Achieving progressive operative autonomy at a teaching hospital in Kenya

Purpose Operative autonomy during training is necessary to produce competent surgeons. A lack of autonomy may lessen trainee readiness for practice upon completion of training. Within training programs in Kenya, there is less faculty oversight, but the impact on autonomy has not been assessed. This study evaluates and describes trainee operative autonomy at a teaching hospital in Kenya where there is a deliberate attempt by faculty members to balance oversight and provide appropriate graduated autonomy. Methods Autonomy was measured with the Zwisch scale utilizing the System for Improving and Measuring Procedural Learning (SIMPL (TM)) application, a workplace-based assessment platform facilitating real-time feedback for surgical trainees. We reviewed the levels of autonomy perceived by trainees and faculty and compared autonomy by post-graduate year (PGY). We explored this relationship using ordinal mixed models with trainee PGY level and case complexity included as fixed effects and procedures as a random effect. Results From Jan 1, 2021, to Dec 31, 2021, 619 evaluations were completed by all 14 residents and 7 faculty in the general surgery program. By PGY, there was an increase in perceived granted autonomy by both faculty and trainees. On mixed modeling, trainees achieve more autonomy with advancing PGY [coefficient: 1.77 (95% CI 1.37-2.17), p<0.01]. Fourth- and fifth-year trainees achieved meaningful autonomy, defined on the Zwisch scale as passive help or supervision only, in 79% of operative evaluations (96 of 121). Conclusions This study shows an increase in autonomy granted to trainees with more advanced training years. Meaningful autonomy can be achieved within surgical training, which should help to prepare surgeons for independent practice in Kenya.