BTK Autonomy

Hello, and welcome to this episode of Behind the Knife in Surgical Education. We are the General Surgery Education team from Cleveland Clinic. I'm Puja Barman, a general surgery resident and surgical education research fellow. I'm Judith French. I'm the PhD Education Scientist for the Department of General Surgery at the Cleveland Clinic.

And I'm Jeremy Lipman. I'm the DIO and Director of Graduate Medical Education here. On today's episode, we discuss resident autonomy in the operating room. Surgeons who've been in practice a long time now might remember being awarded a frightening amount of independence in the or, but feeling that it built character and skills and made them better surgeons.

Many surgical residents today worry they don't get enough autonomy and there are data supporting that claim, and they feel unprepared for independent practice by the time they graduate. Today we're joined by two surgeons, one early career and one recently retired. To hear perspectives on the past, present, and future of resident autonomy, how much is the right amount?

Dr. Tracy Hull was a

colorectal surgeon at Cleveland Clinic for over 30 years. I. She completed her residency training at SUNY in Syracuse, New York, in colorectal fellowship at Cleveland Clinic. She has served as president of the American Society of Colon and Rectal Surgeons and Vice Chair of Staff and Trainee Development and Assistant program director for the colorectal fellowship at Cleveland Clinic.

She's been awarded numerous awards for teaching and mentorship of medical students, residents, fellows, and other faculty, including the Real Resident Development Award and Kaiser Permanente Award for Excellence in teaching clinical faculty. Our second guest, Dr. David Rosen, is in his seventh year as a colorectal surgeon at Cleveland Clinic.

He completed general surgery, residency and surgical critical care fellowship at USC in Los Angeles, colorectal fellowship at Washington University in St. Louis, and is currently pursuing an MBA at Case Western Reserve University. He serves as director of the robotic cadaver lab for colorectal surgery faculty at Cleveland Clinic and

Vice Program chair of the Oscar's annual meeting.

He won teaching awards during every year of his residency, and in 2024 was awarded three separate teacher of the year awards by the medical students, residents, and fellows at Cleveland Clinic. We're thrilled to welcome these beloved surgical educators to the show. So to kick us off, could you tell us about a time during your residency when you got more autonomy than you felt ready for?

We'll start with you, Dr. Hull. So, I did my surgery residency in the 1980s and we had an exceptional amount of autonomy. There was a private practice hospital, a couple of 'em, the academic hospital and the va. So particularly at the va, we had a lot of autonomy where the staff would be next door in their offices in the academic hospital and we would be doing cases.

The case that I can remember that kind of gave me some nerve wracking. Thoughts. There were two, two situations, actually, both at the

va. The first was a patient that needed an xlo by femme, and I had done a tremendous amount of vascular surgery at the private practice hospital, just a huge amount. And so the staff said, I think you can do this on your own, and he was next door and I knew I could call him, and I wasn't afraid to call him if I needed help, and I had really good.

Third year in intern help. And I was extremely nervous, but was able to do the entire case on my own. And then another case was when I was a fifth year at the VA doing a pelvic pouch in a patient and I got into some presacral bleeding and I due to pack. And I was just about ready to call the staff, and then I remembered I had read in DCR about using thumbtacks.

So I did call the staff actually and had them sterilize some thumbtacks off the bulletin board and had the bleeding stop

before the staff got over there. So those were two instances where everything turned out fine, but certainly made my heart rate and blood pressure go up. It sounds like it was lucky that everything went well in the end, Dr.

Rosen. Thanks so much for having me. I'd like to start by saying my I regret that you read Dr. Hall's CV before mine as that is quite embarrassing to hear the little things I've done after the great Tracy Hall, but asking about some. When I got more autonomy than I felt ready for in residency, there are two times I, I immediately thought of both kind of happened by nature of the circumstance.

The first case I was on the acute care service and was called emergently to the ob GYN suite where they were doing a crash c-section for an abruption. They saw D cells and they need to get the baby out quickly. Patient had multiple abdominal surgeries and they're having a

difficult time appreciating the anatomy and getting to the baby.

And so they called out to the general surgeons for help and I was the first one there responded, and my staff was not there yet. And so I just quickly scrubbed in and got into the abdomen and the ob, GN attending said, look, it is a perforation. We need to get the baby out. So I. Reached in and pulled the baby out and they said, well, don't grab it by the head.

I said, well, this is not my, especially, I'm just doing what you're telling me. But that was a time just kind of got called and reacted. And secondly, in the ICU, there was a patient. ENT patient in the ICU had a big pharyngeal resection. Basically a patient that obstructed and needed an emergent crike.

And I was the first one to respond, and I was able to successfully do it and, and crank that patient who couldn't get intubated. And so those were two times kind of by circumstance, you know, I just relied on my training, was able to react and have good outcomes. It's a little bit of a dicey question, but can you share any stories when maybe things didn't go as smoothly

as you would've hoped, perhaps because you didn't have the supervision you needed?

I mean, I think anytime we talk about trainees having too much autonomy and leading to patient harm, we always think about either negligent staff or if there had been better supervision, those things wouldn't have happened. But I think I, I'll preface this by saying I think it's important to know that bad outcomes happen no matter who the.

Most senior level surgeon in the room is so, you know, even though there are are mistakes that can happen with trainees, the same happens if there's no trainees and, you know, everyone can make mistakes and have poor outcomes. And, you know, there's good data that shows that patient outcomes are actually improved when residents are involved.

There's times where in residency that you know, myself or my colleagues have been lysing adhesions without. Supervision and can think of missed autotomies that we've had to take back. But we know that is a risk of, you

know, preoperative abdominal surgery and that can happen to anyone. But yes, there's been times when in re in my training, when I was doing things surgically that had, you know, perioperative complications and tough to know if there was someone more seen in the room if that would've happened or not.

Dr. Hall, anything you can share? I talked to some of the residents, I called them actually, that I did my training with and, and we were brainstorming about this and in the, or, we could not come up with any situation over the five plus years we were there that we could remember that, that that occurred and the patient had a bad outcome.

We were talking about. Remembering bad outcomes when the senior surgeon was in the room, and it could happen to anybody, but we couldn't think of any reason because we were there and there was no no staff surgeon there. There were times on the floor where I. Interns missed a high potassium. This was one thing that I had

forgotten, but one of my year mates had reminded me and the patient coded on the floor and you know, the patient survived, but it was an oversight by the intern who.

Probably should have called somebody more senior if they didn't know what to do. I can tell you in the emergency room, my third day of being a doctor I was at the private hospital and the staff and the senior resident took call from home and a 22-year-old woman came in who had been in an MVA and was really, really.

Probably no way she was gonna survive anyhow. And the ER staff was an internal medicine. I don't know if resident person did not look very old to me, and the patient needed a chest tube and I had never put a chest tube in and didn't know how to put a chest tube in. The er doctor screamed at me that I didn't know how to put a chest tube in and the patient was gonna die 'cause I didn't know how to put a chest tube in.

And the staff was there within 10 minutes and put a chest tube in. Then the poor woman died. Anyhow, she, she had terrible, terrible injuries and I was ready to quit. And the, the staff had to really talk to me. I was ready to leave and quit, and I had nightmares about chest tubes. I have to say, until I learned to put one in on cardiothoracic, I would talk about it in my sleep.

My husband said he was reminding me of that. So it doesn't have to be in the or. Thank you for sharing those stories. I'm also curious from the other side of things, you both shared some stories as, as trainees in times that maybe there was more autonomy than you were ready for, but as a faculty member were there times where you were working with residents and trying to figure out how much autonomy to give them and maybe there was too much autonomy and that led to patient harm?

I don't think there was any ever any irreversible harm. I remember Dr.

Fazio used to tell us that he could, he would not let us do anything in the anal area without him being in the room the entire time. But he said he could fix anything in the abdomen if we got in the wrong plane or something. And that always, that kind of always echoed with me.

But I, I think I was really pretty careful about trying to assess the person. And their skillset before I wasn't standing directly over them at the table. And there were a lot of times where, especially laparoscopically, I was not scrubbed because I knew I would take over and I had to sit on my hands while I guided the, the resident or the fellow where I thought they should be dissecting laparoscopically.

I think that's a, a great way because everybody can see what's going on. But it's really hard to sit there. It's really hard to watch. 'cause I know I could do it a lot faster and move a lot faster, but I can't remember a time where patients really came to permanent harm because of a

resonance autonomy.

There have been times where patients have had a bad outcome because they had just. A horrible circumstance, but it wasn't because there was a resident involved, it was just because it was a bad outcome because of a horrible circumstance. Yeah. I'd say similarly, I, you know, there's times when you know, when you're in the operating room and you're doing, you know, complex multi quadrant surgery that we do as colorectal surgeons.

You only have two hands and there's times you need assistance, whether it's residents or PAs and and whatnot. And, and yeah. There are times where there's been bad outcomes. I've had trainees that have put the EEA stapler when inserting it through the rectum and just gone up too fast and gone right through the staple off rectal stump.

There's been times, you know, when doing things laparoscopic a bad outcome, I mean, you fix it, right? I don't consider that a bad outcome unless you can't fix it. Well, it, I wouldn't call it a good outcome. I mean, I think you're right. That's not a No, it's,

it's, it's not what I consider, I mean, yeah, you don't want that to happen, but you can't do everything.

And I don't consider, I if, if the patient had a leak and you couldn't fix it, or you couldn't do the anastomosis because there was a leak, to me, that's a bad outcome. That's just part of doing surgery to me. Yeah, I, I, I don't disagree. I guess, I mean, the second half of the point I was gonna make is that I, I've also done those things while residents are in the room, self-limiting kinda issues, risks of things that come along with surgery that we then fix, but enter autotomies or col autotomies or vascular injuries, things like that.

Those are all risks of surgery no matter who is there. And I, I, I don't think that risk is significantly increased by. Resident autonomy. I don't think it's increased at all by residents being involved in the case. So let's go ahead and, and take a step back because we keep using the term autonomy and I'm just curious if we all have sort of a

general idea as to what that means to each of us.

So, Dr. Rosen, why don't we start out with you? Can you give us your definition of what autonomy actually is? When I see my trainees, I want them to be autonomous surgeons when they graduate and are off on their own. And what I mean by that is I want them to be able to independently assess the situation and make an independent decision as to what to do and to have the confidence in their decision making to know what to do, and then have the confidence and skill to then do it.

Most of us, when you hear autonomy with regards to surgery and in the or which we're talking about, you think of operating by yourself without a staff guiding you and telling you what to do, or even maybe watching you or maybe watching if they're not saying anything. But I think that's what we all think of.

But I think the days of that have really changed for multiple reasons that I think we'll get into later. And, and, and so I think of it less that today than

maybe I did as a trainee. So wait, can you say more though, about operative autonomy or autonomy in education? So, you know, you're talking about autonomy in practice, but when you're in clinic or scopes on the floor, what does autonomy for a training mean?

How do you define it there? Very similar autonomy for a trainee is to be able to do things independently and by themselves without needing to be, you know, handheld and coached and walked along. And it's doing, it's, it's having their own decisions and their own techniques and their own plan, Dr. Hall.

So, I think of autonomy this way. I think of it is making your own decisions versus being told what to do. So in the or. You have increased responsibility, but you know when, when you need to seek guidance, whether you're a trainee or whether you are a faculty, I think it's taking on more responsibility as you gain experience.

What do you think the residents get out of that? Do you think that there's a benefit for the residents and fellows, any trainee having that opportunity to, to do things independently? Yeah, I think it's, I think it's really interesting and, and really an important part. I can remember when I first started as staff, I had had a lot of opportunity to do a lot of independent surgery.

And I thought I knew I was doing, and then when I was setting it up and, and my, I remember my first year, I couldn't figure out how to set up the retractors and get people to retract and. I, I think that if I had had a little bit more of that kind of autonomy that while I was in training, then when I.

I operated till I was beyond my technical skillset, and then the, the senior person came in, I would've been

able to pay attention to that a little bit more. And, and so what happens is, and I think that happens today, is people then learn on their own and there's no safety net of a senior person to come in and, and give 'em additional guidance.

That sort of implies that you should leave residency or fellowship prepared to take on everything. No, but you need to be prepared to take on the basic things. I have to tell you, when I finished my fellowship at the clinic, I did the clinical associate year because I didn't feel ready, you know, that year of really.

Being forced, or giving the opportunity is a better word, to really do a lot of very complex things. That was really important. And then Dr. Ry, or Dr. Fazio came in when it was, you know, at the, at the end of my skillset.

And I think that was when I really became a surgeon. And I don't. I think that, and I had a lot of autonomy, so I think that the, the whole goal has to be to push people to the limit of their skillset.

And then when the senior person comes in, they can say, okay, that's where I should have been going, or That's the plane I should have been in. And, and I think. To me that that's important. That's an important way to push people to, to learn and then to be able to troubleshoot on their own. It's really interesting to hear about the arc of your own development as a surgeon from those experiences.

I'm curious how that influenced. Your perception of autonomy when you went from a trainee to a staff surgeon. So how did your own experiences with autonomy transform once you

became staff? And do you think, how do you think that influenced how you approached giving residents autonomy once you were kind of in that position?

So when I was an early staff, there wasn't enough residents and or fellows and I had a lot of medical student who fir medical students who first assisted me. And let me tell you, that to me was very challenging and really made you get very clever and figure out how to make things work. I remember complaining once to Dr.

Fazio about it, and he told me it is building my character as I went along. And then gained a little bit more seniority and then had actually people that were in surgery training in the OR and I graduated up enough and seniority and got interns. I, I thought it was really important to. Let them do things that should be in their skillset.

Like, you know, there was no laparoscopy in those days, so making the

incision and closing the fascia so that they could handle instruments and, and sometimes. They needed more practice and they needed more practice in not tying. And I have to say that I was pretty hard on 'em. But those people, as they matured in our surgery residency, they were grateful and they told me they were grateful for the opportunities to be able to do those things as they, they went along and then.

Eventually I got, we had third years on the service and I got a got third year that rotated with me. And then I could, I could really let that person do a lot more because they had, they had done more as a intern and I knew them and I knew their commitment and their passion. I think that. Into it a lot.

There are people that come in the OR and they act like they are entitled, and that would just absolutely make me feel very hesitant to let them have a lot of responsibility. I think you have to

try to, sometimes you can't do your homework before you come in because you get thrown in somebody's room.

I get that. But overall, you know, I, I expect people to. Kind of know what's, what the plan is if they can, and I expect them to practice tying at home and practice using instruments so that when they get the opportunity that they fumble a little bit more with a little bit more skill. I. Ask about perception of autonomy and how it's changed since my training.

It, it has changed somewhat when you think about autonomy as you know, doing things independently. I think it's kind of a double-edged sword in a way for and to what Dr. Hall was saying. I agree very much. You kind of have to know the trainee and their skillset because to let someone. Do something that is appropriate for their skill level and do it well and the patient does well, that's very confidence boosting and I think a very positive outcome of

autonomy.

But if there's someone who make a mistake or do something poorly and something that you've set them up to fail 'cause they're not ready for, then that can be a very negative. Experience. So for me, where I did my general surgery training, we did a large portion of our training at a public county hospital, and sometimes there was less oversight than at some of the private hospitals, just in the nature of how many patients there were and things going on.

Lack of staff coverage. And that was good thing for times that were very confidence building and less so for things that were confidence shaking. So I think when I think about what autonomy to give a trainee, it's always very useful for me to have operate with 'em and know where they're at and set them up to, whether it's leading a junior through a certain part of the case that I think would be appropriate or doing certain aspects of things independently.

But that's kind of where I, I, I see autonomy nowadays. I think there's a way to get that

information without having worked with them before. At, at large institutions like here in the Cleveland Clinic. You know, I rely on my colleagues who have worked with trainees before. You kind of get a sense when someone comes onto your service, they, you can reach out to other faculty.

I've worked to get a sense of what their skill sets are, where they excel, where they struggle. It's tough to know exactly. 'cause not everything is completely translatable. You know, if someone is. Great at doing some endovascular procedures. Would they necessarily be great at doing something, you know, laparoscopic colon resection?

But over time, especially as by the time they've become a senior resident and ready for the, you know, level of autonomy as the senior operating resident, by that point, I've, I've worked with 'em and kind of have a sense, so. So what barriers do you face as a surgeon educator in providing more autonomy to your trainees?

Dr. Hall, we can start with you. The culture and time. So that was

something that all my year mates said when I called them up to ask 'em about our residency experience and what they thought was a difference. So, the five of us, two others were in academics and two others had had their whole career in private practice.

So it was a good cross to ask them the difference in what they saw from our residency till now. And I had to agree with what they said when I was a resident. Even the private practice people took the time to take us through cases and teach us and give us a lot of instruction in the OR. And I mean, they were private practice.

They, they were not money driven, but money was like, their more important than I think in the academic world where, you know, it wasn't so much, everybody was, had a fee and you were paid a fee versus in the private practice, but, but everybody was less busy and there was less paperwork.

And they had, they had a lot of time to teach and you don't have that luxury nowadays.

We're so driven by do more, be thrifty in the or with the time there's not enough or time for everybody. Do more cases. I think we need to have a. A really good examination of the culture and what we're expecting the surgeons to do. I think the surgeons are expected to catch the fall on a lot of different things.

We don't have enough nurses, well, we just put more pressure on the, on the surgeons, and I think that is somewhat extended to education. Just expected to do so much more and be so much busier, do so many more cases in a day. It's really hard to slow down and take the time to allow the resident, even if you're standing over them, to be able to do, you know, a huge part of the case.

You have to really, I.

Take a deep breath and really be committed to it. And I think we need to reexamine our priorities. Their hours are less and they're probably gonna get less in the future, the precious time we have with them in the or. We have to really take great advantage of it. And I don't think that that's prioritized.

And the other thing is, when I was an intern, we were in the or. A lot of times interns are not in the or they're, they're doing paperwork, and I think we need to look at all of that and say, what are we trying to do here? Brings up a good point, Dr. Rosen, you know, how do you strike that balance between patient safety, education, efficiency?

You know, we're at the same meetings month after month where we're talking about. Case numbers and patient volumes and access, and not a lot about how much autonomy we're given the residents in the operating room. Yeah, it's really hard.

It's really, really hard because like Tracy was saying, you're always being told to do more cases, do 'em quicker, see more patients, and so time is absolutely a, a barrier because there's no doubt letting someone who's less experienced with a procedure do it takes more time.

I think the way I try to balance that out is by really trying to talk to the trainee and figure out what they're trying to get out of each individual case. There's a day where I see I've got three big resections and I can tell that maybe my team is less familiar with the types of cases I do, and you know, all three of them are REVE cases and I can tell it's gonna be a longer day.

Then I might preface that and sort of set the playing field with the trainee to say, Hey, here's what we're up against. We both wanna be home before midnight. You know, there are times that I'm gonna have to move the case along, but why don't you tell me what aspects of this case do you really want me to slow down and let you get some time working on?

Where are you struggling, where do you wanna improve? An example of that

is when I have back to back, you know, robotic, low anterior resections after, you know, chemo, radiation and, and consolidation, chemotherapy. Those you on obese patients, those tend to be longer cases, and doing two of those in a day is a long day.

So oftentimes I tell the trainee. You know, this might not be the day you're doing this case, skin to skin, but what aspect of this dissection do you want to really work on? And I'll make sure I slow down and stop and give you the time. Some people use things like set timers and do time. I, I don't like to do that because it seems a little bit more, you know, unnecessary pressure.

I kind of just sort of see how the flow is going and, and the trainees I've found to be really respectful and appreciative. That, and, and understanding of that as well. It's never a perfect system. Everyone wants to do more in terms of trainees doing the case. But I've found that to help. The other thing I'll say, the other barrier that I've seen too, is how visible everything is nowadays.

Not only with. You know, being watched over outcomes and complications on the hospital and administrative level, but also, you know,

with social media and, you know, online presences, we're all rated and evaluated by patients. And so your outcomes are being watched. And patients tell me all the time how much they research me and watch my videos and stuff like that before they come to see me.

So that's another barrier. You need to have good outcomes because that becomes public information. Maybe we'll just take advantage of having puja here. So in a case like that where you walk in and you're thinking you're gonna be doing these two fantastic cases with Dr. Rose, and he is a great teacher, he is won all kinds of awards as you told us, and then he is telling you, you're only gonna do this part or that part.

I mean, how does that leave you feeling? Do you feel like you got the, the experience you wanted from that case? I. I think that having some of the discussion ahead of time where I can tell that the surgeon I'm working with is thinking about all of these things together, that we do have a busy day today.

And also I

wanna make sure that you have time to practice your skills. That I think would mean a lot to me. I think when we have a little bit of a, a preview of what we're up against, I think that helps a lot to just know that our education is a priority. But we, I mean, we're aware as residents also that there are constraints outside of our control when it comes to time and efficiency and that.

You know, getting as many cases done during the day, you know, is a priority to the enterprise at large. So we know it's not a specific person who's taking opportunities away from us. And I'll add too that it's always a, and I preface those conversations too, too by saying it's a fluid situation. If we're moving along and the trainee is doing great, I certainly don't take back over.

You just keep going and do as much as you can, and if you're being efficient, then you keep moving along. A lot of people took a lot of time to allow me to learn how to do surgery, and it's all of our

responsibility to do the same. So I take that very seriously and that means a lot to me. I also think that the residents have responsibility to do as much practicing on their own, on the simulation models and not tying and using instruments.

There are residents that I think could really benefit. From doing that before they come to the or. So I think they have a little responsibility to have their skills as honed as possible, just handling instruments. And when I was learning laparoscopy, which was far outside my residency, I, I got a box and got.

Two different laparoscopic graspers and just would keep threading the needle back and forth until I felt much more comfortable with it and, and doing different procedures, just looking in a box. It really improved my ability to be able to do it then, you know, when, when it was in a

real person. So I, I think that it's like every other.

Thing you do in life, you gotta practice and you still keep practicing. I mean, there were things that I had to learn to do that I never did in my residency on my own, by just watching a video and reading about it because new procedures come up or new ways of doing things. So I think that there is some responsibility on the trainee that they need to make sure they have been practicing as much as possible with.

Every tool that's available that is not in the patient. So thus far, we've talked a lot about the resident autonomy from an education perspective. We'd like to see how patients can be included in this conversation as well. So how do you include patients in the conversation around resident autonomy? What do you tell them about resident involvement?

When

you're. Talking to patients in clinic and going through the informed consent, and how do you respond if a patient expresses reluctance about residents being involved in their case? Yeah, so that comes up. Oftentimes patients will preface it and ask like, you're doing this procedure, right? Or, I met your resident, but I wanna make sure that you're the one doing the surgery.

And the way I addressed that, as you know, I said, this is a teaching hospital where we train the next generation. And I came from a place where that was done too. And I wouldn't be here if. Other people didn't give me the chance to operate under their guidance and watchful eye, and I do the same thing.

I'll be there from beginning to end. Everything will be done under my guidance, but I also only have two hands. And sometimes there are other things that are required. I consider the, the resins are basically an extension of my care, and I need them to be involved in order to give you a successful outcome.

Everything that. We will be doing is with you in mind. That usually puts nervous patients at ease, and I think for the most part,

patients are fine with trainees if they trust their surgeon. So I think that's about building rapport with the patients and getting them to be on the same page as you. So I would say to patients, you're asking the wrong question.

What you should be saying and thinking is, you want me to do this the same way every time that I find it successful? And if that means that I'm using trainees, that's what I need to do. I, I had patients who'd say, I want no trainees in the room. And I'd say, fine. Find another surgeon because that's not the way my system was set up and I, and I was very specific about that and very specific.

When they asked if trainees did parts of the case, I said, yes. I said, I'm always around, but I might not be in the room. I said, I don't put your bladder catheter in. A lot of patients had no idea. I said, the nurse sometimes does. They had, they have no idea. Things are safe. I said, you're asking the wrong question.

Your question should be, or your thought should be, I

want you to do things, how you always do it so you have a successful outcome. There were patients who said, well, I want, you know, no resident to be in the room or to work on me. And I said, fine, find another surgeon 'cause I won't be your surgeon. Was not my way of doing things.

Well, this has been a fantastic conversation. I'm really grateful to both of you for being here. Maybe we'll give you a moment for an educational sign out. You know, a couple things that you want our listeners to take away from this conversation about autonomy and education. I think the main things to take away about educational autonomy is that I think it's different for each trainee.

Just like when we think about promoting our colleagues and working our way through meeting people where they are and promoting them to help setting our colleagues up for success in their careers. We have to do the same with the residents. We have to be honest with them. See where they are, where their operative skills are, tell them where they need to improve and try to help them get there.

And, and the big

part of that is taking the time, right? A lot of people took a lot of time with us, train us and allow us to struggle and to get where we are. And that's what contributed to a big part of my success. And I think we all need to be committed to do the same for the trainees we have. We know that they do a ton of work on Ourves in terms of perioperative care and calls and paperwork and stuff.

And so we need to make sure we pay it back to them. The first thing that I always wanna see is passion on both sides, both with the trainees and with the surgeon. So that's my first thing really. You've gotta be passionate. There'll be days when you're not, but overall, you've gotta have a lot of passion.

I think you have to practice whatever you can practice. Outside of the or, and I can remember being an intern and we were on every other night, so there wasn't a lot of time. I was not in the hospital, but they gave me a needle driver and a pair of forceps and I practiced sewing on oranges. And you know, I remember sewing on Fig Newton cookies because somebody

told me that it was like sewing on the liver, which believe me, it's not, but you know, it was, it was challenging.

Tying and using those instruments. So you know you have muscle memory and it's like second nature. You gotta practice that stuff. There is free time now and people have free time, believe it or not. And when you have free time go to the OR and scrub in and second assist. You can learn a lot a by watching.

I. Learn a lot by watching. And number two, that tells the surgeon when you're on that surgeon service that you really are interested in, you know, you can show some of your skills. So that, that getting to know you phase that I think is really difficult to be able to give autonomy. You get over a little bit of that, you know that that goes a long way.

So don't think you won't learn something. Dr. Turnbull, who was the father of colorectal surgery, assisted Dr. Jones in hundreds of operations as his first assistant. And when Dr. Jones dropped over dead and Dr. Turnbull had to

take his practice on, he had only ever done one case on his own. And he had been so observant as a first assistant, he was able to do these very complex cases and have wonderful outcomes.

And a lot of it was because he had had the opportunity to see Dr. Jones operate and assist him, and when it was his turn, he knew what to do. So don't belittle being the first assistant or the second assistant because you still learn stuff. Tracy, do you still enjoy fig Newton's or have you lost your appetite for them?

I never liked him, but. But my senior resident told me that it was like sewing on the liver, and so I bought a pack of fig Newtons and sewed on 'em, and they're not very easy to sew on. But let me tell you, it was kind of skill provoking. They don't bleed too much. No, thank goodness they don't. Big Newton sales are about to skyrocket after.

Well, just wanted to point out again that you both as master

surgical educators have identified I think a theme that we all thought we would be hearing. That you don't have to be left alone. By yourself to have autonomy, that there's lots of ways to grant autonomy and that it is important that people be pushed to the edge of their abilities and practice, but with guidance.

Thank you so much for doing this. We really appreciate it. And Tracy, enjoy your well deserved retirement. And Dr. Rosen, what can I say?