Autonomy in the OR as a resident

[dr.evil]

To all of those surgery residents out there as well as med students:

What level of autonomy do chief residents have in your programs in the O.R.? Can your chiefs start a case without the attending in the room? Can the chiefs do the entire case without the attending ever coming in the room? What cases can the chief do alone? What cases can the chief do with the attending there for the 'critical steps of the procedure'? What cases does the attending need to be there from beginning to end?

I'm trying to gauge the level of autonomy that a chief resident should have. Please let me know the type of hospital you are at that allows you a certain level of autonomy (i.e. VA, private, university, community, etc).

Do upper levels in your program teach the lower levels?

Please help.

droliver, how are things different at the different hospitals you rotate through?

thanks everyone

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[droliver]

varies a bit.
At the VA I will do pretty much things myself (staff available) except major vascular for which I'll do the exposure & disection & let whose staffing me know to come for the anastamosis. I've had to do a number of fairly complex things @ night emergently recently without staff there (rigid esophagoscopy for a foreighn body, emergent trachs, obstructing colon CA, groin exploration for ruptured psedoaneurysm).

At the university we have a list of procedures we're privledged to do without staff which excludes major vascular or thoracic. Most cases that aren't private patients are done with the chief teaching the lower levels.The staff usually stick their head in & offer to help for some of the more diffucult cases, but thats rare you need it. On trauma we routinely have to do some emergency huge damage-control cases before staff is available.

Our rotations @ the private hospitals consist of private patients & your autonomy is pretty limited there. I do most all of the cases I scrub on, but you're doing it however someone wants you to do it. Sometimes some attendings will want a chief there to do a hard case for them or use some technique or equipment that they aren't comfortable with. Experience under these conditions is valuable (you learn a lot from the people who are the real artists in practice) but for a lot of things I feel you need to struggle by yourself some to learn how to do things. Its why I always tell my students going into surgery that I think university/indigent settings are preferable to strictly private programs for becoming a better surgeon (there's a happy medium b/w too much & too little supervision). I think most of the older surgeons feel the same way & regret some of the changes that have inevitably crept into surgical education.

I've always felt that we had a pretty good mix of mentored & independent experience here & not too heavily balanced one way or the other. Even here though, things have changed a lot in my 5 years. There is a gradual chipping away of resident independence as the forces of medical liability, medicare auditing of records, and the financial rewards (for attendings) of more complete documentation have come into play. There is now 100% more interaction of our trauma staff on a day to day basis with those services as we've had four new faculty in that area come in & reorganize it over the last 2 years. The VAMC has also demanded more accountability on a national level that has led to more supervision under that system as well