Effective Senior Surgical Residents as Defined by Their Peers: A Qualitative Content Analysis of Nontechnical Skills Development

Abstract

Objective

This study aims to define an effective senior resident and understand the process of leadership and nontechnical skill development in the transition from junior to senior surgery resident.

Summary Background

General surgery residents are responsible for patient care, technically demanding operations, and diverse care team management. However, leadership skill development for the transition from junior to senior resident roles is often overlooked.

Methods

We conducted 15 semi-structured focus groups with surgery residents from an urban, academic institution. Focus group transcripts were inductively coded. Using content analysis and constant comparative methodology, primary codes were refined into categories and organized into higher-level themes.

Results

Thirty-three general surgery residents completed fifteen focus groups. Six themes were identified. Three themes describe the process of becoming an effective senior resident: how to define a senior resident’s scope of practice, the transition process, and the importance of personal investment. Three themes were identified regarding effective seniors: ideal traits, teachable skills and the team and patient impact.

Conclusions

Surgery residents define an effective senior resident as the team member with the highest level of experience who manages the big picture of patient care. The transition is improved by personal engagement and acknowledgement of the transition. Ideal traits of effective seniors, including emotional intelligence and inherent personality traits, allow a resident to more naturally assume this role; however, teachable skills, such as communication, expectation setting and competence, can be taught to improve one’s effectiveness. The actions of a senior resident impact the team and patient care, underscoring the importance of understanding this role.

Mini Abstract:

This is a qualitative analysis of how general surgery residents define an effective senior resident and navigate the current process of leadership and nontechnical skills development in the transition from junior to senior surgery resident. Six themes were identified: how to define the scope of practice of a senior resident, the transition process, the importance of personal investment, ideal traits of effective senior residents, teachable skills and the team and patient impact. Recommendations for programs to support this transition are provided.

Introduction

Surgical training is designed to develop doctors who are clinically competent and technically sound. Additionally, there are a multitude of nontechnical skills that are imperative to surgical practice, examples of which include team leadership, professionalism, and communication.^1–3 At present, the development of these nontechnical skills has limited emphasis in surgical training with minimal formal instruction.^4–6 Therefore, the attainment of these skills primarily occurs through observation and trial-and-error as residents progress through their training.^3,7,8 Leadership, or the ability to influence and inspire others to accomplish a common task, is exerted daily by surgeons through their encounters with patients and trainees in clinical and educational settings.^9,10 Residents have been shown to utilize multiple different leadership strategies throughout their training.¹¹ Courses focused on nontechnical skills and leadership development have been implemented for residents and are viewed as beneficial but with limited data on the lasting impact of these interventions.^12–17

There are many important transitions within surgical training. The most well-studied are from medical school to internship and from the completion of training to independent practice.^18,19 However, another important transition in surgery training occurs between the first and third years as residents advance from junior to senior residents and their role and level of responsibility changes. This transition has been studied less frequently, though some curricula have been implemented to improve confidence and enhancing teaching skills and leadership.^20–22

Our understanding of this critical transition in a surgeon’s training is limited, including how one prepares, what skills are important, and the current experience of learning these skills. In this qualitative study, we aim to define what makes an effective senior resident and understand the current process of leadership and nontechnical skills development in the transition from junior to senior general surgery resident.

Methods

Study materials and procedures were reviewed and approved by the Partners Human Research Institutional Review Board (Protocol 2019P002302). Participants provided verbal consent at the beginning of each focus group. This study was conducted using qualitative content analysis with an inductive approach.^23–25 Methods are reported based on the COREQ checklist.²⁶

Focus Group Guide Development

The Focus Group Guide was developed by a single member of the research team (TC), a general surgery resident in her two years of dedicated professional development time. The guide included questions to understand how current residents define junior and senior residents, the specific traits of effective senior residents, and how residents currently obtain these skills. The guide was reviewed by the Massachusetts General Hospital Surgical Education Research Group and further refined after the first focus group in accordance with group consensus.²⁷ Representative questions from this guide are presented in Table 1.

Table 1:

Representative Questions from Focus Group Guide

How do you define a senior and a junior resident?

Think of a senior resident who is an effective resident. What specific skills can you identify that are important to being an effective senior surgical resident?

Think of a senior resident who you felt was not an effective senior. What are some skills they were lacking?

How are these skills currently obtained?

Do you feel prepared to be a senior resident? Do you feel there is enough guidance during this transition?

Are these skills that you have previously defined something that can be taught?

Is there anything that can be done to better improve the transition from being a junior to a senior surgical resident? Any innovations or system changes?

Participant Recruitment and Focus Groups

Categorical general surgery residents from all clinical years of residency and integrated vascular surgery residents from post-graduate years (PGY) 1–3 at a single urban academic institution were invited by email to participate in PGY-level concordant focus groups. Residents responded by email and were scheduled for focus groups based on clinical year during a mutually agreed upon time. Residents were purposefully sampled to include a balanced distribution across PGY levels. All focus groups were conducted by TC from November 2019 through April 2020. The first eleven focus groups were conducted in person in TC’s office while the final four were conducted over ZOOM™ (Zoom Video Communications, Inc, San Jose, CA) due to restrictions imposed by the COVID-19 pandemic. Focus groups were selected to allow for exploration of the topics outlined above through discussion between participants and to elicit a broad range of resident perspectives. Focus groups allow for validation and enrichment of similar experiences. While traditional focus groups often consist of 6–8 participants, due to residency class size limitations (9 residents per PGY), the need for in depth discussions and scheduling limitaitons, focus groups were limited to 2–4 residents.²⁸ This allowed us to achieve the benefits of group discussion within the limitations of the study population.²⁹ Focus groups were conducted with residents of the same PGY because the resident role on the surgical team is often delineated by PGY level and we aimed to minimize hierarchical influence on the resident perspective provided. Participants were provided a study fact sheet at the start of the focus group and the confidential nature of the focus group was outlined by TC. Demographic data collected included PGY-level, age and gender. No compensation was provided to the participants.

Qualitative Analysis

Both in person and virtual focus groups were audio recorded using a digital voice recorder, transcribed using a professional transcription service, deidentified and reviewed for accuracy. We utilized content analysis qualitative methodology. Primary, inductive coding was conducted concurrently with focus group completion by TC. After completion of the first eleven focus groups, primary codes were organized into coding categories. At this point, a second member of the research team, KJ, inductively coded these transcripts, expanding the coding categories. KJ is a general surgery resident from a different academic institution. Both TC and KJ have formal training in qualitative research methodology. Using the constant comparative method, KJ and TC met regularly to review interview transcripts and refine the list of coding categories. We anticipated achieving data saturation after two focus groups per PGY and found redundancy in responses after completion of fifteen interviews. The codebook was then reviewed by the senior author, JL, and further refined with TC, resulting in 26 final coding categories. TC and KJ subsequently tested and agreed upon the codebook. Utilizing Dedoose (version 8.3.41, SocioCultural Research Consultants, LLC, Los Angeles, CA), an online qualitative analysis software, the coding categories were applied to all transcripts and interrater reliability was determined.³⁰ Coding categories were organized into higher level themes. Themes were agreed upon through an iterative approach and quotes that best characterized each theme were identified.

Results

Fifteen focus groups were completed with a total of 33 surgical resident participants. At least two focus groups were completed at each PGY-level (Table 2). The average number of participants per focus group was 2.2 (range: 2–4 residents). The median focus group length was 40 minutes 12 seconds (range: 24 minutes 44 seconds to 54 minutes 17 seconds). The resident participants had a median age of 31 years old (range: 27–39 years). Participants were 48.5% female, which is representative of the full resident cohort (52.2% female). Of the 33 participants, 60.6% had participated in nonclinical professional development years. At our institution, most residents participate in professional development years after PGY3, so of the ten PGY4 and PGY5 residents, 95.2% participated in professional development years. Ultimately, 173 codes were organized into 26 coding categories and 6 themes were identified (Supplemental Table 1). For the 26 coding categories, the overall kappa coefficient was 0.95, indicating substantial coding agreement between the two members of the research team.

Table 2:

Resident Focus Group Participants

Clinical Year of Training	Post-Graduate Year (PGY)	Resident Participants	Total Residents Invited	Percent
First	1	4	11	36.4%
Second	2	4	11	36.4%
Third	3	4	11	36.4%
Professional Development	4–6	11	21	52.4%
Fourth	4–6	6	9	66.7%
Fifth	7–8	4	9	44.4%

Six themes were identified, with three themes specifically related to the transition from being a junior to a senior resident (Table 3). It was necessary to first define the scope of practice of a senior resident and to differentiate the role from junior residents in order to subsequently define how residents currently navigate the transition and what factors are important for a successful transition from junior to senior resident.

Table 3:

Six Themes with Coding Categories and Representative Quotes

Theme	Coding Category	Quotes
Defining the scope of practice of a senior resident	Highest level of experience Big Picture Attendings can count on	"...somebody who is in charge of running the service on a day-to-day basis and oversees more junior residents, takes responsibility for the main points of patient care being carried out, and someone who reports to the attending or the fellows and is a conduit for making sure that patient care is being executed and larger term plans or discussions are communicated between the upper levels and lower levels effectively so that everyone knows what’s going on." (PGY1 general surgery resident)
		"There's an expectation from the attendings that the senior resident will be their proxy when it comes to decision-making for the patients in many circumstances. And I think that… their clinical judgment is much more valued by the attendings and looked for. And I think that there's some expectation that you will be assisting the attendings in sort of crafting the plans for the patients to a much greater extent than junior residents." (PGY4 general surgery resident)
Transition Process	Osmosis Anxiety about transition Toolbox Acknowledgement of the transition	"I think that there are certain conversations and acknowledgments that can happen that add weight to the increased responsibility and recognize the transition… people are watching and the way you behave is really important." (PGY5 general surgery resident)
		"I mean, I think I was anxious… You feel a lot of responsibility on your shoulders. You've certainly seen senior residents lead teams before, but when you've never done it yourself… I think it’s definitely pretty stressful." (PGY4 general surgery resident)
		"A lot of things in residency, it’s just repetition. It’s just volume of exposure… It’s sort of this unspoken cultural thing of you watch your seniors and you absorb what they do and you kind of learn from how other people respond to other people's leadership. These are things that are effective or are respected, and these are things that are not effective or not respected." (PGY1 general surgery resident)
		"The culture that you live and work and grow up in as a resident affects the kind of senior resident… that you are. So that makes me believe that these skills are very teachable." (PGY3 general surgery resident)
Personal investment in the process	Personal Engagement Enthusiasm for Service	"…the people who are the most effective are people who have thought consciously about it and then tried to make themselves more effective, understanding how their behavior affects juniors, understanding how their teaching style can be more effective or understanding how the way that they lead a service can be either amplifying or detracting from the work." (PGY1 general surgery resident)
		"And just some intentionality and some thoughtfulness about who you want to be, even brief, can really change your trajectory." (PGY3 general surgery resident)
Ideal Traits of Effective Seniors	Comfortable in their own skin Role Model Inherent personality traits Emotional Intelligence Stress Management	"And then they are also good team players… They are nice to people, they are polite, they are punctual, they're extremely hard working. They have at least some degree of humility, they are able to admit when they're wrong, learn from their mistakes. They have a continuous drive to always get better and be better." (Professional Development general surgery resident)
		"I think one of the biggest problems that I've seen with seniors over time is when the senior lacks confidence, either in their skills or their knowledge. And you see them transmitting that lack of confidence to the team, diverting responsibility, diverting blame. That can really disrupt a team." (Professional Development general surgery resident)
		"I think the influence of your chiefs when you're a junior cannot be overstated. I think that we all have chief residents from our early years that we try to emulate and that can potentially even overcome your own personality traits and sort of push you to be a different kind of chief that you might’ve been had you not had those interactions. So I do think modeling behavior in residency is a big part of how we are shaped into who we become." (PGY5 general surgery resident)
Teachable Skills	Communication Feedback Competence Teaching while Learning Feedback Expectation Setting	“I think that comes down to the communication…the most effective [seniors] were actually the ones who sat down with me…and said, ’these are the expectations, these are the red lines. And if this happens, let me know'… and that’s all about communication.” (PGY2 general surgery resident)
		"Irrespective of who is on the team, they can take excellent care of the patient, independently, because they have an outstanding knowledge base… and they can do that no matter who they're working with, or who's giving them information or not giving them information just because they're that good, that they can function independently." (Professional Development general surgery resident)
		"We haven’t really talked about teaching yet, but I think that’s an important part of being a senior… We get most of our learning from the residents, not from the attendings. In the operating room is a different story, obviously, but when it comes to doctor and inpatient care, most of what we learned, we learned from our senior residents." (PGY2 general surgery resident)
Team & Patient Impact	Create the mood Giving autonomy to the junior Extreme Ownership Patient Care In the trenches Trust	"An effective senior resident gives the junior resident an opportunity to show what they know and to feel accountability for the patients… I think the most effective senior residents are the ones that have total control of the service while empowering the juniors to essentially feel like they're running the service." (PGY5 general surgery resident)
		"Adaptability, being able to adapt between juniors is a big thing... inability to adapt, that can really make or break a month for a junior, and it can really have an effect on that junior's psyche and their self-esteem." (PGY3 general surgery resident)
		"A good senior resident is in the trenches. So, when things hit the fan, that person is not going home. That person is not ducking out early, they're willing to do even the most menial tasks because they're most invested in the team's performance and the patient outcomes… and they say, 'I'm here to serve the rest of the team, even though I'm at the top.'" (PGY3 general surgery resident)

The first theme defines the scope of practice of a senior resident. Participants defined senior residents in three distinct ways. First, the senior resident is the resident on the care team with the highest level of experience. On some occasions, seniority is defined strictly by the highest PGY-level, while at other times, it is relative to the other team members and rotation-dependent. Seniors are always viewed as the leader of the team, which is both earned through experience but also can feel forced upon residents due to the passage of time in residency. Second, participants define senior residents based on differences in the role requirements. A senior resident focuses more on the big picture while junior residents focus more on the discrete tasks necessary for patient care. With the attendings, seniors guide clinical decision-making and ensure patients are making forward progress. This big picture role relates to a clear difference in accountability, with senior residents taking on a much greater sense of responsibility for patient care, team dynamics, and relationships with attending surgeons. Lastly, the relationship between senior residents and attending surgeons is uniquely different. A partnership exists and attendings rely more heavily on the senior resident, both clinically and in the operating room. A highly functional relationship allows attendings to invest in senior residents’ development by entrusting them with more responsibility and autonomy.

The second theme relates to the transition process. Participants described a feeling of anxiety surrounding the transition from a junior to a senior resident related to specific differences in the roles including the scope of responsibility, interfacing directly with attendings and more complex operative expectations. Many felt both personal and external acknowledgement of the role change was critical. This includes specific rotations or experiences that mark the transition within the culture of a residency, personal reflection on moments of leadership that made the change clear to residents and external acknowledgement by attendings and residency leadership. For example, one participant stated, “the [chief] and [PD] take the rising fours and the rising fives out to dinner and acknowledge that we are the chiefs and rising chiefs and that marks an important transition (PGY5 general surgery resident).” When trying to understand how the transition practically occurs, many residents used the term ‘osmosis,’ referring to the unconscious assimilation of knowledge and styles, often referred to by others as the hidden curriculum. Residents learn how to be a senior resident through observation of their seniors while in the junior role, mimicry of past seniors while in their early senior roles, and trial and error of different styles as they gain more experience. Residents build their own style by blending prior experiences with their own natural leadership abilities. Positive traits were more likely to be informally learned while avoiding negative senior traits was a more active process based on prior experiences. Many described how residency provided a variety of clinical experiences to learn how to become a senior and it was necessary to trust the process. Some actions called greater attention to the process such as informal discussions between residents about how to be a senior and early exposure to leadership roles through one-person teams during PGY2. These early experiences where residents can practice specific skills such as communicating directly with attendings and the ‘flip flopping’ between junior and senior roles were seen as essential in the development of a resident’s leadership abilities. It was clear that there was no formal curriculum dedicated to learning the new skills necessary to be an effective senior, and some residents shared ideas related to the utility of more formal training. Many had participated in leadership courses before residency and felt some didactics on these skills would be useful.

The third theme is the importance of personal investment. Participants reported that based on the current residency structure, nearly all residents are able to become senior residents. However, to become a highly effective senior resident, personal engagement with the process is critical. This engagement was described as a blend of self-reflection about prior performance and an intention-setting process in which residents strive for continual improvement. This process can be aided by working with a coach or faculty member. Active engagement with the process through a constant desire to improve allows residents to become more effective than those who do not actively engage. Participants described how approaching this transition with a curious and enthusiastic outlook allowed them to more effectively manage the clinical team.

Themes four through six detail what makes an effective senior resident and why it matters (Table 3). Participants identified ideal traits of effective seniors, teachable skills that can be enhanced with intentional effort, and the team and patient consequences of being more or less effective.

The fourth theme outlines the ideal traits associated with being an effective senior resident. Many of the ideal characteristics of senior residents that participants described were inherent personality traits, such as openness and thoughtfulness. Emotional intelligence and effective stress management allow seniors to manage difficult clinical and interpersonal situations with ease. These traits are shaped by prior life experiences and residents enter training with different pre-existing levels. Those who naturally exhibit these characteristics can more easily transition into the senior role, while others may need more practice, time and guidance to reach the same functional level. These traits are viewed as more difficult to teach compared to more concrete senior-level skills such as organization or professionalism. Participants also identified the important balance between confidence and humility which allowed seniors to make definitive decisions, trust their juniors and own their own mistakes. Insecurity was seen as detrimental to both patient outcomes and team dynamics. Participants often recounted exemplar senior residents who had demonstrated this humility-confidence balance, and junior participants hoped to emulate their example following the transition.

The fifth theme identified are the teachable skills associated with the most effective senior residents. The skills of communication, competence, setting expectations, delivering feedback and teaching while learning were consistently discussed as essential skills. Importantly, these are also skills that could be optimized with intentional effort. Participants described how clear communication with the team, along with seniors establishing an environment in which all members felt safe to voice concerns led to improved team morale and patient care. In addition to leadership skills, a strong clinical knowledge base and technical abilities are required to be an effective senior resident. A senior resident’s skill level translated to the team by their ability to delineate definitive plans during rounds and their overall confidence level. Setting expectations and providing non-judgmental feedback on junior resident’s performance were also viewed as critical skills that can be taught. Both of these skills allow junior residents to grow more independently because they have clear boundaries and expectations and receive actionable feedback on their performance. Additionally, effective senior residents ask for feedback on their own leadership, which demonstrates a commitment to continual improvement and promotes a team culture of open communication. Lastly, effective seniors exhibit a commitment to teaching and prioritize their role as an educator. They identify teachable moments within clinical scenarios and actively work to improve the junior’s learning experience on the floor and in the operating room.

The sixth and final theme relates to the team and patient impact of being an effective senior resident. Participants highlighted how the approach taken by the senior resident can have a profound impact on the patient care team. The senior is able to create the mood of a team and effective seniors are able to foster a sense of camaraderie, motivate juniors through inspiration instead of fear and create a highly functioning and cohesive team. The most effective seniors utilize multiple different leadership styles and can be flexible and adapt to the needs of their team based on the personality of their juniors, the time of year and the demands of the service. Participants described how effective seniors take extreme ownership of their team, which included standing behind any decisions made by more junior members of the team and taking responsibility for any shortcomings within the team. They felt responsible for all aspects of patient care and are willing to share the workload, demonstrating professional empathy for the junior resident’s experience. This sense of team responsibility can improve trust between team members. Additionally, participants felt effective senior residents create appropriate opportunities for junior resident autonomy on the floor and in the operating room. Creating these experiences were viewed as critical for team dynamics and for junior resident growth and development. When senior residents are not effective, the consequences included a poor learning environment, compromised and inefficient patient care and an overall negative patient experience.

Discussion

Through this qualitative analysis, we have defined an effective senior resident and described how the transition from junior to senior surgery resident is perceived by surgery residents training in an academic institution. By defining the traits and skills of an effective senior resident, surgical educators now have a model to share with junior residents and a standard to guide the development of curricula to help residents achieve these skills. Specifically, we found that an effective senior resident has high emotional intelligence along with skills which allow for effective team and patient management. Temporal progression through residency allows nearly all juniors to become senior residents but personal engagement and acknowledgement of the transition enhances the process (Figure 1). The actions of a senior resident impact the team and patient care which underscores the importance of understanding this role in order to optimize the transition.

Figure 1: Model of the Transition from Junior to Senior Resident.

Along the general surgery training path, residents are responsible for patient care, technically demanding operations, and diverse care team management. Junior residents nearly all become senior residents through the residency process, although each resident achieves varying proficiency in each of these responsibilities. Personal engagement and enhancement of teachable skills and ideal traits can expedite the transition process while negative traits such as, rigidity, apathy and insecurity can create setbacks and negatively impact a resident’s progression.

The findings of this study fit well within Vygotsky’s Zone of Proximal Development framework.³¹ There is a dynamic balance between spontaneous development and the need for teaching and guidance by more competent peers.³² Within the zone of proximal development, a learner is receptive to learning between the upper limit of their current abilities and their future potential. Within residency, interactions with more effective senior residents (competent peers) are crucial for navigating the residency transition. This guidance includes informal instruction, role modeling, and feedback. There is an important relationship between temporal development as a senior resident, called osmosis in this study, and learning from peers and attendings to effectively acquire the skills of a senior resident.

Residents’ definition of an effective senior resident included being a teacher. Being an educator is a critical skill of a senior resident and continues to be throughout one’s career as a surgeon. Dickinson and colleagues conducted a qualitative analysis of how resident’s define an effective surgical educator, and there is clear overlap in the behaviors necessary to be an effective senior resident and educator.³³ These skills include communication, being adaptable, creating opportunities for junior autonomy, competence and providing feedback. The overlap of these discrete skills between these studies highlights the need for further emphasis on their development during residency.

The model of an effective senior resident generated in this study highlights the importance of resident engagement with the process. As residents navigate the transition from junior to senior resident, it is imperative that they actively reflect upon their performance as a leader of a team. This behavior will allow them to make iterative adjustments to their style in order to function at their highest personal level. In addition to personal reflection, collecting feedback related to their performance from junior residents, advanced practice providers, nurses and attendings will help shape their trajectory. It is also critical for residents to be adaptable and cultivate a multitude of leadership techniques as different teams may require different leadership strategies. These recommendations will help ensure time spent in residency is maximized to help residents achieve their greatest potential.

This analysis provides recommendations for surgery residency program leadership. Program directors should be aware of the importance of early rotations that create opportunities for leadership and graduated autonomy. The ‘flip flopping’ between junior and senior resident roles during the PGY2 and PGY3 years was an essential mechanism to learn new leadership techniques and trial different styles. Acknowledgement of the transition by program leadership added gravity to the role of the senior resident, helped early seniors understand the importance of the shift and helped chief residents take extreme ownership of the role within the team and the residency. Feedback on residents’ nontechnical skills from attendings is also crucial for their development. This type of feedback should be encouraged by program leadership and aligns with the current ACGME Surgery Milestones’ of Interpersonal and Communication Skills and Practice-Based Learning and Improvement.³⁴ By using existing feedback mechanisms, residents can be encouraged to increase their personal investment in the process.

This study has several limitations. First, it was conducted at a single urban academic surgery residency, and thus the results may not be transferable to other general surgery training experiences. Also, all residents were invited to participate in focus groups which resulted in a wide distribution across years of training. However, all participants were volunteers which may select for a similar type of resident. Therefore, we may have missed alternative features of effective residents that were not highlighted by this group. The focus groups were conducted by a surgery research resident which may have impacted other residents’ willingness to share honestly about negative experiences. Additionally, the two resident coders are mid-level residents. Both have limited experience as senior residents, and their prior positive or negative interactions with senior residents may have influenced their coding and data analysis. Lastly, this analysis focuses only on the resident perspective and we are missing the perspectives from other members of the care team, including patients, advanced practice providers and attendings. There is a need for future studies to obtain these perspectives in order to triangulate these different viewpoints to better understand the true defining characteristics of an effective senior resident.

In conclusion, a senior resident is the team member with the highest level of experience who is responsible for managing the big picture of patient care. Junior residents naturally become senior residents through the residency process, however personal engagement and external acknowledgement of the transition enhances the process. Ideal traits of effective seniors, such as emotional intelligence and inherent personality traits, allow a resident to more naturally assume this role. Teachable skills, such as communication, expectation setting and clinical competence, can be taught to improve one’s effectiveness. These themes will help guide future professional development activities to enhance the transition from junior to senior resident.

Abbreviations:

PGY

Post Graduate Year