The research team, led by investigators at Washington University School of Medicine in St. Louis, surveyed 118 respondents, 36 general surgery residents and 82 attending surgeons, between May and June of 2025. Participants rated the importance of nine distinct autonomy signals on Likert scales, covering everything from the fraction of the operation performed to whether the attending scrubbed into the case, and they also answered open-ended questions about how they conceptualize and experience autonomy. The quantitative analysis included descriptive statistics, Welch’s t-tests to accommodate unequal variances and sample sizes, effect sizes calculated with Hedges’ g, and an exploratory factor analysis designed to uncover hidden dimensions in how each group organizes its thinking about autonomy. The free-text responses were then subjected to rapid qualitative content analysis, with independent inductive coding by one resident investigator and one attending investigator whose codes were reconciled through consensus meetings.

Three signals separated the groups with statistical significance, and the effect sizes were large enough to matter educationally. Residents rated the fraction of the operation they personally performed as more important to autonomy than attendings did, scoring it 4.0 versus 3.5 on the rating scale, a difference with a moderate effect size of 0.53. The starkest divergence concerned being allowed to struggle: residents rated this signal at 4.4 on average while attendings gave it 3.6, a difference the authors describe as substantial, with an effect size of 0.84. Attendings, by contrast, placed greater weight on operating room set-up, the positioning, prepping, and draping that precede the incision, rating it 3.6 compared with the residents’ 3.0. On the remaining signals, including performing specific portions of the case, attending presence at the table, intraoperative and preoperative decision-making, extent of dissection, and being corrected, the two groups did not differ significantly. Subgroup analyses found no meaningful differences across resident training stages or attending years in practice, although the importance attendings placed on the fraction performed trended upward with experience.

The exploratory factor analysis added a structural layer to these findings. Both residents and faculty produced two latent dimensions, and both groups clustered technical execution items, such as the fraction performed, performing specific portions, and extent of dissection, into a shared dimension. But the surrounding architecture differed in revealing ways. Residents grouped being corrected and having the attending scrubbed alongside preoperative decision-making, suggesting that they experience supervision and independence as points on a single relational continuum. Attendings instead paired preoperative decision-making with operating room set-up, reflecting a cleaner separation between cognitive readiness and technical execution. The authors caution that these factor structures are exploratory and hypothesis-generating given the sample size, but the pattern implies that residents experience autonomy dynamically and relationally, while faculty conceptualize it in more compartmentalized domains.

The qualitative arm of the study, however, is where the human texture of the problem emerges. Both residents and faculty described autonomy in nearly identical conceptual language: not as task completion but as cognitive ownership, the ability to independently formulate an operative plan, anticipate intraoperative steps, and assume responsibility across the perioperative continuum. One faculty respondent summarized high autonomy as the resident performing critical decision-making in the workup, the operative plan, and postoperative management. Residents agreed, but they emphasized that technical participation without decision-making authority does not constitute true autonomy, describing low-autonomy cases as those where they were doing a lot but not being involved in planning or decision making. This shared definition makes the practical divergence all the more puzzling, and the study argues it explains why autonomy can be experienced so differently even when both parties believe they are aligned.

The two groups also told strikingly different stories about what it means to do the case. Residents more frequently equated autonomy with hands-on performance of meaningful operative steps, identifying anatomy, leading dissections, and performing level-appropriate tasks. Faculty framed technical performance as necessary but insufficient, emphasizing safe execution with minimal guidance rather than sheer volume of activity. The metaphors each group used are telling: faculty described low-autonomy surgery as paint by numbers, while residents described the same experience as just following along with the bovie. Operative flow emerged as another shared but differently interpreted signal. Residents experienced autonomy when permitted to control the case and the operating room, directing pace and sequencing, whereas faculty viewed smooth flow as evidence of readiness for entrustment rather than autonomy itself. When faculty interrupted flow to maintain safety or momentum, residents often read the intervention as a revocation of trust.

Safe struggle proved to be the most fragile point of misalignment. Faculty frequently described deliberately allowing residents to wrestle with difficulty within defined safety limits as a core teaching strategy. Residents, however, experienced autonomy as easily revoked the moment a case grew hard, and abrupt takeover during moments of struggle was commonly interpreted as a loss of trust rather than a safety-driven decision. The groups also attributed autonomy loss to different causes: faculty cited patient safety, case complexity, efficiency pressures, and recognition of danger zones, while residents frequently blamed contextual or affective factors such as attending anxiety, time pressure, or stylistic preference rather than their own performance. Residents uniquely emphasized the emotional stakes, describing low-autonomy experiences as demoralizing and identity-threatening, reducing them to assistants or technicians rather than developing surgeons. Faculty rarely named identity formation explicitly, focusing instead on progression toward independent practice.

These threads converge in a conceptual model the authors propose, distinguishing faculty-granted autonomy, grounded in entrustment decisions shaped by safety, efficiency, preparation, and cognitive readiness, from resident-perceived autonomy, grounded in experienced agency, technical leadership, safe struggle, and professional identity. Entrustment theory, which frames autonomy as a dynamic supervisory judgment based on competence, reliability, and contextual risk, provides the theoretical scaffold. When granted and perceived autonomy align, the model suggests, trust, engagement, and progressive independence follow; when they diverge, residents may perceive autonomy loss even when the attending believes entrustment is being appropriately calibrated. The study builds on the team’s earlier work documenting seniorization, the gradual shift of Entrustable Professional Activities toward more senior residents at Veterans Affairs hospitals, and on a broader literature documenting declining resident autonomy in the operating room.

The authors translate their findings into concrete recommendations: training programs should explicitly define and discuss autonomy to build a shared framework; entrustment decisions should be intentionally narrated, particularly during moments of struggle or takeover, so that intent is clear and trust is preserved; assessment tools and Entrustable Professional Activities should incorporate both technical and cognitive dimensions of autonomy; and faculty development should emphasize strategies for allowing safe struggle while recognizing its centrality to how residents experience their training. The study carries limitations the authors acknowledge candidly: the response rate could not be calculated because the listserv population was unknown, the sample likely overrepresents academically engaged educators, more than half of resident respondents were on dedicated research time, the cross-sectional design cannot track change over time, the newly developed survey lacked formal psychometric validation, and multiple exploratory comparisons were performed without adjustment. Even so, the multi-institutional scope and the integration of quantitative and qualitative evidence give the conclusions weight. The deeper message resonates beyond surgery: autonomy in training is not a single dial but a negotiated meaning, and closing the gap may depend less on granting more autonomy than on making the granting visible.

Subject of Research: Divergent perceptions of operative autonomy between general surgery residents and faculty

Article Title: General surgery resident and faculty perceptions of autonomy: a mixed-methods analysis

Article References: Brocke, T. K., Fox, C., Wang, D., Vetter, J., Awad, M. M., & Ohman, K. A. (2026). General surgery resident and faculty perceptions of autonomy: a mixed-methods analysis. Global Surgical Education – Journal of the Association for Surgical Education, 5(1), Article 191. https://doi.org/10.1007/s44186-026-00593-5

Image Credits: AI Generated

DOI: 10.1007/s44186-026-00593-5

Keywords: operative autonomy, surgical education, general surgery residency, entrustment, mixed methods, resident training, faculty perceptions, safe struggle, professional identity, entrustable professional activities, medical education, survey research