My name is Javier Lorenzo. I'll be your moderator today. Today I have two really dynamic speakers who are going to speak to us on the topic of conditional autonomy. I'd like to introduce Dr. Steve Gundin. He is the Chief of Acute Care Surgery at Vanderbilt University. He also serves as the Product Director for the Acute Surgery Fellowship. Dr. Nicole Siparsky, who is a Chief of Acute Care Surgery and Surgical Critical Care at Rush University Medical Center. She's also the Surgical Director of the Adult Intensive Care Unit. Her clinical interests include necroplastic infection, shock, surgical nutrition, and education. Welcome both. Thank you. Thank you. A little minor correction. I'm not the Chief, but I am the Program Director of the Acute Care Surgery Program here at Vanderbilt. Thank you, Steve. Thank you, Dr. Gundin for that correction. Wondering if we can start this discussion with just definition. Maybe you both can define, what do we mean when we talk about conditional autonomy, particularly in the context of surgical training? It's an important concept. It's the idea that we need to give autonomy to people where it's appropriate. In the history of residency, there was a long period of time where there really wasn't this balance between letting the resident do things and letting the attending do things. We allowed residents to do whatever they felt like they were comfortable with. When they felt uncomfortable, they called the attending. Then over time, that's changed for a number of reasons. If you look back at, there's a lot written about this. There are a couple of key time periods that really affected the level of autonomy that residents got in training in fellows. First, when they introduced the relative value unit, what you saw was a lot more pressure on productivity. Surgeons were doing a lot more for billing, and they were doing a lot more in reducing the autonomy of the residents to try to get cases through as quickly as possible. That reduced the autonomy of the residents a little bit. Following that, everybody knows where duty hour restrictions came from. Residents weren't allowed to be around all the time. They couldn't stay late for a case and that kind of stuff, and that also reduced their autonomy. It also mandated more presence of the attending to compensate for some of that time. So we saw a little bit of a loss of autonomy. And then there's a couple others coming forward that all come out of mainly Medicaid and Medicare billing that have really mandated what the attending has to be present for and mandated that they're present more. And so people got concerned about that, and their concern was, well, if the attending's around, then by definition, the resident's not gonna get as good of experience. And whether or not that's true, we can talk about. But that was the concern that people came up. So this idea of conditional autonomy came out of that, where you're a chief resident, I'm gonna let you do this with me in the room and me not interfering, and I'm gonna watch you, and if something goes wrong, then I'm going to intervene at that point rather than me just do it with you. And similarly, two o'clock in the morning, I'm on a home call and somebody needs a central line, I can allow the chief resident or the fellow to do that if it's within the scope of their autonomy. Instead of just defining everything as this black and white level of autonomy. And so that's the idea of conditional autonomy. What independence are we gonna give any given trainee based on how much experience they have, how well we know them, and what the actual activity they're doing is? I would just add to that that if you think of conditional autonomy as the new way of viewing education, then the old way would be calendar-based. So for example, if a surgery residency was five years and everyone was expected in their intern year to learn how to do a central line, by their second year, everybody would do their own central lines unsupervised. But we all know that most people are not good at everything all the time, that most people have strengths and weaknesses and that they progress at their own pace. So in the old way, if you were a resident, you would just be expected to do a procedure that was at your level. And if you didn't know how to do it, that was a problem. In the new way, you move along at the pace that you move along and you're given an appropriate level of autonomy for your skill, experience, confidence, et cetera. So in the old way, you would just be expected to know how to do something by a certain time, or conversely, not be allowed to do something that you might actually already be ready to do simply because it's too early. I wonder whether, do you feel like the old, there's a merit to what the old way was trying to establish, meaning providing a longitudinal or a selected amount of time for all those experiences to happen? Or do you think the new way is the way forward? I think as the representative of the old guard in this old cop, new cop routine. I see, so you're the old cop. You're gonna represent the old. I'm the old cop, although I like to think I look as youthful as Steve. You do. Thank you. The old guard would say that that is what is proven. That's what we have done. That's how we have done it for a long time. And that why mess with something that works? We know it works. Why mess with it? So- And Steve, you represent the new guard, so. Yeah, and I think Nicole's point is very valid. So people who made it through college and graduate school and initial training, they're all very smart. They're all very driven. And you could take any of them and put them in just about any specialty and say, figure it out, right? And they would eventually and potentially faster. But what we have to remember is that there's a cost to that. And the cost is the patients, right? And so if we make a basic tenant that we can't hurt anyone and we build a training regimen around that, then it almost mandates this kind of approach where I have to be nearly 100% sure that the person is not gonna get hurt by not having a more senior person. And it's a very, very difficult balance. But again, if you go with more of a sink or swim approach, their first couple of attempts, they're gonna sink. And then eventually they're gonna figure it out and they're gonna be able to do whatever case you told them to do. But those first five or 10 that don't go well, those are on us as the trainers. And so I think that's what we really need to be thinking about when we're looking about going forward with how we're gonna approach training. Dr. Konderk, I wonder as a representative of the new guard, is there a framework that you use when you graduate your trainees with this conditional autonomy? Is there like a rubric? We know it's not time-based, maybe milestone-based, but what's the framework that you use? Yeah, so in my training program, two different approaches. One is we use what's called the Jewish stages, which people may have heard of. I'm just gonna tell you what they are for the benefits of anybody who's listening. And there's four, and they start from the most help, which we call show and tell. And I'm sorry, supervision only. And that is, we're gonna just watch, sorry, I started from the top, but we're gonna just watch that person. I'm gonna be either in the room or available. I'm certainly gonna be there for the critical portions. Let's say we're doing an exploratory laparotomy, and I have a June 30th second year fellow in acute care surgery. Probably in all honesty, I can stand behind them and watch. And I can tell them, yeah, I agree with your decision to take that piece of small bowel, but I can't tell them that's the one that I would take. If we have somebody who's a little bit less trained, we're gonna talk about passive help. So I'm gonna be scrubbed, right? And I'm going to be right there in the field working with that trainee, but I'm gonna keep my mouth shut. And I'm gonna let them be the attending for the case. And we're all familiar with having done that from our residencies. And if something's going south, then I'm gonna kind of jump back in, but I'm gonna make them find the problems. I'm just gonna help them by, the little things that you do as a good assist that you might not get when you have a more junior assist. We all know how that is, when you're operating with a chief versus operating with an intern, everything is just right where you want it. And I'm gonna set it up for them, but I'm gonna make them do it. Active help is more, I'm gonna say to them, we're gonna take this piece of small bowel. How are you gonna do it? And then they're gonna tell me how they're gonna do it. And then I'm gonna let them do it. And then show and tell is what we do with our most junior residents, which is, you're not quite ready to clear out the cystic duct and the cystic artery because you don't have the technical skills yet. I'm gonna let you take the gallbladder off the gallbladder fossa. You're gonna see how I do the hard part. You're gonna do the easy part. That'll develop your technical skills until you're ready to move on to the next stage. So that's kind of how we approach it from a technical skills point of view. The other thing that you alluded to is even more than that, we have to take people for entire procedures and do the same thing. And the way that many people are doing that, ourselves included, is we have level one, two and three supervision. So level one supervision, I am present in the room, right? And so all of that ZWISH stuff falls under that level one supervision category. But I have to have a little bit more than that because I'm not just training somebody to do technical procedures, I'm training them to be a entire attendant. And so then we have level two supervision, which is, I'm in the hospital, but I may not be in that room with them. And so from a licensing point of view and stuff, that does require a certain level of certification and everything to allow somebody to operate by themselves. But in that setting where for us, we have instructors who are second year fellows and are boarded, I can be in the hospital, they do an API and they're boarded, they're good enough to know if something's going south, they're gonna call me and I'll be right there. And then we have level three supervision, which is, you're gonna do what you're gonna do overnight. And then the next morning, we're going to go over every single case that you did. We're gonna go over every single trauma that you did. And we're gonna talk about how you could have just turned the knobs a little bit to make it a little bit better. And I think those things also are things that we've always seen in the transition from being a senior resident or a junior fellow to being a full-on attending, where we all know when we hire a brand new graduated first-year attending, they're gonna be okay, but you're gonna need to talk to them some. They're still learning, they're still getting used to it. All of us are, and we all have somebody senior to us that we talk to. We've now just put a framework on it. I see. How about you, Dr. Sparsky? What framework do you find helpful? I think that it is always helpful to train a resident or a fellow from beginning to end. When you start at the beginning, you can have some historical confidence in their training. You know what they know, you've taught them what you would teach everyone at that level. Again, with the same idea that at each level, I teach them this, I teach them that. So that when they reach a point where they should be independent in much of what they're doing, you can be confident and give them that independence. That is hard to do. I don't think that's a universal experience. It's hard for new surgical faculty to do that fresh out of training, because they themselves are fresh out of training. And it's hard to do that with residents that maybe you didn't train early on. Maybe they rotated into your program or transferred to your program. Or you're just meeting them as a fellow where they should be fully trained. But as is often the case, they might be a little weak in one aspect or two aspects of their sort of common experience. So I do think that there are times when the concept of a graduated training is hard to apply. And that probably hurts the trainee that ensures the patient's safety. But I think we're moving more and more towards patient safety and farther and farther away from training, which is why the concept of conditional autonomy has become recently a very hot topic. The idea that we can't completely sacrifice training or it will be pretty rough situation moving forward. We have to find some way to move forward and give people some autonomy in a graded way. So I do think that it's good to have it. And there are people in our field who advocate for it. They advocate for establishing a systematic application of standards for progression from one stage to the next stage or for autonomy in this aspect of the procedure so that they can move forward to that aspect of the procedure. And it's out there. I've heard a little bit about it. I'm not an expert on it, to be honest, but I am an expert in the old way and the old way doesn't work as well as it used to. Steve mentioned the training Steve mentioned the duty hour restrictions. The old days, we spent a lot more time in the hospital training. Certainly I spent a lot more time in the hospital training and not all that time was good quality time, right? We all spent those post-call hours, writing notes half awake and scrubbing into cases, very, very tired, not clearly not getting out of it as much as a relatively awake resident will get out of their case experience. So I think the times have changed a lot. The idea that they need to have that many cases or have that many hours of work to just magically be ready for the next stage is not necessary. So in that way also, I think conditional autonomy is a good thing. People will be ready to do something sooner than they would have before. They have very nice simulation models now for much of what they do early on, laparoscopy, basic technique of suture closure, some really advanced simulation models for other specialty things that actually might allow them to be better at it earlier on than we were, which we probably don't want to admit out loud, but it's true. So I do think there are ways for us to move forward with this, but it is still new. And for many of us old dogs, it's hard sometimes to come around. I wonder, since you bring it up, I wonder if we can just take a few minutes to talk about the role of technology in surgical education and how that might have impacted conditional autonomy or the level in which residents graduate to a certain milestone. For the reasons that you mentioned, it can be pretty sophisticated. Some of these models can be pretty neat and by the time you've done this a couple of times, by the time you see a real person, you're ready for it. What's your experience as educators with these new methods of educating the surgical trainees? And if they do work, how have you put that into operations in your own training programs? Maybe we can start with Nicole. Well, just as a point of comparison in the old days, we had things like the dog lab. I don't know if they have a dog lab where you are, Steve, but where I trained, we had something called the dog lab and it was a place where it was an animal lab that you practice surgical techniques in. And it was kind of a point of humiliation if you were sent to the dog lab, that meant that you needed to practice some aspect of your training. Oh. But I think there was a lot more in real time training where you were expected to magically conceive skills in a case or have conceived them through practicing in an animal model. And it didn't leave a lot of room for actual practice. You can only make a hole in a vena cava in a pig and practice fixing it so many times and it actually feel kind of real so that you could apply that in a real life trauma setting. So in those ways, you can only suture so many banana peels together or do so many vena cava repairs in a pig to really get the skills you need. And so I think that sort of antiquated idea that the practice has to happen in an animal or an actual patient, thankfully has been replaced with some more modern approaches, which I think Steve can describe. Yeah, so I agree with a lot of that. And I'm sure every one of us got told at some point in our careers as residents, if you can't tie knots, you can't be a mayoa. And I think that point still stands, right? So what that really means is before you go to the OR, you should do all the things that you can do to be good at that skillset that are possible without using an actual human patient. And I think that, again, still stands. The models have come such a long way, and actually the practice of surgery has come such a long way, that there's a lot you can do now, right? So it used to be, before we were doing so many of our cases laparoscopically or robotically, that we would expect people to have basic suturing skills, basic knot skills, know how to manipulate the instruments, but there wasn't a whole lot else you could do at home, right? There wasn't a whole lot else you could do in a lab without sacrificing an animal. And we do actually still have a pig lab that we use. We do a lot of cadaver work with our residents and fellows. And I think that that has huge value, especially after you've done something and you don't understand what just happened, to go to a cadaver lab and have time to figure it out is an excellent way of learning, right? That's adult learning by definition. You did, you tried to do something, you didn't know how to do it. You went, you fit, you learned it on your own, and then you came back and you did it right the next time. And that's exactly the model that I wanna see our residents and fellows use. But now that we have so many other approaches to surgery, if you're gonna do a case, you might not need to do 40 gallbladders to be reasonably decent at them because you could have learned how to do all the technical skills already, right? In either a box trainer or a video simulator, that kind of thing. And they're not perfect, but they're so close that just the manipulation of the instruments you should have. And then to be frank, there's YouTube, right? So if I wanna see 30 different ways of doing a laparoscopic case, I can do that at home on my smart TV. I can do that on my laptop or my phone when I'm riding on a train. It's very, very easy to do. And the benefit is you can squeeze it into these little gaps of time that we didn't know how to use before. And so I think from that point of view, technology has been very, very beneficial. But I also do agree with Nicole, there is no replacement for the actual thing. It's just a matter of being able to get everything you can get out of that case when you're in it. And we can never replace the, not only the technical and the strategic parts of operating or doing procedures on real humans, but also the emotional side, right? The first time that you do a bad trauma and it's a belly full of blood and you can't find it, it's scary, right? And the first time you do that, even as an instructor with an attending there, it's scary because you don't know what to do next and you haven't learned yet that you have to figure that out. There is no calling someone else because you need to figure this out now. And that emotional side of it, that's also extremely valuable and that can never really be replaced outside of the hospital. I agree with that, Steve. Another aspect of critical care training specifically that we really don't spend a lot of time talking about is communication. When we think about it, so much of what we do depends on good communication, whether it's with the patient or a patient decision maker or colleague or a trainee. Communication is not intuitive. I didn't grow up learning the eight common aspects of good communication. When I didn't understand something, I was just told again, but a little louder. So I didn't learn that growing up. I learned it in my practice. And that's not something that most of us are formally trained to do. Communication isn't something most of us go to a simulation lab to practice on a virtual patient or something of that nature. But even things like that are being designed now to address real deficits in the clinical world, both in the trainee level and also the faculty level. We've been talking a lot about conditional autonomy for trainees, but we don't all graduate training fully perfect faculty members. We become more and more better at what we do over time with a lot of experience, ironically, on real patients. So I think what you'll also see coming in the near future is a whole battery of simulation-based training exercises to improve the non-procedural skills that we all really need. Yeah, there's a lot to be said about that, for sure. And I think that has traditionally been valued. And I've been told plenty of times at work and maybe at home that I need to work on my communication skills. And that's just a thing- It's kind of intuitive. And there are ways to do it now, and they're very impressive. I'll tell you one example is many places will record any trauma activation that they have. We do too. And there are people who will put metrics on when you called for certain things in a given scenario and then measure it on the video and say, this is how that went. And also go back and look at, well, yeah, you did say that, you think, but what you actually said was maybe we should, or we could, or the stuff we hear all the time that isn't as clear to the room. And seeing yourself do that is hugely valuable because that gets corrected really quickly once you've seen it. So these are aspects of training that are not traditionally appreciated in the old model. Where you were just expected over time to just metamorphosize into this perfect creature. And when in fact it really takes practice and focused training, not only practice to become skilled at that task, whatever it is, but also that you are taught the skills you don't have, not just magically expected through over and over practice to acquire them. So to summarize, definitely simulation and the new tools are getting more sophisticated. There's a role for them, but there's also a role for the old school way of doing things. If you have to do it on a patient, you have to get that visceral sensation of being in the moment, how to communicate, but how to own your own emotions, which are gonna look a little different if you're in a real life scenario versus a simulated scenario. And you both made a comment of how the, the training pathway doesn't really stop when you graduated. Nothing magical happens, from your skills, from your last year of training to your first year as an attending. If anything, I think we can all attest that that learning curve is even more steep your first couple of years as an attending. So let's pivot on something that I think we all have witnessed as educators, right? I think we all have great trainees, but occasionally there's that trainee that is not gonna meet that milestone, that trainee that either from the old guard point of view, the second year that is functioning at the level of a first year or an intern, or we're gonna use a new metric or the new rubric, that person who's never graduated from level one or never graduated from the watch level or show and tell from the Swiss scale. How do you guys deal with those trainees that are not meeting those milestones and are not graduating at the expected scale or rate? In the old world, they would have three options. Very simply, they were either fired, they were held back and made to repeat the experience again, or they were held back and they were made to repeat the whole year again. So they either graduate late or never. Wow. How common does that happen now? I don't think it is that common, but I think it happens commonly enough that we all know a few people who that's happened to. Yeah, and I think newer ways of doing this. So they're very objective and that can be really helpful. It actually can be really harmful if misapplied. What I'm seeing a lot of now is we are doing this somewhat well, but not as a core tenant of training. And we could be. And so you'll see, we measure these things objectively, but because they're so objective, there's no way to subjectively say, you're not quite there yet. And we're not fitting it into these categories well enough. And so you see people that actually legitimately would benefit from repeating a year going on to the next year. And the problem with that is if we don't write down what their deficits were and what we're gonna do to make them better, then they only fall more behind. And we all know this problem. You have a trainee who you say, maybe that person should redo their intern year. They come back as a second year, like, okay, well, they weren't ready before, so I'm not gonna let them do anything. And I'm gonna do that because I'm gonna protect my patients and we feel good about that decision. But we really shouldn't because there's a whole lot more patients that are coming down the road and we're just kicking this can. And so if we can objectively say with our categories, look, here's where you are on this procedure. Here's what I had to do. That's the category that you're in. Here's where you are deficient. Then I can give them something that they can actually objectively fix. And like we talked about, there's a million ways to do it. And so I think we need to be stronger in saying to our trainees that are a little bit behind, you're failing, or you're almost failing, or this is not going well. And I don't hear that language at the beginning of the conversation. And then with all of these evaluation tools and supervision tools and conditional autonomy tools, I can say to them, here are the measures that I'm actually using to say that to you. I'm not just being mean. I don't just not like you. These are the categories that we define. You don't meet them in these places. Now, why don't you and I sit down and come up with a plan of how we're gonna get you to that point. It is currently February. We have until July. Let's go. I don't think that really exists in the surgical world in a concrete form yet. I have not seen that. Certainly taking every case, for example, and dissecting it into every element, opening the skin, dissecting the layers, identifying the anatomy, whatever, all the way down to closing, or writing orders that include the right medications, et cetera. It's so many steps, right? It's so complicated. It would be very time-consuming, but probably time well-spent to give people a roadmap. I think the current generation of trainees is sort of notorious for wanting to have clear guidelines and expectations of them. And I think one of the challenges is it's very hard to conceive of every possible thing that a person should know. But in reality, that is all pretty standard. We just need to be better about communicating it. Again, skills that none of us were taught training before we need to acquire. So this is very much a process in evolution. As we talk about communication, I wonder, I read a few studies in conditional autonomy on how we communicate what that is to patients and how sometimes that perception from patients is not well understood that a trainee is going to be operating on me and that a trainee of this skill level will make some decisions on my surgery. So I'm wondering if you guys can talk about two questions. One is, to what extent do you involve your patients in these discussions about conditional autonomy that some of these decisions under surgery or the care in the hospital will be made by a surgeon in training? And, you know, are outcomes any different when patients are care under the full supervision or full clinical decision-making of a faculty attending or the care of one that is governed by conditional autonomy? I know those are two loaded questions, but maybe we'll start with Nicole. Why don't you, what do you think? You know, I actually, I think in general, when I tell people about the surgery that I think that they need, I tell them that I do the surgery with trainees and they often ask, well, but you're going to do it, right? And I tell them it's a graduated process, but I will be there for the whole thing. If I say anything less than that, that usually does not create a happy patient. And for the most part, I am present for almost all or all my procedures. But in the reality, it would be nice if I was there less. And I think some of that comfort level is not there for patients anymore. And some of it is not there for me sometimes. So I think it goes both ways. So if I was to adopt a more structured model for this, I might find more comfort in that gradual process of giving them autonomy and also explaining that to patients. But I too am growing with this. So I haven't gotten there well yet. Yeah, I tend to agree with all of that. I do tell my patients, you know, I'm going to have a resident, I'm going to have a fellow. And from time to time, I even tell my patients, hey, no, I had my resident do that part of your case because, you know, skin closure, they're better at it than I. No question, they do it more than I do because I always have them do it. But I do tell them for the major parts, they will be there. And, you know, they're going to have to be doing this in whatever amount of time. And so I have to teach them and I'm going to do that. Most of the time for me, it's been fairly well received. On occasion, no, but when it isn't, I explain to them, look, I could do this by myself, but your outcome will be worse because I need help doing this. And so that kind of jumps to your other question, which is outcomes. And that really has been looked at that, you know, with appropriate supervision. So if we're giving thought to all the stuff we just talked about, there is no reason that outcomes should ever be worse. And in some places people find that they're better. And I think that's true. I think having a fellow or an instructor operating with me or a senior resident who knows what they're doing, they've caught things that I've missed a million times. I'm sure we all have that experience. Yeah. I also sometimes jokingly say, well, the procedure requires four hands and I only have two. And then they kind of joke, like kind of giggle and we move on, it's awkward. So honestly, again, learning new ways to approach this, I think it's a work in progress. So I don't think we've written a book on it yet completely. So what is the future of conditional autonomy? Maybe as we circle back to the two opinions, the old guard and the new guard, which I actually think if I'm hearing Nicole's tone a little bit better, you come around a little bit and you're adopting more of the new way of thinking. I wonder just to end, if we can address maybe the future of conditional autonomy from your own perspective, what might that look like? Well, I think from the old guard perspective, what we most need is education. We can't do things a new way if we're not taught how to. We need to understand how to do it. We need to see it done. We need to practice it and get good at it. And we need our trainees in turn to learn a new way as well. And I think what you see is that this is gonna be something that we're thinking about in every case we do, every procedure we do and every patient that we see. And you're starting to see that with the availability of technology where we're getting real-time evaluations of cases on cell phones. And maybe someday we'll have real-time autonomy on cell phones, which obviously won't be perfect, but it may say this resident has done this case 30 times. This is what the previous evaluations have been. They can't do this part. They can do the rest of the parts. And then we know, and we have it right in front of us when we start. I think that the days of just being told good job and that was it, those are over because we've learned that that's not very helpful in the growth of trainees and interpreting passive-aggressive non-communication is equally unhelpful that we need to do the hard work. But if we have constructive ways of going about it, instead of it being personal tack, it's a learning opportunity that a trainee can grow from. That too requires some training for the faculty. Many of us were trained by people who either just shook our hands at the end of the case or said good job, or the minute the critical part of the procedure is over, they were out of there as fast as they could get out of there because they didn't want to tell you about how you need to improve A, B, or C, or how you really just don't know what you're doing on task D. So giving faculty some new communication skills, again, back to communication, giving them those skills, but also giving them a place to practice rather than just telling them to go out in the world and do it, I think that simulation labs would be playing a critical role in the evolution of training in this way. Wonderful. Well, thank you again, Dr. Siparsky. Thank you, Dr. Kondak for your time and your thoughts today. I think the future of surgical training looks bright with leaders like you in the field. So thanks for your time and best of luck for the two of you. Thank you. It's been a pleasure to be with you today. Thank you to both of you. Take care.

conditional autonomy

surgical training

trainees

autonomy levels

patient safety

simulation-based training

communication skills training