Resident hesitation in the operating room: does uncertainty equal incompetence?

• Published in: Medical education Vol. 52; no. 8; pp. 851 - 860
• Main Authors: Ott, Michael, Schwartz, Alan, Goldszmidt, Mark, Bordage, Georges, Lingard, Lorelei
• Format: Journal Article
• Language: English
• Published: England Wiley Subscription Services, Inc 01.08.2018
• Subjects: Medical education; Supervisors
• ISSN: 0308-0110; 1365-2923
• DOI: 10.1111/medu.13530

Context In postgraduate medical programmes, the progressive development of autonomy places residents in situations in which they must cope with uncertainty. We explored the phenomenon of hesitation, triggered by uncertainty, in the context of the operating room in order to understand the social behaviours surrounding supervision and progressive autonomy. Methods Nine surgical residents and their supervising surgeons at a Canadian medical school were selected. Each resident–supervisor pair was observed during a surgical procedure and subsequently participated in separate post‐observation, semi‐structured interviews. Constructivist grounded theory was used to guide the collection and analysis of data. Results Three hesitation‐related themes were identified: the principle of progress; the meaning of hesitation, and the judgement of competence. Supervisors and residents understood hesitation in the context of a core surgical principle we termed the ‘principle of progress’. This principle reflects the supervisors’ and residents’ shared norm that maintaining progress throughout a surgical procedure is of utmost importance. Resident hesitation was perceived as the first indication of a disruption to this principle and was therefore interpreted by supervisors and residents alike as a sign of incompetence. This interpretation influenced the teaching–learning process during these moments when residents were working at the edge of their abilities. Conclusions The principle of progress influences the meaning of hesitation which, in turn, shapes judgements of competence. This has important implications for teaching and learning in direct supervision settings such as surgery. Without efforts to change the perception that hesitation represents incompetence, these potential teaching–learning moments will not fully support progressive autonomy. The impact of the principle of progress, resident hesitation and perceptions of competence on teaching in direct supervision settings are explored.