C4 - 08: CREATION OF OPERATIVE REPORTS BY SURGICAL TRAINEES: A NEEDS ASSESSMENT INCORPORATING A NATIONAL SURVEY OF GENERAL SURGERY PROGRAM DIRECTORS
Benjamin D Ferguson, MD, PhD; Department of Surgery, University of Chicago
Background: Dictation of operative reports by surgical residents was once commonplace. However, this practice seems to have decreased in frequency for current trainees. This trend has not been described at a national level, and underlying factors have not been identified. We sought to describe national trends in the creation of operative reports by general surgery residents and identify factors contributing to a decline in operative reporting by residents.
Methods: An 18-item survey was distributed to program directors (PDs) of American general surgery programs (n=239) using Google Forms. The survey included items regarding the practice of resident creation of operative reports through dictation and/or written documentation, reasons for cessation of resident participation, logistics surrounding report creation, and motivations for and attitudes toward this practice.
Results: The response rate was 31.8% (76/239). 90.8% of programs involve residents in operative reporting. 71.4% of the programs that do not currently involve residents previously did involve residents in the creation of operative reports within the past 10 years. Medicolegal barriers (80%) and decreased resident operative autonomy (40%) were most the common reasons for cessation of resident involvement. Verbal dictation (78.5%) is the most common approach for operative reporting by residents, followed by electronic notes (21.4%). 100% of programs involving resident participation allow deposition of the resident operative report into the medical record; 91.3% of programs require subsequent cosigning and/or amendment by the surgical attending. Nearly two-thirds of programs report that residents view operative report creation favorably. Only 33.3% of programs provide instruction on operative reporting.
Conclusions: Most general surgery residency programs currently allow residents to create operative reports with appropriate supervision. Few of these programs incorporate formal instruction in the creation of operative reports. Attrition of resident participation in operative reports seems limited to individual institutions rather than suggestive of a national trend. Future directions include the development of a formal operative report dictation curriculum and assessment of early-career attending surgeons regarding operative reporting practices.