In this study, we aimed to assess the confidence of SSRs in preforming the most prevalent procedures. Confidence is gained over several years of training with the development of skills and experience. It is hard to assess the confidence level as there is no objective way to assess confidence. (23)
Our first expectation was that those residents with a higher number of completed cases as primary surgeon would be more confident. Our study showed no correlation between the number of cases and the level of confidence except with regard to MRM. One explanation for the lack of significant correlation between the number of cases performed and confidence level in procedures other than MRM is the small number of residents who completed over 850 and over 950 cases as the primary surgeon. In previous studies, evidence is conflicting regarding whether the number of completed cases increases a resident’s confidence in the operation room or not. Some studies have found an association, (23, 26, 27) while others have not. (17, 24, 28) The authors who found no difference have suggested that after completing a certain minimum number of cases, surgical resident’s confidence plateaus. (24) It would also seem that building confidence among surgical residents is a multistep process and does not rely solely on caseload. Previous research that assessed what elements residents (both medical and surgical) identify as confidence building include working through decisions with the consultant, managing sick patients, having good support from other residents, being given responsibility for critical issues in patient management, and making decisions on their own, among many other factors. (11) We believe the correlation found in MRM procedure, could be explained by the fact that breast cancer is the most common malignancy among females in Saudi Arabia (SA), (29) and MRM is a very common procedure performed in almost every hospital regardless of its facilities. This theory is further supported by the finding that breast surgery was the most commonly selected fellowship among our respondents.
With regard to predictors of increased confidence, we found that SSRs sponsored by the Ministry of Health hospitals had a higher confidence level compared to their peers. This could be related to the fact that the Ministry of Health hospitals usually have a larger variety of cases due to wider eligibility criteria for patient admission. Non-Saudis were also found to be more confident in performing the aforementioned surgical procedures. This might be because entry into the program is more competitive for them due to the limited number of seats.
We found no statistically significant difference in the level of SSR confidence based on gender. Other research has shown male gender to be predictive of increased confidence. (10, 16, 23, 26) It has also been shown that when asked to assess themselves in the operating room, general surgery residents tend to underestimate their abilities compared to the supervising surgeons’ assessment, with females tending to underestimate themselves to a greater extent than their male colleagues (though this was not statistically significant). (30) This finding is not limited to surgery, as it has been demonstrated even outside the medical field. It has been shown that when females perform a task well they are likely to attribute it to their good fortune, whereas, if it is performed poorly, they attribute it to a lack of skill, with the opposite being true in males. (31)
Older age was the only factor associated with a higher number of completed cases during the residency. Regardless of the number of completed cases, the confidence level was not altered.
Nearly 94% of the SSRs in this study plan to pursue a fellowship program. The range quoted in the literature we reviewed showed this percentage to be between 60–80% in North America. (21, 22, 24, 32) Another study showed that the number of surgeons in the USA pursuing fellowship is increasing: from 60% in 1989 to 80% in 2011. (18) The reasons the SSRs showed such a large interest in pursuing fellowship could be multifactorial. Reasons could include SSRs feeling that the general surgery field in SA is very competitive. That they need to have subspecialty training, in order to get a good job in a prestigious hospital or a large city. Additionally, residents suppose that they still need more operative exposure to develop their skills. Coleman et al suggested that fellowships offer more operative experience which overcomes the confidence issues that many residents have faced. (21) SSRs may also perceive society as having a “mental pyramid of certificates,” with certain nations offering more prestigious certificates than others.
In our study, we found the main motivator for fellowship training was a strong interest in the specialty, with only 13.8% stating that the lack of confidence was one of the reasons for pursuing a fellowship. This large percentage of residents wishing to pursue fellowship may support the idea of a modular format of surgical training. This has been advocated by some surgical educators in North America. In this case, a basic surgical core curriculum is introduced for the first 2–3 years of surgical training, followed by one of two pathways, a specialist in surgery (such as hepatobiliary, thoracic, colorectal, etc.) or general surgery training. (33) Previous research shows that many residents in the USA support this. (21) A potential downside could be a shortage of “general” surgeons. It could also contribute to the graduation of surgeons who are not needed. A modular format would allow subspecialty certification only, while the current standard allows certification in two specialties, namely general surgery, and the subspecialty.
The most selected fellowship program among the SSRs in this study was breast surgery, followed by minimally invasive/bariatric surgery. This might be because both of these fellowships deal with very common surgical conditions, with a definite need in many institutions and hospitals.
Trauma is considered one of the major areas of general surgeons’ practice; therefore, measuring the surgical residents’ preparedness in this field is critical. Previous research has shown that the volume of trauma the SSRs are exposed to has been decreasing. (34) Considering this, we enquired about the levels of trauma centers in which the SSRs received their trauma training. We expected that training in Level I trauma centers would be reflected on the confidence level; however, this was not what we found. In fact, there was no difference between the level of the trauma center and the level of SSR confidence in performing essential trauma procedures. This might be because most residents surveyed had their trauma rotation in Level I trauma centers.
The main limitation of this study is that the main outcome of interest was confidence and not actual competence. Confidence is a self-reported measure that may be biased by many factors, such as one’s sense of self-belief, insight, and fear of judgement by peers, despite a survey’s anonymity. Though the level of confidence in the procedures did match our expectation overall, there is disagreement in the literature as to what is an acceptable level of confidence. What is the minimum acceptable percentage of SSRs who should be comfortable performing a laparoscopic cholecystectomy or colectomy? There were SSRs in our study who rated themselves as not confident in performing appendectomies, for example. We also did not assess the SSRs’ abilities in other areas such as clinical decision making outside the operating room. The sample size was not large, and that could have affected detecting significant difference across the different subgroups. The sample could have been biased with more confident residents responding because it was distributed at a review course, which would have been attended by more prepared SSRs. Most respondents were from large cities, which may have influenced some of the answers such as the plans for fellowship training. However, our study provides educators with some evidence for the areas of weakness in SSR training. It helps administrators plan subspecialty training needs. We had a high response rate of over 89%. We suggest the next step should be a study correlating resident confidence and competence in the operating room with the assessment of an unbiased experienced surgeon to gauge their ability to assess themselves, while at the same time identifying areas of discrepancy between them and their educator’s assessment.