The Effect of Patient Education on the Perceptions of Resident Participation in Surgical Care

APDS ANNUAL MEETING PAPER

The Effect of Patient Education on the Perceptions of Resident Participation in Surgical Care$ Jason W. Kempenich, MD,* Ross E. Willis, PhD,† Robert J. Blue, DO,* Mohammed J. Al Fayyadh, MD,† Robert M. Cromer, MD,* Paul J. Schenarts, MD,‡ Kent R. Van Sickle, MD,† and Daniel L. Dent, MD† Department of General Surgery, Keesler Medical Center, Keesler AFB, Biloxi, Mississippi; †Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas; and ‡Division of Surgery, University of Nebraska Medical Center, Omaha, Nebraska *

OBJECTIVE: To decipher if patient attitudes toward

resident participation in their surgical care can be improved with patient education regarding resident roles, education, and responsibilities. DESIGN: An anonymous questionnaire was created and distributed in outpatient surgery clinics that had residents involved with patient care. In total, 3 groups of patients were surveyed, a control group and 2 intervention groups. Each intervention group was given an informational pamphlet explaining the role, education, and responsibilities of residents. The first pamphlet used an analogy-based explanation. The second pamphlet used literature citations and statistics. SETTING: Keesler Medical Center, Keesler AFB, MS.

University of Texas Health Science Center at San Antonio, San Antonio, TX. PARTICIPANTS: A total of 454 responses were collected

and analyzed—211 in the control group, 118 in the analogy pamphlet group, and 125 in the statistics pamphlet group. RESULTS: Patients had favorable views of residents assisting with their surgical procedures, and the majority felt that outcomes were the same or better regardless of whether they read an informational pamphlet. Of all the patients surveyed, 80% agreed or strongly agreed that they expect to be asked permission for residents to be involved in their care. Further, 52% of patients in the control group agreed or ☆ The views expressed in this material are those of the authors and do not reflect the official policy or position of the U.S. Government, the Department of Defense, or the Department of the Air Force. The work reported herein was performed under United States Air Force Surgeon General-approved Clinical Investigation No. FKE20150020E. Correspondence: Inquiries to Jason W. Kempenich, MD, FACS, Assistant Professor, Associate Program Director, General Surgery, Department of Surgery, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr – MC 7842, San Antonio, TX 78229-3900; E-mail: [email protected]

strongly agreed to a fifth-year surgery resident operating on them independently for routine procedures compared to 62% and 65% of the patients who read the analogy pamphlet and statistics pamphlet, respectively (p ¼ 0.05). When we combined the 2 intervention groups compared to the control group, this significant difference persisted (p ¼ 0.02). CONCLUSION: Most patients welcome resident participa-

tion in their surgical care, but they expect to be asked permission for resident involvement. Patient education using an information pamphlet describing resident roles, education, and responsibilities improved patient willingness to allow a chief resident to operate independently. ( J Surg Ed ]:]]]-]]]. Published by Elsevier Inc on behalf of the Association of Program Directors in Surgery) KEY WORDS: graduate surgical education, patient care,

patient education, autonomy COMPETENCIES: Patient Care and Procedural Skill, Professionalism, Interpersonal and Communication Skills

INTRODUCTION Resident education was founded on a model of gradually giving surgical residents increasing levels of responsibility and autonomy with patient care as they approach graduation in preparation for independent practice.1 More recently, there have been mounting concerns regarding the preparedness of general surgery graduates for independent practice because of a lack of autonomy in training.2-4 Contributing to this decline are public concerns regarding safety5 as well as an increasingly patient-centered standard of care.6 In our recent survey7 of the general public, we found that 96% of the general public were agreeable to resident

Journal of Surgical Education  Published by Elsevier Inc on behalf of the 1931-7204/$30.00 Association of Program Directors in Surgery http://dx.doi.org/10.1016/j.jsurg.2016.05.005

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participation in their care. When resident participation was defined as involvement with surgical procedures, enthusiasm waned to 82%, and if asked whether residents should participate in complex procedures, agreement dropped to 59%. This presents a unique hurdle to surgical training for residents as there seems to be less patient enthusiasm for resident involvement with surgical procedures.8 Santen et al.,9 in a study examining patients’ willingness to allow residents to perform Emergency Department procedures, found that 60% of patients did not understand that a resident may be performing a procedure for the first time. They suggested that although patients may have a general understanding that physicians undergo a training process, they do not understand the details of the educational process. In a postoperative survey of hysterectomy patients, Kim et al.10 found that only 63% of patients who had a resident involved in their care were aware that a resident participated in their surgery. There are multiple studies evaluating patient perceptions of resident involvement in patient care, but there is limited information regarding evaluating methods for informing patients of resident involvement in care.8,9,11 Dutta et al.12 showed in a survey of program directors that surgeons seem to prioritize educational goals over patient autonomy while addressing patient concerns in practice. They suggest that attending surgeons should explain resident roles, reinforce the patient’s contribution to resident education, and obtain consent. We seek to establish whether education of patients with an informational pamphlet explaining resident roles and responsibilities can improve patient perceptions of resident participation.

MATERIALS AND METHODS Patients receiving care in outpatient surgical clinics at 2 general surgery resident programs, Keesler Medical Center

and the University of Texas Health Science Center at San Antonio, were surveyed. The outpatient clinics were composed of general surgery clinic and various subspecialty clinics of general surgery (colorectal, bariatric surgery, surgical oncology, and vascular surgery). Institutional review board approval was obtained at both participating institutions before commencement of the study. A 5-point Likert scale was used for all questions, and the questionnaire was piloted and feedback solicited from representative individuals. The questionnaire was then finalized after discussion and agreement among the investigators. The questions asked are shown in Table 1. A total of 3 groups of patients were surveyed, a control group and 2 intervention groups. The control group was composed of all patients presenting to outpatient surgery clinics with residents participating in patient care. Upon checking in for their appointment, patients were asked to complete a brief questionnaire regarding their views of resident involvement in their care before interacting with resident physicians or faculty. The questionnaire was collected by a medical technician, batched, and then retrieved by the investigators. No identifying information was collected. After completion of the control group, the intervention groups were surveyed. Each intervention group was given an informational pamphlet explaining the role, education, and responsibilities of residents before answering their questionnaire. The 2 versions of the pamphlet were distributed in alternating fashion. The first intervention pamphlet was developed using the airline industry as an analogous example of the surgery attending, resident, medical student, and surgical technician hierarchy, similar to the pilot, copilot, and ground crew. The second pamphlet used literature citations13-16 and statistics that showed the benefit of resident involvement. Both pamphlets explained the education and role of a medical student, resident, and

TABLE 1. Survey Questionaire (1) I welcome resident participation in my health care under the direct supervision of my doctor. (2) If I had to have a complicated surgery, I would consent to a first- or second-year resident participating in my care and assisting with the procedure. (3) If I had to have a complicated surgery, I would consent to a third-, fourth-, or fifth-year resident participating in my care and assisting with the procedure. (4) If I had to have a routine surgery, I would consent to a first- or second-year resident participating in my care and assisting with the procedure. (5) If I had to have a routine surgery, I would consent to a third-, fourth-, or fifth-year resident participating in my care and assisting with the procedure. (6) I think surgical outcomes are the same or better with resident participation in patient care and surgical procedures. (7) If I needed a routine procedure, I would consent to a fifth-year resident performing my procedure independently. (8) I expect to be asked permission for a resident to be involved in my health care. (9) If I have surgery, I want to know how much of the procedure is going to be done by the resident. (10) My overall surgical health care is better with residents involved. (11) Having residents involved in my health care is inconvenient. (12) Have you ever had a resident participate in a surgical procedure performed on you? (13) Did you read the pamphlet about resident involvement in your health care? (Intervention groups only) 2

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attending physician in patient care. Both pamphlets also explained that residents do not “practice” on patients but are guided through procedures by the attending surgeon until they achieve competency. The pamphlets ended by thanking patients for participating in the education of our residents and encouraged patients to ask any questions they may have. Each pamphlet was assessed for readability. The average Flesh-Kincaid grade level was 5.7 for the analogy pamphlet and 6.8 for the literature and statistics pamphlet. If we eliminate the analysis of the reported literature in the statistics pamphlet, the Flesh-Kincaid grade level dropped to 5.8. Both pamphlets and the questionnaire were translated into Spanish, and readability was analyzed and found to be similar. Responses were compiled for each group, and the median response for each question was calculated. The KruskalWallis test was then employed to analyze the distribution of responses among the 3 groups. In cases where a significant difference was identified, a Mann-Whitney U test was used for pairwise comparisons. Additional analysis of questionnaire items 3 through 6 was undertaken with the Wilcoxon signed rank test.

RESULTS Before data collection, we conducted a power analysis that revealed that approximately 291 responses would be needed to provide a 95% confidence interval with a 10% margin of error. A total of 556 responses were collected. Response rates were 83% for the control group, 63% for the analogy pamphlet group, and 68% for the statistics pamphlet group. Patients in both intervention groups were asked if they read the pamphlet, and the responses from those patients who did not read the pamphlet were excluded. Final analysis after exclusion included 454 total responses as follows: 211 in the control group, 118 in the analogy pamphlet group,

and 125 in the statistics pamphlet group. Further, 70% of those patients who received the pamphlet reported reading it. There were 126 patients in our sample who previously had a resident participate in a surgical procedure performed on their person, 90 had not, and 221 were unsure. There were no statistical differences based on patients’ previous experience with resident participation in surgery. Patients in the control group were very welcoming to resident participation under the direct supervision of their doctor with 85% responding agree or strongly agree to resident participation compared to 88% for the analogy pamphlet group and 87% for the statistics pamphlet group. There was no statistical difference in either intervention group compared with the control. Furthermore, 93% of all patients answered neutral, agree, or strongly agree that they think surgical outcomes are the same or better with resident participation. Patients had favorable views of residents assisting with their surgical procedures as well. Questionnaire items 2 through 5 (Table 1) asked if patients would consent to residents participating in their care and assisting with their procedure. The questions delineated if the procedure was complex or routine and if a senior-level (PGY 3-5) or junior-level (PGY 1-2) resident would be involved. There was no difference in responses among the control group and the 2 intervention groups. We then compiled all responses from the 3 groups, and they are listed in Table 2. If patients were having a routine procedure, 65% would strongly agree or agree to a junior-level resident assisting and being involved with their care versus 52% if they were having a complicated procedure (p o 0.001). Patients were then asked the same question but instead, a senior-level resident would be assisting and be involved with their care. In this case, 82% of patients agreed or strongly agreed to a seniorlevel resident involvement with a routine procedure compared to 77% if the procedure was complicated (p o 0.001). Responses were also significant when comparing responses for junior-level residents with senior-level residents for complicated procedures (p o 0.001) and routine proce-

TABLE 2. Patients’ Willingness to Consent to a Resident Participating in Surgical Care and Assisting With a Procedure Based on Training Level and Procedure Complexity Junior resident Complex procedure n ¼ 449 Senior resident Complex procedure n ¼ 451 Junior resident Routine procedure n ¼ 446 Senior resident Routine procedure n ¼ 448

Strongly Disagree

Disagree

Neutral

Agree

33 (7%)

67 (15%)

115 (26%)

166 (37%)

68 (15%)

10 (2%)

21 (5%)

74 (16%)

208 (46%)

138 (31%)

19 (4%)

33 (7%)

102 (23%)

198 (44%)

94 (21%)

9 (2%)

12 (3%)

60 (13%)

220 (49%)

147 (33%)

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Strongly Agree

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TABLE 3. If I Needed a Routine Procedure, I Would Consent to a Fifth-Year Resident Performing My Procedure Independently Control Group, n ¼ 206

Analogy Pamphlet, n ¼ 113

Statistics Pamphlet, n ¼ 120

52% 24% 24%

62% 27% 11%

65% 16% 19%

Strongly agree or agree Neutral Disagree or strongly disagree Control versus Analogy versus Statistics, p ¼ 0.05. Control versus (Analogy þ Statistics), p ¼ 0.02.

dures (p o 0.001). These results would support that both the educational level of the resident and the complexity of the procedure have significant effect on patient enthusiasm for resident participation. In the control group, 52% of patients agreed or strongly agreed to a fifth-year surgery resident operating on them independently for routine procedures compared to 62% and 65% for patients who read the analogy pamphlet and statistics pamphlet, respectively (p ¼ 0.05; Table 3). Pairwise comparisons revealed no statistical difference in responses between the 2 intervention groups. We then consolidated the data of the 2 intervention groups (combined, 64% agreed or strongly agreed) and compared them to the control group, and the difference persisted with a significance of p ¼ 0.02. In addition, we analyzed the group of patients we excluded who received a pamphlet but did not read it and found that their responses were not statistically different compared to the control group. After reading either pamphlet on resident roles, education, and responsibilities, patients were more willing to allow a chief resident to perform routine procedures independently. Of all the patients surveyed, 80% agreed or strongly agreed that they expect to be asked permission for residents to be involved in their care, and 83% agree or strongly agree that they want to know how much of a procedure would be done by a resident. Only 6% of patients disagreed or strongly disagreed that residents make their surgical care better. Further, 12% of patients agreed or strongly agreed that resident involvement was an inconvenience. There were no statistical differences between the control group and the 2 intervention groups for these questionnaire items.

In a recent survey of the general public, we found that the general public was less enthusiastic toward resident participation if they were having a surgical procedure, particularly if it was a complex procedure.7 Santen et al.9 reported in their survey of emergency department patients that although 80% felt it was important to know the level of training of their physician, only 58% actually knew. Several authors have suggested that early discussion of resident education, roles, and responsibilities is important for patient satisfaction.6,8,10-12 Our aim in this study was to improve patient

receptiveness to resident participation in surgical care with an educational pamphlet addressing these concerns. For the items we queried, there were no differences in patient responses between the 2 education pamphlets we developed (one using the airline industry and the other quoting statistics favorable to resident involvement). We did find a significant difference between the control group and intervention groups with regard to chief residents performing procedures independently. Patients’ willingness to consent for a chief resident to perform a routine procedure independently on their person after reading our pamphlet increased from 52% to 64% (p ¼ 0.02). Cogbill et al.17 reported in a survey of general surgery program directors that only 38% of general surgery programs offer an autonomous outpatient general surgery experience. The reason for this was not delineated in their survey, but multiple explanations have been suggested for the decrease in resident autonomy including the 80-hour work week,1 new and innovative technologies being applied to general surgery,1 financial constraints,18,19 legal limitations,20 quality of patient care,21 patient expectations,22 and public opinion.5 In our recent survey of teaching faculty and residents, greater than 97% agreed that residents require autonomy in training to develop into an attending surgeon, but more than 40% felt they currently had too little autonomy at their institution.7 We were encouraged that a relatively minor intervention in an outpatient surgery clinic had a positive effect on patient endorsement for resident operative autonomy. Similar to our results, in an outpatient survey of ophthalmology patients requiring cataract surgery, 49% reported they were likely or very likely to allow residents to perform their cataract surgery.11 Cowles et al.8 found in a survey of postoperative inpatient surgical patients that only 3.5% of patients would agree to a resident performing their entire procedure. Their study did not separate junior and senior residents, and most patients had undergone complex procedures. In our survey, if patients were having a routine procedure, 65% of patients would agree to a junior resident assisting versus 82% who would agree if it were a senior resident (p o 0.001). We also found a significant decrease in patient receptiveness to resident involvement (junior or senior level) if they were having a complex procedure performed versus a routine procedure. Our survey clearly supports that both of these factors play a major role in patient comfort with resident involvement. Of note, we did

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DISCUSSION

not define complex or routine procedures for the patients as we felt that this would potentially lead to confusion. Admittedly, we may not agree with patient assessment of which procedures are more or less complex, but their responses are still valid regarding their reaction to resident involvement if they perceive their surgery to be routine or complex. However, Cowles’ group found that in patients who have been asked postoperatively to rate the complexity of their case, they seem to have an adequate understanding if their surgery was more or less complicated. They also concluded that although residents are well received, there is reluctance when it comes to procedures. We were encouraged that if patients felt they were having a complex procedure, 77% would still agree to a senior resident participating with their surgery. One of the major limitations of distributing an informational pamphlet to patients is that it requires patient participation to read the material. Of those patients who received a pamphlet and completed the questionnaire, 70% reported actually reading the pamphlet. In addition, the response rates were much lower in the intervention groups compared to control. Possible explanations include illiteracy, disinterest in the pamphlet topic, and information overload. Patients are often presented with multiple forms to fill out before an outpatient appointment, and our pamphlet was one more item that may not have been a priority for the patient. Another potential concern in the study is that patients who are more interested in having resident involvement may be more likely to read the pamphlet. In the analysis of patients who received the pamphlet but did not read it, there was no statistical difference in their responses as compared to control suggesting that the pamphlet is responsible for the improved patient perception of residents. Given the positive effect that our informational pamphlet had for patients who read it, future research into other educational materials or media may be warranted to reach a broader audience. Counihan et al.6 in a recent survey found that greater than 85% of teaching faculty felt that patients very infrequently express concerns about trainee involvement. They also found that when concerns are brought to light, 84% of surgeons were able to successfully negotiate patient concerns to have trainee involvement. Our results as well as others support that overall, patients are positive toward resident involvement.8,11 Although concerns are seemingly infrequent, others have pointed out that we have a moral imperative to provide our patients with this information and acquire their consent.6 Unfortunately, this discussion may be infrequent and left to the clinic nurse.23 To further complicate the issue for patients, Schlitzkus et al.24 found that only 60% of nurses are aware that an intern is a doctor, and 56% have the perception that residents are not allowed to perform any part of an operation without an attending physician. We agree with several authors who have called for a standardized approach for introducing resident

involvement in patient care.6,8,10-12 We are sensitive to the increasing demands required in a busy outpatient surgery clinic, but we do agree with others that the primary responsibility to educate patients regarding resident roles and responsibilities rests with the attending surgeon.8,10,11 Further, 80% of the patients we queried expected to be asked permission for resident involvement, and 83% wanted to know what portions of a procedure a resident would perform. Wisner’s and Kim’s groups found similar results in their surveys.10,11 We believe an informational pamphlet may help to standardize the approach, minimize the time footprint in clinic, and assist the attending physician to make this discussion a habit. At least anecdotally in our study, several teaching faculty felt that more discussion was sparked with the patient regarding resident involvement when the pamphlet was distributed. Further study is required to verify these observations. We would caution that we do not believe that the pamphlet distributed can suffice for disclosure of resident involvement. Multiple authors have suggested that the best practice for disclosing resident involvement includes discussion with the patient as early as possible.8,10,11 Wisner et al.11 found in their study of patients receiving cataract surgery that many patients found an informed consent form detailing resident involvement inadequate if not accompanied by a discussion with the attending physician. Although 83% of patients in our survey want to know how much of a procedure would be done by a resident, others have pointed out that patient understanding and expectations for their surgical care may not be grounded in reality.8,11 Cowles’ group found that many patients do not understand that often a resident and attending are working as a team to perform a procedure.8 This makes detailing exact surgical steps a resident would perform on a consent form difficult, if not impossible. Only an open discussion with their attending surgeon can fully inform a patient of the role and hierarchy of residents within the surgical team, supervision supplied by the attending, and the benefits of resident involvement.6,8,11 We believe the pamphlet allows for early introduction of resident involvement in patient care and can set the groundwork for a meaningful discussion about resident involvement and attaining patient assent. We did not improve patient receptiveness to resident involvement using an informational pamphlet except regarding a chief resident independently performing routine procedures. There are several possible explanations. First, patients are already fairly positive toward resident participation, as 85% of the control group agreed or strongly agreed that they welcome resident involvement. Others have found similar results with O’Malley et al.25 reporting 95% of patients at an outpatient internal medicine clinic to be favorable toward residents, and Cowles et al.8 reported that 86% of postoperative inpatients were comfortable with resident involvement. Our survey and Cowles’ group also found that only 12% of patients feel residents are an

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inconvenience. Second, Reichgott and Schwartz26 found that most negative responses regarding resident participation were the result of patients not being aware that a resident was involved in their care. Cowles’ group also found a positive correlation between patient expectation for resident involvement and allowing resident participation.8 Although the control group did not receive a pamphlet, our questionnaire alone may have alerted the patient to resident involvement negating significant results between the pamphlet groups and control group. Third, our study population spanned outpatient surgery clinics including general surgery and other subspecialties of general surgery including surgical oncology, vascular, bariatric surgery, and colorectal. This heterogeneity we felt was a strength to accurately represent patient perceptions across a general surgery residency program. Application of these results to any individual clinic may not be as generalizable, and the effectiveness of the pamphlet for patient education may vary significantly for a general surgery patient requiring a hernia repair versus a surgical oncology patient concerned about a possible diagnosis of cancer. Last, we did not collect demographic data from our patients prospectively, and the survey was anonymous preventing any subgroup analysis. We can only comment on the general makeup of beneficiaries within the practices surveyed. In the Keesler surgery practice, 14% of patients are active duty, 14% are active duty dependents, 32% are retirees, and 40% are other beneficiaries (such as patients cared for jointly with the Veterans Administration Hospital). For the University of Texas Health Science Center at San Antonio surgery clinics surveyed, approximately 60% of responses were from clinics where patients were predominantly funded through Medicaid or local financial aid program and 40% were private insurance or Medicare-funded patients. Further study is required to identify patient factors that may influence affinity for resident involvement. There are several limitations to our study. First, the data were collected from a geographically limited area. The institutions involved in the survey are in the south and southwestern United States and may not be representative of all other regions of the country. In addition, the institutions included were a university/academic program and a military program. There was not a community teaching hospital or private practice residency program represented. We also recognize that these results are not generalizable to patients seeking care at institutions that do not train residents or have minimal resident involvement. By surveying patients seeking care at institutions with residents, we have self-selected patients who may have more familiarity with resident involvement. Next, our study only included outpatient surgery clinics and did not include patients admitted to the hospital. Further investigation including these groups is warranted. Lastly, as we alluded to above, the use of the terms “complicated” or “routine” as well as “direct supervision” in the questionnaire (Table 1) is 6

potentially open to interpretation depending on knowledge of surgical procedures and background.

CONCLUSION Most patients welcome resident participation in their surgical care, but they expect to be asked permission for resident involvement and want to know the degree to which residents would be involved. The attending surgeon is responsible for this disclosure of residents’ role within the surgical team. When patients decide to consent to resident participation for a surgical procedure, both the training level of the resident and the complexity of the procedure play a significant role in patients’ comfort with resident involvement. Patient education using an information pamphlet describing resident roles, education, and responsibilities improved patient willingness to allow a chief resident to operate independently.

REFERENCES 1. Lewis FR, Klingensmith ME. Issues in general surgery

residency training—2012. Ann Surg. 2012;256(4): 553-559. 2. Greene FL. Transition to practice: a bold move. Gen

Surg News. 2013;40(3):1. 3. Mattar SG, Alseidi AA, Jones DB, et al. General

surgery residency inadequately prepares trainees for fellowship. Ann Surg. 2013;258(3):440-449. 4. Napolitano LM, Savarise M, Paramo JC, et al. Are

general surgery residents ready to practice? A survey of the American College of Surgeons board of governors and Young Fellows Association J Am Coll Surg. 2014;218(5):1063-1072. 5. Asch DA, Parker RM. The Libby Zion case. One step

forward or two steps backward. N Engl J Med. 1988;318(12):771-775. 6. Counihan TC, Nye D, Wu JJ. Surgeons’ experiences

with patients’ concerns regarding trainees. J Surg Educ. 2015;72(5):974-978. 7. Kempenich JW, Willis RE, Rakosi R, Wiersch J,

Schenarts PJ. How do Perceptions of Autonomy Differ in General Surgery Training between Faculty, Senior Residents, Hospital Administrators, and the General Public? A multi-institutional study J Surg Educ. 2015;72(6):e193-e201. 8. Cowles RA, Moyer CA, Sonnad SS, et al. Doctor-

patient communication in surgery: Attitudes and expectations of general surgery patients about the Journal of Surgical Education  Volume ]/Number ]  ] 2016

involvement and education of surgical residents. J Am Coll Surg. 2001;193(1):73-80. 9. Santen SA, Hemphill RR, McDonald MF, Jo CO.

18. Chalabian J, Bremner R. The effects of programmatic

change on resident motivation. Surgery. 1998;123(5): 511-517.

Patient willingness to allow residents to learn to practice medical procedures. Acad Med. 2004;79(2): 144-147.

19. Santry HP, Chokshi N, Datrice N, Guitron J, Moller

10. Kim HN, Gates E, Lo B. What hysterectomy patients

20. Arriaga AF, Elbardissi AW, Regenbogen SE, Green-

want to know about the roles of residents and medical students in their care. Acad Med. 1998;73(3):339-341. Patient attitudes toward resident involvement in cataract surgery. Arch Ophthalmol. 2008;126(9):1235-1239.

berg CC, Berry WR, Lipsitz S. A policy-based intervention for the reduction of communication breakdowns in inpatient surgical care: results from a Harvard surgical safety collaborative. Ann Surg. 2011;253(5):849-854.

12. Dutta S, Dunnington G, Christopher Blanchard M,

21. Babbott S. Commentary: watching closely at a dis-

11. Wisner DM, Quillen DA, Benderson DM, Green MJ.

MG. General surgery training and the demise of the general surgeon. Bull Am Coll Surg. 2008;93(7):32-38.

Spielman B, DaRosa D, Raymond JJ. And doctor, no residents please! J Am Coll Surg. 2003;197(6):1012-1017.

tance: key tenstions in supervising resident physicians. Acad Med. 2010;85(9):1399-1400.

13. Venkat R, Valdivia PL, Guerrero MA. Resident

22. Teman NR, Gauger PG, Mullan PB, Tarpley JL,

participation and postoperative outcomes in adrenal surgery. J Surg Res. 2014;190(2):559-564. 14. Hernandez-Irizarry R, Zendejas B, Ali SM, Lohse CM,

Farley DR. Impact of resident participation on laparoscopic inguinal hernia repairs: are residents slowing us down? J Surg Educ. 2012;69(6):746-752. 15. Castleberry AW, Clary BM, Migaly J, et al. Resident

education in the era of patient safety: a nationwide analysis of outcomes and complications in residentassisted oncologic surgery. Ann Surg Oncol. 2013;20 (12):3715-3724. 16. Patel SP, Gauger PG, Brown DL, Englesbe MJ,

Cederna PS. Resident participation does not affect surgical outcomes, despite introduction of new techniques. J Am Coll Surg. 2010;211(4):540-545. 17. Cogbill TH, Klingensmith ME, Jones AT, Biester

Minter RM. Entrustment of general surgery residents in the operating room: factors contributing to provision of resident autonomy. J Am Coll Surg. 2014;219 (4):778-787. 23. Mavis B, Vasilenko P, Schnuth R, Marshall J, Jeffs

MC. Medical students’ involvement in outpation clinical encounters: a survey of patients and their obstetrician-gynecologists. Acad Med. 2006;81(3): 290-296. 24. Schlitzkus LL, Agle SC, McNally MM, Schenarts KD,

Schenarts PJ. What do surgical nurses know about surgical residents? J Surg Educ. 2009;66(6):383-391. 25. O’Malley PG, Omori DM, Landry FJ, Jackson J,

Kroenke K. A prospective study to assess the effect of ambulatory teaching on patient satisfaction. Acad Med. 1997;72(11):1015-1017.

TW, Malangoni MA. Resident preparation for careers in general surgery: A survey of program directors. J Surg Educ. 2015;72(6):e251-e257.

26. Reichgott MJ, Schwartz JS. Acceptance by private

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patients of resident involvement in their outpatient care. J Med Educ. 1983;58(9):703-709.