The Construction of Surgical Trust: How Surgeons Judge Residents' Readiness for Operative Independence

Objective: The aim of this study was to explore how trust was constructed between surgeons and residents in the operating room. Background: Entrustment is increasingly being used as a key element to assess trainees' competence in the clinical workplace. However, the cognitive process involved in the formulation of surgical trust remains poorly understood. Methods: In semistructured interviews, 9 general surgeons discussed their experiences in making entrustment decisions during laparoscopic cholecystectomy. Template analysis methodology was employed to develop an explanatory model. Results: Surgeons described the construction of trust as a stepwise process taking place before, during, and after the procedure. The main steps were as follows: (1) an initial propensity to trust based on the perceived risk of the case and trustworthiness of the resident; (2) a decision to initiate trust in the resident to begin the surgery; (3) close observation of preliminary steps; (4) an evolving decision based on whether the surgery is "on-track" or "off-track"; (5) intervention if the surgery was "off-track" (withdrawal of trust); (6) re-evaluation of trust for future cases. The main reasons described for withdrawing trust were: inability to follow instructions, failure to progress, and unsafe manoeuvres. Conclusions: This study showed that surgical trust is constructed through an iterative process involving gathering and valuing of information, decision-making, close observation, and supervisory intervention. There were strong underlying themes of control and responsibility, and trust was noted to increase over time and over repeated observations. The model presented here may be useful in improving judgements on competence in the surgical workplace.