P3.Q333: “They feel like they can't do anything”: A Qualitative Exploration of Surgeon and Resident Perspectives on Safety, Oversight, and Autonomy on Pediatric Surgery Rotations

Background: From its nascence as a clinical specialty, pediatric surgery has remained a core discipline within the purview of general surgery training. Previous research has shown that surgical residents on pediatric surgery rotations have difficulty adjusting to differences from their other rotations with adult patients. Suboptimal support impedes residents’ learning, burdens other surgical team members, and compromises patient safety. We sought to characterize pediatric surgical team members’ perceptions of safety, oversight, and autonomy with the goals of helping to promote shared understanding and identifying best practices to optimize resident education while maintaining safety.

Methods: This study takes a phenomenological approach in exploring individuals’ beliefs and subjective experiences. We used purposive and snowball sampling to recruit pediatric surgical attendings, advanced practice providers (APPs), fellows, and surgical residents from major academic general surgery residency programs and affiliated pediatric hospitals from across the United States. Semi-structured interviews were conducted virtually between October 2023 and January 2024. Interviews were recorded and transcribed, and a code book was developed inductively by two researchers trained in qualitative methods. Iterative coding was performed with Dedoose via the constant comparative method, and thematic analysis revealed patterns and broader insights. Data collection and analysis occurred concurrently until there was data sufficiency after 28 interviews.

Results: Pediatric surgical team members had variable views on patient safety, in part informed by their proximity to mechanisms which catch errors, which include individual and systems-level approaches. They commonly perceived there to be a high degree of oversight for surgical residents and consequent lower degree of autonomy to ensure patient safety. While this is regarded as appropriate, it has both pros and cons for the resident experience. The need for increased oversight arises from factors related to the pediatric surgical context, patients, parents, attendings, and residents, both individually and in relationship to one another (Figure 1). Although attendings often find it difficult to grant autonomy to residents, attendings and residents shared practices which they found to be helpful in overcoming those various factors to achieve this goal (Table 1).

Conclusion: Pediatric surgical team members have complex perspectives on patient safety. Many perceive high levels of oversight and consider it to be appropriate, but acclimating may be challenging for residents who are used to more autonomy on other rotations. Understanding the numerous factors which contribute to these dynamics may help residents and attendings navigate this unique clinical environment, achieve appropriate levels of autonomy while still ensuring excellent patient care, and optimize the learning experience.