “definitely able to” defining most efficacious and “not able” the least. The surveys also assessed entrustment: how often assessments and operative plans were modified based on four of the five original American Board of Surgery–entrustable professional activities. The residents’ surveys were distributed as an optional post-test after the 2020 American Board of Surgery In-Training Examination. The program directors’ surveys were distributed through the Association of Program Directors’ listserv.

The researchers received 1,367 responses from residents, representing 296 of 328 programs (90%); and 108 responses from program directors, representing 108 of 342 programs (32%). The findings disproved the researchers’ hypothesis: Both groups had fairly congruent perceptions of residents’ self-efficacy in being able or not able.

“We also found that both groups perceived similar levels of entrustment in the preoperative phase, with the exception of biliary stone disease and operative plans of blunt abdominal trauma, where our PGY-5 residents rated themselves to have higher levels of entrustment,” Dr. Kearse said.

The findings corroborate previous findings of a deficit in self-efficacy. “Acknowledging this deficit is a first step; it’s critical in identifying and developing self-efficacy, which is necessary for personal growth and lifelong learning, in our trainees,” Dr. Kearse said.

They found it heartening that both residents and program directors perceived high levels of entrustment. “This suggests that trainees have high levels of self-efficacy related to their patient care; however, it’s important that we consider both clinical decision making and operative abilities.” Dr. Kearse presented the study results at the 2023 Southeastern Surgical Congress.

Valentine Nfonsam, MD, MS, the chair of surgery at Louisiana State University, in New Orleans, who reviewed the study for discussion, considered the research a nicely done comparative study, but he questioned use of the level 5 Likert scale, where 5 is “definitely able to,” rather than 4 and 5, where 4 is “most likely able to.”

“Due to the imposter syndrome and humility, I’m sure most residents will be less likely to rate themselves as 5. The scores of 4 or 5 for the program directors were considered as entrustable, which I think makes sense,” he said.

Dr. Nfonsam also asked about two limitations mentioned in the paper: that the post-ABSITE survey was conducted six months before graduation, and that program directors were asked about the entrustment of their average PGY-5 residents. “Do the authors feel that their conclusions might not be very strong if these two limitations were mitigated?”

Dr. Kearse said the reason why 5, or “definitely able to,” was chosen is that it really refers to someone’s ability to do something. “Either they can, or they can’t. If we’re targeting self-efficacy as a measure, this is something we can change, that we can modify to give our trainees the perspective to say, ‘Yes, I can or [no] I cannot’ do something.”

As for the mitigation of limitations, she doubts that would affect the conclusions. “The residents’ survey was disseminated in 2020, at the beginning of the pandemic, so we believe there was probably less progress made in terms of efficacy in those remaining six months of training because so many things had changed during that time,” Dr. Kearse said.