Several challenges threaten the traditional premise of graduated independence in general surgery training, leading to a lack of readiness in graduating surgeons. The objective of this study was to determine the factors contributing to faculty decisions to grant residents autonomy in the operating room, the barriers to granting this autonomy, and the factors that facilitate entrustment.

An anonymous online survey was distributed to 239 attending surgeons at 7 institutions. Questions consisted of open-ended and structured 5-point Likert scale questions. Descriptive statistics were calculated, and a qualitative analysis of free-text responses was performed to identify emergent themes.

There were 116 attending surgeons who responded to the survey (49%). Factors most important to increasing resident responsibility and autonomy in the operating room were the resident's observed clinical skill and the attending surgeon's confidence level with the operation. Factors believed to prevent awarding graduated responsibility and autonomy in the operating room included an increased focus on patient outcomes, a desire to increase efficiency and finish operations earlier, and expectations of attending surgeon involvement by the hospital and patients.

Among themes discerned in faculty responses to an open-ended question about the greatest challenges in graduate surgical education, 47% of faculty identified work-hour regulations/time restrictions. Fourteen percent pointed to a change to a shift-work mentality and decreased ownership of responsibility for patients by residents; 13% described a lack of resident autonomy due to increased supervision requirements.

This study identified several factors that attending surgeons report as significant limitations to transitioning autonomy to surgical residents in the operating room. These issues must be addressed in a direct manner if progressive graduated responsibility to independence is to occur in the next era of graduate surgical training.