Are trainees entrustable? Rethinking autonomy in orthopaedic training - A trainee’s perspective
By Sivakumaran Inthujan
Orthopaedic Registrar, National Hospital of Sri Lanka, Colombo, Sri Lanka
There is a moment in every orthopaedic trainee’s journey when the trainer steps back, looks at the operative field, and says, “You do the next step.”
For someone watching from outside the operating theatre, it might seem like a small instruction. For the trainee, it can mean much more. It represents trust, responsibility, and the recognition that learning must eventually translate into independent practice.
But it also brings uncertainty. Am I ready? Does my trainer trust my ability, or is this simply another opportunity to learn? What happens if I struggle? And how do I know when I am ready to take the next step?
As trainees, we spend years learning how to operate. Perhaps we should spend more time discussing how we learn to become surgeons who can be trusted to operate.
Beyond the number of operations
Surgical training often places considerable emphasis on operative exposure. We record procedures, document our roles, and count the operations we have performed. These records are important. They help us understand our experience and identify gaps in our training.
But does completing a particular number of operations necessarily mean that we are competent to perform them independently?
Two trainees may have assisted in the same number of procedures but acquired very different levels of experience. One may have observed most of the operation, while another may have performed substantial portions under supervision. Even when their technical exposure is similar, their clinical judgement, decision-making and ability to recognise complications may differ.
As trainees, we understand the importance of gaining operative experience. However, we also recognise that experience and competence are related, but they are not interchangeable.
A surgical logbook tells us what we have recorded doing. It cannot, by itself, tell us everything about how well we performed, how we made decisions, or whether we are ready to take greater responsibility.
Perhaps the question should not simply be, “How many operations have you performed?” but also, “What have you learned from them, and what can you now be trusted to do?”
The complicated relationship between autonomy and supervision
Every trainee wants to progress. We want to move from assisting to performing, from following instructions to making decisions, and from depending on our trainers to developing independent judgement.
Yet autonomy is not simply the freedom to operate without a trainer standing beside us.
Sometimes, close supervision provides the confidence to attempt something unfamiliar. At other times, an opportunity to lead a procedure – with appropriate support available – can help us recognise our strengths and limitations.
The challenge is that trainees do not all progress at the same rate, and competence does not develop uniformly across every procedure.
A trainee may be comfortable performing a routine procedure but still require close guidance when confronted with an unusual fracture pattern, unexpected intraoperative findings or a complication. This does not necessarily represent a failure of training. It reflects the reality that surgical competence is multidimensional and procedure-specific.
From a trainee’s perspective, good supervision is not merely about having someone present to intervene. It is about having a trainer who understands when to demonstrate, when to guide, when to allow independent performance and when to step in.
The aim should not be to eliminate supervision, but to make it responsive to the trainee, the procedure and the patient.
Can we measure trust?
Trust is central to surgical training, but it can be difficult to measure.
A trainer's decision to allow a trainee to undertake an operation may depend on previous performance, familiarity with the trainee, case complexity, available support and the trainer's own experience. Some of these factors are readily documented; others may remain intuitive.
This raises an important question: can we make decisions about trainee autonomy more transparent, consistent and evidence-informed?
My interest in this question led me to examine what surgical logbook data might reveal about supervision, case complexity and postoperative complications.
In a retrospective analysis of 1,608 surgical cases recorded in three orthopaedic trainees' logbooks at a single centre in Sri Lanka, the overall recorded complication rate was 6.5%. After adjustment for case complexity and procedure type, supervision level was not significantly independently associated with postoperative complications.
These findings need to be interpreted cautiously. The study involved only three trainees, was observational, and assessed complications rather than competence or entrustability directly. It cannot establish that different levels of supervision are equivalent, that autonomy has no effect on complications, or that trainees can safely operate without appropriate supervision.
Nevertheless, the work prompted a broader question for me: could routinely collected training data help us understand how operative experience, supervision and patient outcomes relate to one another?
A logbook is not a complete measure of competence. But, when combined with structured assessment, reliable outcome recording and thoughtful feedback, it may contribute to a more comprehensive understanding of surgical development.
What trainees need from their trainers
As trainees, we have responsibilities of our own. We must prepare adequately, recognise our limitations, seek help when necessary and remain open to criticism. Autonomy should not become an entitlement, and confidence should never substitute for competence.
But trainers also have an important role in making progression understandable.
Trainees benefit when expectations are clear, feedback is specific and opportunities for increasing responsibility are linked to demonstrated performance. It is difficult to improve when we do not know what is expected of us or why we are not yet ready to progress.
A discussion after an operation can be as important as the operation itself: What went well? What could have been done differently? Which decisions required guidance? What would the trainee need to demonstrate before undertaking the next similar procedure with less supervision?
These conversations transform supervision from a passive presence into an active educational process.
Entrustable professional activities offer one framework for thinking about this progression. Rather than judging readiness solely through procedure counts or isolated technical skills, they focus on whether a trainee can undertake defined professional activities to an appropriate standard with a specified level of supervision.
For trainees, such approaches could make progression more transparent. For trainers, they could provide a structured basis for decisions that might otherwise rely heavily on personal judgement.
No assessment framework can remove uncertainty entirely. Surgical practice is too complex for that. But we can strive to make decisions about responsibility more deliberate and better supported by evidence.
Learning to be trusted
As trainees, we often measure progress through examinations passed, procedures completed and responsibilities acquired. These are visible milestones. Learning to recognise our limitations, however, is less easily measured and equally important.
A surgeon who knows when to seek help is not necessarily less competent than one who proceeds independently. In some circumstances, recognising the need for assistance is itself evidence of sound clinical judgement.
Ultimately, entrustability is not simply about whether a trainee can perform an operation. It is about whether that trainee can undertake the relevant professional activity safely and appropriately, including making decisions, anticipating problems, responding to complications and recognising when support is needed.
We should also acknowledge that the responsibility for safe surgery never belongs to the trainee alone. It exists within a wider system of supervision, training, teamwork and patient care.
Perhaps, then, the question Are trainees entrustable? should not be answered by case numbers, complication rates or a trainer's confidence alone.
It requires a more complete assessment of competence, judgement, professional behaviour and readiness for responsibility.
As a trainee, I do not see autonomy as the absence of supervision. I see it as the gradual development of the ability to take responsibility while recognising when that responsibility exceeds my current capabilities.
Autonomy should be earned, assessed and progressively extended – not granted blindly or withheld indefinitely.
Our goal is not simply to become surgeons who can operate independently. It is to become surgeons who understand when they are ready to do so, when they need support, and how those decisions affect the patients who trust us with their care.