16 Mar

Documenting Readiness for Unsupervised Practice

Posted by: Debra DaRosa
in Blog
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Surgeons in teaching hospitals are challenged with balancing their responsibility to patients for ensuring optimal operative outcomes, and their responsibility to prepare residents for independent practice.  Overseeing quality of care and supervising residents is further complicated by shortened resident duty hours, emphasis on operating room cost efficiency, as well as surgeon clinical productivity. These forces reduce time critical for teaching and honing residents’ operative skills and judgment.1  As noted in a  monograph published by the Josiah Macy Foundation, the development of essential skills  is delayed if learners are not afforded sufficient independence or authority for patient care.  The monograph reiterates the concerns of program directors and faculty that residents do not receive sufficient opportunity to act independently in the current teaching environment and are less prepared for practice.  These concerns were most strenuously expressed with procedure-based specialties.2  


No system currently exists to measure and document which operations a graduating general surgery resident can safely perform without direct supervision.  Recently added requirements for operative evaluation by the American Board of Surgery may address this to some degree, but will still not provide details about the types of operations a resident can independently and safely perform, as well as manage pre and post-operatively.  There are significant concerns that resident education in general surgery does not adequately prepare residents for practice in the specialty.3   A survey of  North American surgical fellowship program directors reported concerning deficiencies in incoming fellows.  These fellows had completed five years of  general surgery residency training, yet it was felt that recent cohorts  exhibited declining operative skills, autonomy, patient ownership, and trust in their abilities to function as independent surgeons.4  

The SIMPL system includes a tool that offers an easy approach for documenting resident readiness for independent practice.  It offers program directors data useful for:

  1. determining the extent of autonomy each resident and groups of residents achieved by procedure
  2. providing feedback to residents on what they need to accomplish to earn the next level of autonomy for a given procedure
  3. clinical rotation planning so the exposure to procedures and duration increase the likelihood that residents will achieve the level of autonomy for selected operations outlined in the rotation objectives.
  4. identifying attendings who may need faculty development to learn how to more effectively teach in the operating room.
  5. as collated across programs, determining the average number of cases needed to achieve autonomy.

A general surgery residency should not function as “middle school” expecting additional experience through fellowships to complete the training.  This is critical because fellowships are not required, and surgeons can legally start operating on patients once they graduate and pass their board certification examinations. 

It is not suggested that SIMPL will resolve all of the above listed concerns, but it is certainly a move in the right direction for heightening accountability and documenting which operations residents are capable of doing safely and independently.   I think it is in the best interests of residents, faculty, and patients.

Debra A. DaRosa, Ph.D.
Professor Emerita of Surgery and Medical Education
Northwestern University



  1. Reznick R, MacRae H.  Teaching surgical skills – Changes in the wind.  NEJM. 2006;355:2664-2669.
  2. Weinstein D (Chair) Conference: Ensuring an effective physician workforce for the United States: Recommendations for graduate medical education to meet the needs of the public.   Josiah Macy Jr. Foundation; Nov 2011.
  3. Bell RH, Biester TW, Tabuenca A, Rhodes, RS, Cofer JF, Britt LD, Lewis FR.  Operative experience of residents in US general surgery programs: A gap between expectation and experience.  AnnSurg.  2009;249:719-724.
  4. Matter SG, Alseidi AA, Jones DB, Jeyarajah DR, Swanstrom LL, Aye RW, Wexner SD, Martinez JM, Ross SB, Awad MM, Franklin ME, Arregui ME, Schirmer BD, Minter RM.  General surgery residency inadequately prepares trainees for fellowship.  Ann Surg.  2013;258:440-449.