Operating Without Direct Supervision During Pediatric Surgery Fellowship: When, How, and Why?

Background: There is concern that finishing pediatric surgical fellows may not be ready for independent practice due to a lack of operating without direct supervision during their training. The adoption of Entrustable Professional Activities (EPAs) as an assessment metric further highlights the need to evaluate practices and policies regarding fellow operative autonomy.

Methods: A survey was distributed to the 59 pediatric surgical training program directors (PDs) in North America. PDs were asked about their program's policies and criteria regarding when a fellow may operate without direct supervision. Respondents were queried about a range of procedures as to whether their recent fellows had operated without direct supervision in situations in which the attending surgeon was not scrubbed but available in the operating room or not in the operating room at all. PDs were asked if any malpractice case resulted from an operation in which a fellow operated without direct supervision.

Results: Surveys were completed by 44 (75%) PDs. Few programs reported protocols or criteria to determine eligibility for indirectly supervised operating. None require specific parental consent when a fellow functions as a teaching assistant. Most PDs reported that fellows operated iwithout an attending surgeon scrubbed for basic procedures such as laparoscopic appendectomy. However, only a small minority recalled a fellow operating i with only another trainee on complex cases like esophageal atresia repair. One malpractice suit was reported.

Conclusion: There is substantial variability in fellow operative autonomy among pediatric surgical training programs. Few programs have established protocols to determine trainee readiness for independent operating and parental consent for teaching assistant cases is not typically obtained.