Resident Hesitation in the Operating Room: Uncertainty in the Context of the Principle of Progress

In postgraduate medical programs, ‘progressive autonomy’ encourages residents to face moments of uncertainty. We explored the phenomenon of 'hesitation,' triggered by uncertainty, in the context of the operating room in order to understand the social behaviors surrounding supervision and progressive autonomy. Nine surgical residents and their supervisors were selected from a Canadian medical school. Each resident-supervisor pairing was observed during an operative procedure and subsequently participated in separate post-observation semi-structured interviews. Constructivist grounded theory was used to guide the collection and analysis of the data. We found that teaching and learning in the operating room is heavily influenced by the principle of progress. The principle of progress suggests that maintaining progress throughout an operative procedure was a highly valued norm by both supervisors and residents alike. Resident hesitation was often the first indication of a disruption to this principle of progress. A lack of resident progress during a procedure was perceived by supervisors as a sign of incompetence and influenced the teaching-learning process. We considered the implications of these three newly described phenomena, that is, the principle of progress, the meaning of hesitation, and influence on judgments of competence, for teaching and learning in direct supervision settings such as surgery. Medical educators, by being aware of these phenomena, could maximize their teaching-learning moments and foster progressive autonomy.