Distortions in the Balance Between Teaching and Efficiency in the Operating Room.

INTRODUCTION: The balance between teaching and operative efficiency (i.e., continuing operative case progression) is difficult for even the most experienced master surgeon educators. The purpose of this study was to explore influencing factors behind attending surgeons' decisions to break the balance between operative efficiency and teaching in the operating room. METHODS: Semistructured interviews were conducted with surgeons across the United States via Web-based video conferencing. The interviews were audio-recorded and transcribed. Qualitative analysis using the framework method was utilized, and emergent themes were identified. RESULTS: Twenty-three attending surgeons from 8 academic institutions and 11 surgical specialties completed interviews (14 men and 9 women). Attending surgeons consider a variety of factors associated with their dual roles (surgeon versus teacher) when balancing operative efficiency and providing appropriate independence for residents with oversight to promote autonomy. These were divided into surgeon-role-related factors (patient safety, financial factors, scheduling factors, preservation of faculty reputation for efficiency, and mode of operation) as well as teacher-role-related factors (preparation, level, and technical skill of the resident). These factors then informed attending surgeons' determinations about how the case was progressing, which prompted them to intervene and reduce resident autonomy or allow the resident to continue. CONCLUSIONS: Surgeons consider numerous factors when deciding how to balance resident teaching and autonomy while preserving operative efficiency. These findings provide helpful insights for surgical departments to consider inclusion in faculty-development programs, resident education, and systematic improvements.

Efficiency of Increasing Prospective Resident Entrustment in the Operating Room.

BACKGROUND: Prospective resident entrustment (i.e., trust an attending surgeon intends to give to a resident in the near future) in the operating room (OR) closely associates with granted future autonomy. However, the process of determining resident entrustment takes time and effort. Thus, this study aimed to assess the efficiency of granting incremental resident entrustment for upcoming surgical cases. METHODS: We analyzed prospective resident entrustment of 6 chief residents in 76 cases of laparoscopic cholecystectomy, laparoscopic colectomy, ventral hernia, and inguinal hernia scored by attending surgeon, resident, and a surgeon observer. Matched direct costs and operative time were extracted from hospital billing. We assessed the efficiency of granting incremental prospective resident entrustment with direct cost per minute incurred in the evaluated case. Effect size was computed to assess the differences between groups. RESULTS: Sixty-three cases (82.9%) were matched; 47.6% (30/63) of matched cases received prospective resident entrustment score ≥ 4. The direct cost per minute increased in three procedures (laparoscopic cholecystectomy, laparoscopic colectomy, and ventral hernia) with increased intention of granting incremental resident entrustment. Inguinal hernia was the only procedure in which chiefs were entrusted with future independence while the direct cost per minute decreased. CONCLUSIONS: Our findings demonstrate more time and effort are required (except for inguinal hernia) for residents to be entrusted with increased independence in the future. Faculty and resident development programs are recommended to improve the efficiency of the process of granting incremental operative entrustment to optimize resident training quality and cost of care delivery.

Development of Residents' Self-Efficacy in Multidisciplinary Management of Breast Cancer Survey.

BACKGROUND: Treating patients with breast cancer is multidisciplinary; however, it is unclear whether surgery residency programs provide sufficient training in multidisciplinary care. Self-efficacy is one way of measuring the adequacy of training. Our goal was to develop a method of assessing self-efficacy in multidisciplinary breast cancer care. METHODS: Based on a literature review and subject-matter expert input, we developed a 30-item self-efficacy survey to measure six domains of breast cancer care (genetics, surgery, medical oncology, radiation oncology, pathology, and radiology). We constructed and validated the survey using a seven-step survey development framework. The survey was administered to general surgery residents at a single academic surgical residency. RESULTS: Response rate was 66% (n = 31). Internal consistency was strong (Cronbach alpha = 0.92). Self-efficacy was moderate (mean = 3.05) and tended to increase with training (postgraduate year [PGY] 1: mean= 2.37 versus PGY 5: mean= 3.54; P < 0.001), providing evidence for construct validity. Self-efficacy was highest in the surgery (3.56) compared with others (genetics 2.67, medical oncology 3, radiation oncology 2.67, pathology 2.67, and radiology 3.33). This trend was similar across all PGY groups, except for interns, whose self-efficacy in surgery was low. CONCLUSIONS: We created a survey to assess self-efficacy in multidisciplinary breast cancer care and provided initial evidence of survey validity. Although self-efficacy in surgery improved with years in training, medical and radiation oncology self-efficacy remained low. As modern breast cancer treatment is highly multidisciplinary, an expanded education program is needed to help trainees incorporate multidisciplinary clinical perspectives.

Resident Autonomy in the Operating Room: How Faculty Assess Real-time Entrustability.

OBJECTIVE: This study aimed to identify the empirical processes and evidence that expert surgical teachers use to determine whether to take over certain steps or entrust the resident with autonomy to proceed during an operation. BACKGROUND: Assessing real-time entrustability is inherent in attending surgeons' determinations of residents' intraoperative autonomy in the operating room. To promote residents' autonomy, it is necessary to understand how attending surgeons evaluate residents' performance and support opportunities for independent practice based on the assessment of their entrustability. METHODS: We conducted qualitative semi-structured interviews with 43 expert surgical teachers from 21 institutions across 4 regions of the United States, using purposeful and snowball sampling. Participants represented a range of program types, program size, and clinical expertise. We applied the Framework Method of content analysis to iteratively analyze interview transcripts and identify emergent themes. RESULTS: We identified a 3-phase process used by most expert surgical teachers in determining whether to take over intraoperatively or entrust the resident to proceed, including 1) monitoring performance and "red flags," 2) assessing entrustability, and 3) granting autonomy. Factors associated with individual surgeons (eg, level of comfort, experience, leadership role) and the context (eg, patient safety, case, and time) influenced expert surgical teachers' determinations of entrustability and residents' final autonomy. CONCLUSION: Expert surgical teachers' 3-phase process of decisions on take-over provides a potential framework that may help surgeons identify appropriate opportunities to develop residents' progressive autonomy by engaging the resident in the determination of entrustability before deciding to take over.

Teaching, Learning, and Performance in the Surgical Workplace: Insights From the Examination of Intraoperative Interactions.

This Conversations Starter article presents a selected research abstract from the 2017 Association of American Medical Colleges Central Region Group on Educational Affairs annual spring meeting. The abstract is paired with the integrative commentary of three experts who shared their thoughts stimulated by the study. These thoughts explore the value of examining intraoperative interactions among attending surgeons and residents for enhancing instructional scaffolding; entrustment decision making; and distinguishing teaching, learning, and performance in the workplace.

Behind the pattern: General surgery residsent autonomy in robotic surgery.

Objective: Robotic surgery is increasingly utilized and common in general surgery training programs. This study sought to better understand the factors that influence resident operative autonomy in robotic surgery. We hypothesized that resident seniority, surgeon work experience, surgeon robotic-assisted surgery (RAS) case volume, and procedure type influence general surgery residents' opportunities for autonomy in RAS as measured by percentage of resident individual console time (ICT). Methods: General surgery resident ICT data for robotic cholecystectomy (RC), inguinal hernia (RIH), and ventral hernia (RVH) operations performed on the dual-console Da Vinci surgical robotic system between July 2019 and June 2021 were extracted. Cases with postgraduate year (PGY) 2-5 residents participating as a console surgeon were included. A sequential explanatory mixed-methods approach was undertaken to explore the ICT results and we conducted secondary qualitative interviews with surgeons. Descriptive statistics and thematic analysis were applied. Results: Resident ICT data from 420 robotic cases (IH 200, RC 121, and VH 99) performed by 20 junior residents (PGY2-3), 18 senior residents (PGY4-5), and 9 attending surgeons were extracted. The average ICT per case was 26.8 % for junior residents and 42.4 % for senior residents. Compared to early-career surgeons, surgeons with over 10 years' work experience gave less ICT to junior (18.2 % vs. 32.0 %) and senior residents (33.9 % vs. 56.6 %) respectively. Surgeons' RAS case volume had no correlation with resident ICT (r = 0.003, p = 0.0003). On average, residents had the most ICT in RC (45.8 %), followed by RIH (36.7 %) and RVH (28.6 %). Interviews with surgeons revealed two potential reasons for these resident ICT patterns: 1) Surgeon assessment of resident training year/experience influenced decisions to grant ICT; 2) Surgeons' perceived operative time pressure inversely affected resident ICT. Conclusions: This study suggests resident ICT/autonomy in RC, RIH, and RVH are influenced by resident seniority level, surgeon work experience, and procedure type, but not related to surgeon RAS case volume. Design and implementation of an effective robotic training program must consider the external pressures at conflict with increased resident operative autonomy and seek to mitigate them.

Measuring Chief Resident Skill and Entrustment Progression in An Operative Coaching Program: Four Years' Experience.

OBJECTIVE: Operative coaching (OC) may facilitate improvement of surgery residents' competencies by optimizing learning and teaching. We investigated how residents' operative skills and prospective entrustment (PE) progress throughout the chief year in our OC program, how OC is perceived by participants, and how OC may facilitate learning and teaching. DESIGN, SETTING, AND PARTICIPANTS: This is a mixed-methods study conducted within the Ohio State University Wexner Medical Center General Surgery residency. Validated performance evaluations with procedural-specific skill, general skill (GS), step-specific guidance required (SSG) (an autonomy measure), and PE measures completed by chiefs, faculty coaches, and attending surgeons from 7/2018 to 6/2022 were reviewed. We also interviewed OC participants to understand their experience. Descriptive statistical and qualitative content analysis were applied. RESULTS: 441 evaluations from 147 OC cases completed by 22 chiefs, 5 faculty coaches, and 24 attendings were included. Overall, resident GS (p = 0.036), SSG (p = 0.023), and PE (p = 0.002) significantly improved throughout the year. PE significantly correlated (all p < 0.0001) with SSG (r = 0.73), followed by procedural-specific skill (r = 0.59), then GS (r = 0.57). On average, chiefs underestimated their surgical skills while attendings overestimated autonomy they permitted to residents. Chiefs, coaches, and attendings reached consensus on chiefs' PE upon graduation. Five graduated chiefs and 5 attendings were interviewed. Chiefs described OC as effective in improving their self-regulated learning and particularly valued 3 OC elements: neutral authentic feedback, third-party real-time observation, and actionable feedback. Attendings noted OC promoted their engagement in skills assessment and teaching. CONCLUSIONS: Our findings suggest chief residents' skills, autonomy, and PE progress steadily along their OC journey. Despite differences in residents', coaches', and attendings' perceptions of skill, measures of autonomy reliably correlate with entrustment. OC promotes resident learning, faculty teaching, and assessment of resident skills, autonomy, and PE in the OR.

Cumulative Sum Chart as Complement to Objective Assessment of Graduating Surgical Resident Competency: An Exploratory Study.

BACKGROUND: Rater-based assessment and objective assessment play an important role in evaluating residents' clinical competencies. We hypothesize that a cumulative sum (CUSUM) chart of operative time is a complement to the assessment of chief general surgery residents' competencies with ACGME Milestones, aiding residency programs' determination of graduating residents' practice readiness. STUDY DESIGN: We extracted ACGME Milestone evaluations of performance of operations and procedures (POP) and 3 objective metrics (operative time, case type, and case complexity) from 3 procedures (cholecystectomy, colectomy, and inguinal hernia) performed by 3 cohorts of residents (N = 15) during their PGY4-5. CUSUM charts were computed for each resident on each procedure type. A learning plateau was defined as at least 4 cases consistently locating around the centerline (target performance) at the end of a CUSUM chart with minimal deviations (range 0 to 1). RESULTS: All residents reached the ACGME graduation targets for the overall POP by the end of chief year. A total of 2,446 cases were included (cholecystectomy N = 1234, colectomy N = 507, and inguinal hernia N = 705), and 3 CUSUM chart patterns emerged: skewed distribution, bimodal distribution, and peaks and valleys distribution. Analysis of CUSUM charts revealed surgery residents' development processes in the operating room towards a learning plateau vary, and only 46.7% residents reach a learning plateau in all 3 procedures upon graduation. CONCLUSIONS: CUSUM charts of operative time complement the ACGME Milestones evaluations. The use of both may enable residency programs to holistically determine graduating residents' practice readiness and provide recommendations for their upcoming career/practice transition.

What factors impact surgical operative time when teaching a resident in the operating room.

Purpose: Resident involvement would likely lead to prolonged operative time of a surgical case performed at academic medical centers. However, little is known about factors beneath this phenomenon. The purpose of this study was to investigate whether factors from case (procedure type, surgical case complexity, and surgical approach), teacher (attending surgeon experience and gender), and learner (resident postgraduate training year and gender) would influence operative time of surgical cases involved teaching a resident (SCT). Methods: A single-institution retrospective analysis of 3 common general surgery procedures, including cholecystectomies, colectomies, and inguinal hernia, with involvement of general surgery residents between 2016 and 2020 was conducted. Surgical operative time was defined as the "cut-to-close" time from incision to completion of wound closure. Analysis of variance for continuous variables and multivariable linear regression were applied. Results: A total of 4,417 eligible SCT were included. The average operative time was 114.8 ± 78.7 min. SCT with male resident involvement showed a significantly longer operative time than those with female residents (117 vs. 112, p = 0.01). Comparable operative time was observed between male and female attending surgeon cases (115.5 vs. 110.8, p = 0.15). SCT operating time decreased with increased resident training level, except for SCT with involvement of Year2 residents. SCT with Year5 residents demonstrated the lowest time to case completion (110.5 min); SCT with major complications took least time to complete (105.7 min). Univariate and multivariate analysis revealed resident training year level, resident gender, and case complexity as factors associated with significant differences in operative time. Attending surgeon experience, surgeon gender, surgical approach, and procedure type did not impact SCT operative time. Conclusion: Our study findings suggest resident training level, resident gender, and case complexity are factors significantly associated with SCT operative time of cholecystectomies, colectomies, and inguinal hernia. Attending surgeons are recommended to factor them into pre-operative planning.

Is Robotic Console Time a Surrogate for Resident Operative Autonomy?

OBJECTIVE: Robotic-assisted surgery is an increasing part of general surgery training, but resident autonomy on the robotic platform can be hard to quantify. Robotic console time (RCT), the percentage of time the resident controls the console, may be an appropriate measure of resident operative autonomy. This study aims to characterize the correlation between objective resident RCT and subjectively scored operative autonomy. METHODS: Using a validated resident performance evaluation instrument, we collected resident operative autonomy ratings from residents and attendings performing robotic cholecystectomy (RC) and robotic inguinal hernia repair (IH) at a university-based general surgery program between 9/2020-6/2021. We then extracted RCT data from the Intuitive surgical system. Descriptive statistics, t-tests and ANOVA were performed. RESULTS: A total of 31 robotic operations (13 RC, 18 IH) performed by 4 attending surgeons and 8 residents (4 junior, 4 senior) were matched and included. 83.9% of cases were scored by both attending and resident. The average RCT per case was 35.6%(95% CI 13.0%,58.3%) for junior residents (PGY 2-3) and 59.7%(CI 51.1%,68.3%) for senior residents (PGY 4-5). The mean autonomy evaluated by residents was 3.29(CI 2.85,3.73) out of a maximum score of 5, while the mean autonomy evaluated by attendings was 4.12(CI 3.68,4.55). RCT significantly correlated with subjective evaluations of resident autonomy (r=0.61, p=0.0003). RCT also moderately correlated with resident training level (r=0.5306, p<0.0001). Neither attending robotic experience nor operation type significantly correlated with RCT or autonomy evaluation scores. CONCLUSIONS: Our study suggests that resident console time is a valid surrogate for resident operative autonomy in robotic cholecystectomy and inguinal hernia repair. RCT may be a valuable measure in objective assessment of residents' operative autonomy and training efficiency. Future investigation into how RCT correlates with subjective and objective autonomy metrics such as verbal guidance or distinguishing critical operative steps is needed to validate the study findings further.

A controlled study to determine measurement conditions necessary for a reliable and valid operative performance assessment: a controlled prospective observational study.

OBJECTIVE: This study evaluated operative performance rating (OPR) characteristics and measurement conditions necessary for reliable and valid operative performance (OP) assessment. BACKGROUND: Operative performance is a signature surgical-practice characteristic that is not measured systematically and specifically during residency training. METHODS: Expert surgeon raters from multiple institutions, blinded to resident characteristics, independently evaluated 8 open and laparoscopic OP recordings immediately after observation. RESULTS: A plurality of raters agreed on operative performance ratings (OPRs) for all performances. Using 10 judges adjusted for rater idiosyncrasies. Interrater agreement was similar for procedure-specific and general items. Higher post graduate year (PGY) residents received higher OPRs. Supervising-surgeon ratings averaged 0.51 points (1.2 standard deviations) above expert ratings for the same performances. CONCLUSIONS: OPRs have measurement properties (reliability, validity) similar to those of other well-developed performance assessments (Mini-CEX [clinical evaluation exercise], standardized patient examinations) when ratings occur immediately after observation. OPRs by blinded expert judges reflect the level of resident training and are practically significant differences as the average rating for PGY 4 residents corresponded to a "Good" performance whereas those for PGY 5 residents corresponded to a "Very Good" performance. Supervising surgeon ratings are higher than expert judge ratings reflecting the effect of interpersonal factors on supervising surgeon ratings. Use of local and national norms for interpretation of OPRs would adjust for these interpersonal factors. The OPR system provides a practical means for measuring operative performance, which is a signature characteristic of surgical practice.

The long game: Evolution of clinical decision making throughout residency and fellowship.

BACKGROUND: The purpose of this study was to explore the trajectory of autonomy in clinical decision making. METHODS: We conducted a qualitative secondary analysis of interviews with 45 residents and fellows from the General Surgery and Obstetrics & Gynecology departments across all clinical postgraduate years (PGY) using convenience sampling. Each interview was recorded, transcribed and iteratively analyzed using a framework method. RESULTS: A total of 16 junior residents, 22 senior residents and 7 fellows participated in 12 original interviews. Early in training residents take their abstract ideas about disease processes and make them concrete in their applications to patient care. A transitional stage follows in which residents apply concepts to concrete patient care. Chief residents re-abstract their concrete technical and clinical knowledge to prepare for future surgical practice. CONCLUSIONS: Understanding where each learner is on this pathway will assist development of curriculum that fosters resident readiness for practice at each PGY level.

Operative Coaching for General Surgery Residents: Review of Implementation Requirements.

Operative coaching offers a unique opportunity to strengthen surgery residents' skill sets and practice readiness. However, institutional organizational capacity may influence the ability to successfully implement and sustain a coaching program. This review concentrates on the implementation requirements as they relate to institutional organizational capacity to help evaluate and determine if adopting such a coaching model is feasible. We searched English-language, peer-reviewed articles concerning operative coaching of general surgery residents between 2000 and 2020 with the MEDLINE database. The abstracts of 267 identified articles were further screened based on the presence of 2 inclusion criteria: general surgery residents and operative coaching. Then we summarized the reported implementation requirements. Findings revealed the implementation requirements (ie people, processes, technology/support resources, physical resources, and organizational systems) of 3 major types of resident operative coaching models were different. Video-assisted coaching faces the most barriers to implementation followed by video-based coaching; in-person coaching encounters the least barriers. Six questions are generated helping residency education leaders assess their readiness for an operative coaching program. Evaluation of the implementation requirements of a desired coaching program using the 5 organizational capacity elements is recommended to ensure the residency's ability to achieve a successful and sustainable program.

A Novel Operative Coaching Program for General Surgery Chief Residents Improves Operative Efficiency.

INTRODUCTION: We evaluated the effect of an operative coaching (OC) model on general surgery chief residents' operative efficiency (OE) measured by operative times. We hypothesized that higher levels of entrustment surgeons intend to offer resident in future similar cases are associated with improved OE. MATERIALS AND METHODS: From July 2018 to June 2019, we used a validated instrument to score prospective resident entrustment in 228 evaluations of 6 chief residents during 12 OC sessions each (3 lap colectomy, 3 lap cholecystectomy, 3 ventral hernia, 3 inguinal hernia). Operative times of matched case CPT codes performed by coached chiefs (N = 500) were matched via CPT code to the cases of uncoached chiefs in the academic year 2016-2017 (N = 478). Statistical analysis was performed using Pearson correlation and one-way ANOVA. RESULTS: Prospective entrustment scores from coached chief residents were associated with significantly shorter operative times in matched complex cases (CC) (r = -0.58, p = 0.0047). A similar trend was observed in noncomplex cases (NCC) (r = -0.29, p = 0.18). Compared to the historical cohort, coached chief residents showed a decrease in mean operative time during complex cases (p = 0.0008, d = 0.44), but an increase in mean operative times for noncomplex cases (p < 0.0001, d = 0.33). CONCLUSIONS: An OC model improves chief residents' prospective entrustment leading to increased OE in cases with greater levels of operative complexity, showing a decrease in mean operative time compared to uncoached residents in certain procedures. This is the first report showing formal coaching may be a method to enhance chief resident OE.

Predicting prospective resident entrustment: From evaluation to action.

OBJECTIVE: We aimed to identify potential variables predictive of a resident achieving faculty future entrustment as a way to enhance attending surgeons' planning of teaching in the operating room leading to improved resident operative autonomy in practice. METHODS: We reviewed 273 resident performance evaluations from 91 surgical cases that were collected from 11 general surgery chief residents and 16 attending surgeons between April 2018 and June 2019 using a validated evaluation instrument. The primary outcome measure was prospective resident entrustment estimated by the rater for future similar cases. We used descriptive statistics and the boosted tree analysis model to find potential predictors for the outcome measure and examine test-retest reliability by procedure. RESULTS: Step-specific guidance (r = 0.77, p < 0.0001) was the variable most highly associated with prospective resident entrustment in bivariate linear analysis. The boosted tree analysis demonstrated step-specific guidance was the strongest predictor for prospective resident entrustment in the OR, and its predictive importance was much higher than the overall guidance (0.64 > 0.18). Test-retest reliability was from 0.93 to 0.98 across procedures, indicating the likelihood that attending surgeons granted future autonomy complied with their evaluation of prospective resident entrustment was high. CONCLUSIONS: By assessing step-specific guidance, attending surgeons can reliably judge residents' future entrustment and potentially better plan for operative teaching/supervision that may lead to granting a surgical resident operative autonomy on similar cases in the future. Our findings provide insight into prospective faculty development of surgical teaching aimed at improving resident readiness for independent practice.

Evaluation of an instrument to assess resident surgical entrustable professional activities (SEPAs).

BACKGROUND: The purpose of this study was to examine the reliability and the validity of the new surgical entrustable professional activities (SEPAs) instruments. METHODS: A prospective evaluation of six procedure-specific SEPAs instruments derived from the validated OPRS evaluation tools was conducted in 2018. Each instrument includes an open-ended feedback item and a series of Likert-Scale rating items. Attending, resident and a constant 3rd surgeon-observer completed the same evaluation for the observed case within 3 days of each evaluated operation. RESULTS: 40 cases performed by 10 residents and 11 attending surgeons were observed and evaluated. The SEPAs instruments were supported by strong validity evidence. Factor analysis revealed three latent variables are consistent with the core construct of SEPAs instrument. Internal reliability was high with Cronbach's α ranging from 0.84 to 0.94 across the six procedures. Test-retest reliability varied from 0.74 to 0.93 in the study sample. CONCLUSIONS: The SEPAs instruments are reliable and valid tools for assessment of crucial aspects of resident learning and surgical entrustable professional activities that lead to entrustment and eventually surgical autonomy.

Residents' method for gaining operative autonomy.

INTRODUCTION: The goal of this study was to explore the resident construct for their perceived successful method of actions that lead to OR autonomy during residency and the strategies they employed. METHODS: We conducted focus group interviews with residents from the General Surgery (GS) and Obstetrics & Gynecology (OBGYN) departments at a single academic institution across all clinical postgraduate years (PGY) using convenience sampling. Audio recordings of each interview were transcribed, analyzed and emergent themes were identified using a framework method. RESULTS: A total of 38 residents participated. A 3-stage resident method to gain operative autonomy emerged. This progresses from building rapport, developing mutual entrustment, and finally to obtaining autonomy. We identified 4 common strategies used by residents to construct this method: smart communication, attention to attending preferences, helpful allies and visible attributes. CONCLUSION: Our findings provide insight into resident strategies to achieve progressive autonomy in the OR helping programs improve resident's learning efficiency.

Pre-clinical Stress Management Workshops Increase Medical Students' Knowledge and Self-awareness of Coping with Stress.

OBJECTIVES: To investigate the effects of a stress management workshop on medical students' knowledge of stress and potential coping strategies. METHODS: A panel discussion with small group breakouts on stress in clinical medicine, learning challenges, competition with colleagues, handling stressful events, and recognizing burnout symptoms was conducted with medical students entering clerkships. A longitudinal survey design was utilized to measure pre-, post-, and long-term (3-month) changes in knowledge (impact of stress on personal health, learning, and patient care), confidence, perceived skills, and attitude (towards utilizing adaptive coping strategies) among participating students (N = 135). Paired t test and multivariate analyses were performed to assess the differences between survey responses on a 5-point Likert scale. RESULTS: Survey response rates were pre-90.4%, post-77%, and long-term post-71.1%. Compared to pre-workshop, students reported significant improvement in all four domains immediately post-workshop: knowledge (4.4 vs. 4.7, p < 0.05), confidence (3.6 vs. 3.9, p < 0.05), perceived skills (3.3 vs. 3.7, p < 0.05), and attitude (2.6 vs. 2.8, p < 0.05). Compared to immediate post-workshop, students' scores slightly decreased at 3 months but were overall significantly higher than the pre-workshop scores. CONCLUSIONS: A stress management workshop can improve medical students' knowledge of the impact of stress as well as the use of adaptive stress coping strategies.

Entrustment Evidence Used by Expert Gynecologic Surgical Teachers to Determine Residents' Autonomy.

OBJECTIVE: To identify entrustment evidence used by expert gynecologic surgical teachers to determine obstetrics and gynecology residents' level of autonomy in the operating room. METHODS: A qualitative interview study was undertaken from March to November 2016. Four selection criteria were used to define and purposefully sample expert gynecologic surgical teachers across the United States to represent all four geographic regions. All interviews were audio-recorded and transcribed. We applied the Framework Method of content analysis. Transcripts were iteratively analyzed and emergent themes identified. RESULTS: Twenty-seven expert gynecologic surgical teachers from 15 institutions across the United States participated in 30-minute interviews. We identified four domains of entrustment evidence (resident characteristics, medical knowledge, technical performance, and "beyond current surgical case") commonly reported by expert gynecologic surgical teachers to determine residents' autonomy as well as the particular evidence associated with expert gynecologic surgical teachers' determination of resident autonomy at two decision-making points (surgical time-out and taking over certain intraoperative steps) in the operating room. Onsite direct observation and conversation were two common methods used by expert gynecologic surgical teachers to obtain this evidence. CONCLUSION: Entrustment evidence from resident characteristics, medical knowledge, and technical performance domains and from "beyond current surgical case" was commonly used by expert gynecologic surgical teachers to determine residents' autonomy. Our findings provide a potential framework for designing educational interventions that aim to increase residents' readiness for autonomy and entrustment in the operating room.