Looking Beyond the Numbers: A Comparison of Operative Self-Efficacy, Supervision, and Case Volume in General Surgery Residency.

Background A national survey of general surgery residents revealed significant self-assessed deficits in preparation for independent practice, with only 7.7% of graduating postgraduate year 5 residents (n=1145) reporting self-efficacy for all 10 commonly performed operations surveyed. Objective We sought to understand why this phenomenon occurs. We hypothesized that self-efficacy would be positively correlated with both operative independence and case volume. Methods We compared 3 independent datasets: case information for the same 10 previously surveyed operations for residents graduating in 2020 (dataset 1), operative independence data obtained through the SIMPL OR app, an operative self-assessment tool (dataset 2), and case volume data obtained through the Accreditation Council for Graduate Medical Education National Data Report (dataset 3). Operations were categorized into high, middle (mid), and low self-efficacy tiers; analysis of variance was used to compare operative independence and case volume per tier. Results There were significant differences in self-efficacy between high (87.7%), mid (68.3%), and low (25.4%) tiers (P=.008 [95% CI 6.2, 32.7] for high vs mid, P<.001 for high vs low [49.1, 75.6], and P<.001 for mid vs low [28.7, 57.1]). The percentage of cases completed with operative independence followed similar trends (high 32.7%, mid 13.8%, low 4.9%, P=.006 [6.4, 31.4] for high vs mid, P<.001 [15.3, 40.3] for high vs low, P=.23 [-4.5, 22.3] for mid vs low). The total volume of cases decreased from high to mid to low self-efficacy tiers (average 91.8 to 20.8 to 11.1) but did not reach statistical significance on post-hoc analysis. Conclusions In this analysis of US surgical residents, operative independence was strongly correlated with self-efficacy.

The domino effect: the impact of gender on operative self-efficacy.

BACKGROUND: Studies suggest that there are key differences in operative experience based on a trainee's gender. A large-scale self-efficacy (SE) survey, distributed to general surgery residents after the American Board of Surgery In-Training Examination in 2020, found that female gender was associated with decreased SE in graduating PGY5 residents for all 4 laparoscopic procedures included on the survey (cholecystectomy, appendectomy, right hemicolectomy, and diagnostic laparoscopy). We sought to determine whether these differences were reflected at the case level when considering operative performance and supervision using an operative assessment tool (SIMPL OR). METHODS: Supervision and performance data reported through the SIMPL OR platform for the same 4 laparoscopic procedures included in the SE survey were aggregated for residents who were PGY5s in 2020. Independent t-tests and multiple linear regression were used to determine the relationship between trainee gender and supervision/performance ratings. RESULTS: For laparoscopic cases in aggregate (n = 2708), male residents rated their performance higher than females (3.57 vs. 3.26, p < 0.001, 1 = critical deficiency, 5 = exceptional performance) and reported less supervision (3.15 vs. 2.85, p < 0.001, 1 = show and tell, 4 = supervision only); similar findings were seen when looking at attending reports of resident supervision and performance. A multiple linear regression model showed that attending gender did not significantly predict resident-reported supervision or performance levels, while case complexity and trainee gender significantly affected both supervision and performance (p < 0.001). DISCUSSION: Female residents perceive themselves to be less self-efficacious at core laparoscopic procedures compared to their male colleagues. Comparison to more case-specific data confirm that female residents receive more supervision and lower performance ratings. This may create a domino effect in which female residents receive less operative independence, preventing the opportunity to establish SE. Further research should identify opportunities to break this cycle and consider gender identity beyond the male/female construct.

The Program Director Perspective: Perceptions of PGY5 Residents' Operative Self-Efficacy and Entrustment.

INTRODUCTION: A 2020 survey of post-graduate year 5 (PGY5) general surgery residents linked to the American Board of Surgery In-Training Examination (ABSITE) revealed significant deficits in self-efficacy (SE), or personal judgment of one's ability to complete a task, for 10 commonly performed operations. Identifying whether this deficit is similarly perceived by program directors (PDs) has not been well established. We hypothesized that PDs would perceive higher levels of operative SE compared to PGY5s. METHODS: A survey was distributed through the Association of Program Directors in Surgery listserv; PDs were queried about their PGY5 residents' ability to perform the same 10 operations independently and their accuracy of patient assessments and operative plans for components of several core entrustable professional activities (EPAs). Results of this survey were compared to PGY5 residents' perception of their SE and entrustment based on the 2020 post-ABSITE survey. Chi-squared tests were used for statistical analysis. RESULTS: 108 responses were received, representing ∼32% (108/342) of general surgery programs. Perceptions from PDs of PGY5 residents' operative SE were highly concordant with resident perceptions; no significant differences were observed for 9 of 10 procedures. Both PGY5 residents and PDs perceived adequate levels of entrustment; no significant differences were observed for 6 of 8 EPA components. CONCLUSIONS: These findings show concordance between PDs and PGY5 residents in their perceptions of operative SE and entrustment. Though both groups perceive adequate levels of entrustment, PDs corroborate the previously described operative SE deficit, illustrating the importance of improved preparation for independent practice.

The fundamentals of laparoscopic surgery in general surgery residency: fundamental for junior residents' self-efficacy.

BACKGROUND: Implementation of the Fundamentals of Laparoscopic Surgery (FLS) by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) has served a need for educational structure for laparoscopic skill within General Surgery training since 2004. This study looks at how FLS affects resident self-efficacy (SE) with laparoscopic procedures. METHODS: We conducted a national survey, linked to the 2020 American Board of Surgery In-Training Examination (ABSITE), in which 9275 residents from 325 US General Surgery Training Programs participated. The online survey included multimodal questions that analyzed whether participants felt they could perform the most commonly-logged laparoscopic operations among residents [Laparoscopic Appendectomy (LA), Laparoscopic Cholecystectomy (LC), Laparoscopic Right Hemicolectomy (LRH), Diagnostic Laparoscopy (DL)] without faculty assistance. This used a 5-point scaled assessment, ranging from "not able to" to "definitely able to." Multivariate analyses determined if completion of FLS made a difference for resident self-efficacy, stratified by post-graduate year (PGY). RESULTS: At the time of the survey, 2300 reported completion of FLS. The percentage of FLS completion increased from PGY1 to PGY5 (4.2% n = 59 vs 85.8% n = 893). PGY1 residents who completed FLS, from 48 diverse institutions, demonstrated the most significant increases in SE (p < 0.05) with significantly higher perceived self-efficacy in LA (p = 0.001) and LRH (p = 0.012). PGY2 and PGY3 residents indicated increased SE in DL (p = 0.037, p = 0.015, respectively), based on FLS completion. These FLS effects were less evident in the more senior classes. CONCLUSIONS: Completion of FLS arguably has the greatest benefits for more junior residents, as it establishes a foundation of laparoscopic knowledge and skill, upon which further residency training can build. Successful completion of the curriculum and assessment offered by the Fundamentals of Laparoscopic Surgery leads to greater sense of ability in early trainees.

Do Individual Surgeon Preferences Affect Procedural Outcomes?

OBJECTIVES: Surgeon preferences such as instrument and suture selection and idiosyncratic approaches to individual procedure steps have been largely viewed as minor differences in the surgical workflow. We hypothesized that idiosyncratic approaches could be quantified and shown to have measurable effects on procedural outcomes. METHODS: At the American College of Surgeons (ACS) Clinical Congress, experienced surgeons volunteered to wear motion tracking sensors and be videotaped while evaluating a loop of porcine intestines to identify and repair 2 preconfigured, standardized enterotomies. Video annotation was used to identify individual surgeon preferences and motion data was used to quantify surgical actions. χ 2 analysis was used to determine whether surgical preferences were associated with procedure outcomes (bowel leak). RESULTS: Surgeons' (N=255) preferences were categorized into 4 technical decisions. Three out of the 4 technical decisions (repaired injuries together, double-layer closure, corner-stitches vs no corner-stitches) played a significant role in outcomes, P <0.05. Running versus interrupted did not affect outcomes. Motion analysis revealed significant differences in average operative times (leak: 6.67 min vs no leak: 8.88 min, P =0.0004) and work effort (leak-path length=36.86 cm vs no leak-path length=49.99 cm, P =0.001). Surgeons who took the riskiest path but did not leak had better bimanual dexterity (leak=0.21/1.0 vs no leak=0.33/1.0, P =0.047) and placed more sutures during the repair (leak=4.69 sutures vs no leak=6.09 sutures, P =0.03). CONCLUSIONS: Our results show that individual preferences affect technical decisions and play a significant role in procedural outcomes. Future analysis in more complex procedures may make major contributions to our understanding of contributors to procedure outcomes.

An Analysis of Preliminary General Surgery Residents' Matriculation into Categorical Positions.

OBJECTIVE: To analyze the effects of a pipeline program for preliminary general surgery (GS) residents to optimize their future enrollment into categorical positions. DESIGN: Retrospective review of non-designated preliminary (NDP) GS residents between 2014 and 2020 was conducted. Preliminary conversion rates (CRs) were analyzed for residents who matriculated to categorical GS residency or non-GS residency positions. SETTING: Howard University Hospital, Department of Surgery; tertiary academic hospital. PARTICIPANTS: PGY-1 (n = 14) and PGY-2 (n = 26) NDP GS residents RESULTS: Forty NDP GS residents studied (14 PGY-1 and 26 PGY-2). CR for the total cohort was 67.5% (n = 27), with 59.3% (n = 16) acquiring categorical GS positions and 40.7% (n = 13) obtaining categorical positions in other specialties. CR for PGY-1 residents into categorical GS position was 50% (n = 7), while PGY-2 residents had a CR of 34.6% (n = 9). No significant difference was observed between residents successfully matriculating into GS residency as a preliminary PGY-1 or PGY-2 (p = 0.34). Twelve preliminary residents secured categorical GS positions at this institution with 58.3% (n = 7) obtaining a PGY-1 position, 16.7% (n = 2) obtaining a PGY-2, and 25.0% (n = 3) obtaining a PGY-3 position. 7.1% (n = 1) of preliminary PGY-1 and 46.2% (n = 12) of preliminary PGY-2 residents went unmatched as of 2021. CONCLUSIONS: 67.5% of preliminary residents enrolled in categorical positions. Success rates were highest during the PGY-1 year. A residency program committed to uniform clinical curriculum, and standardized, metric-based decisions may have increased CR for preliminary GS residents. Public sharing of preliminary CRs to applicants may influence residency selection decisions, both for applicants and programs.

Diversity, equity, and inclusion in presidential leadership of academic medical and surgical societies.

BACKGROUND: Our aim was to identify gender and racial disparities in presidential leadership for national medical and surgical organizations. METHODS: We located publicly sourced information on national medical organizations. Years between or since the first diverse presidents were analyzed using descriptive statistics and Mann Whitney U tests. RESULTS: Sixty-seven national medical and surgical organizations were surveyed. 70.8% (n = 34) diversified via gender first (White-female), whereas 26.1% (n = 14) had racial diversity first. Organizations with gender diversity first followed with an African American male president sooner than organizations who first diversified by race (14.7 ± 11.8 v. 27.6 ± 11.3 years, p = 0.018). No significant difference was observed for the third tier of diversification. CONCLUSIONS: Significant gender and racial leadership disparities in national medical organizations are still present. It is notable that organizations with female leaders had a shorter timeline to racial diversity. These findings help to inform strategies to promote and increase diversity, equity, and inclusion in national leadership.

Individual and Institutional Factors Associated with PGY5 General Surgery Resident Self-Efficacy: A National Survey.

BACKGROUND: Variability in post-graduate year 5 (PGY5) residents' operative self-efficacy exists; yet the causes of variability have not been explored. Our study aims to determine resident-related and program-dependent factors associated with residents' perceptions of self-efficacy. STUDY DESIGN: Following the 2020 American Board of Surgery In-Training Examination, a national survey of self-efficacy in 10 of the most commonly performed Accreditation Council for Graduate Medical Education case-log procedures was completed. RESULTS: A total of 1,145 PGY5 residents completed the survey (response rate 83.8%), representing 296 surgical residency programs. Female sex (odds ratio [OR] 0.46 to 0.67; 95% CI 0.30 to 0.95; p < 0.05) was associated with decreased self-efficacy for 6 procedures. Residents from institutions with emphasis on autonomy were more likely to report higher self-efficacy for 8 of 10 procedures (OR 1.39 to 3.03; 95% CI 1.03 to 4.51; p < 0.05). In addition, increased socialization among residents and faculty also correlated with increased self-efficacy in 3 of 10 procedures (OR 1.41 to 2.37; 95% CI 1.03 to 4.69; p < 0.05). Procedures performed with higher levels of resident responsibility, based on Graduated Levels of Resident Responsibility (GLRR) and Teaching Assistant (TA) scores, were correlated with higher self-efficacy (p < 0.001). CONCLUSION: Ensuring that residents receive ample opportunities for GLRR and TA experiences, while implementing programmatic support for resident-dependent factors, may be crucial for building self-efficacy in PGY5 residents. Institutional support of resident "autonomy" and increasing methods of socialization may provide a means of building trust and improving perceptions of self-efficacy. In addition, reevaluating institutional policies that limit opportunities for graduated levels of responsibility, while maintaining patient safety, may lead to increased self-efficacy.

Surgical endoscopy education research: how are we doing?

BACKGROUND: Surgical endoscopy (SE), the official journal of the Society of American Gastrointestinal and Endoscopic Surgeons and the European Association for Endoscopic Surgery, is an important source of new evidence pertaining to surgical education in the field. However, qualitative deficiencies in medical education research have prompted medical education leaders to advocate for increased methodological rigor. The purpose of this study is to review the quality of education-focused research published through SE. METHODS: A PubMed search examining all SE articles categorized as education-related research from 2010 to 2019 was conducted; studies not meeting inclusion criteria were excluded. Remaining publications were independently reviewed, classified, and scored by 7 raters using the medical education research study quality instrument (MERSQI). Intraclass correlation was calculated and data were examined with descriptive statistics. RESULTS: A total of 227 studies met inclusion criteria. There was no significant difference in number of publications by year (average 25.88 [SD 5.6]); 60% were conducted outside of the United States, and 47% (n = 106) were funded. The average MERSQI was 12.5 (SD 2). Most studies used two-group non-random (42%, n = 96) or post/cross-sectional designs (29%, n = 65). Thirty-six (16%) were randomized controlled trials. Multi-institutional studies comprised 24% (n = 54). Of the manuscripts, 96% (n = 217) reported at least one measure of validity evidence and 28% (n = 67) described three levels of validity evidence. Studies primarily reported changes in skills or knowledge (45%, n = 103) or satisfaction or general facts (44%, n = 99), while patient-related outcomes encompassed 3% (n = 6) of studies. ICC between raters was 0.93 (CI 0.90-0.93, p < 0.001). CONCLUSIONS: Based on publications to date, this journal's peer review process appears to facilitate the dissemination of education-related studies of moderate to good quality. However, there were uncovered deficits, ranging from validity evidence to study designs and level of outcomes. This journal's breadth of viewership offers a potential venue to advance education-related research.

Developing a longitudinal database of surgical skills performance for practicing surgeons: A formal feasibility and acceptance inquiry.

BACKGROUND: We explored the feasibility and surgeons' perceptions of the utility of a longitudinal skills performance database. METHODS: A 10-station surgical skills assessment center was established at a national scientific meeting. Skills assessment volunteers (n = 189) completed a survey including opinions on practicing surgeons' skills evaluation, ethics, and interest in a longitudinal database. A subset (n = 23) participated in a survey-related interview. RESULTS: Nearly all participants reported interest in a longitudinal database and most believed there is an ethical obligation for such assessments to protect the public. Several interviewees specified a critical role for both formal and informal evaluation is to first create a safe and supportive environment. CONCLUSIONS: Participants support the construction of longitudinal skills databases that allow information sharing and establishment of professional standards. In a constructive environment, structured peer feedback was deemed acceptable to enhance and diversify surgeon skills. Large scale skills testing is feasible and scientific meetings may be the ideal location.

Diversity, Equity, and Inclusion: A Current Analysis of General Surgery Residency Programs.

BACKGROUND: Local, regional, and national diversity, equity, and inclusion (DEI) initiatives have been established to combat barriers to entry and promote retention in surgery residency programs. Our study evaluates changes in diversity in general surgery residency programs. We hypothesize that diversity trends have remained stable nationally and regionally. MATERIALS AND METHODS: General surgery residents in all postgraduate years were queried regarding their self-reported sex, race, and ethnicity following the 2020 ABSITE. Residents were then grouped into geographic regions. Data were analyzed utilizing descriptive statistics, Kruskal-Wallis test, and chi-square analyses. RESULTS: A total of 9276 residents responded. Nationally, increases in female residents were noted from 38.0 to 46.0% (P < .001) and in Hispanic or Latinx residents from 7.3 to 8.3% (P = .031). Across geographic regions, a significant increase in female residents was noted in the Northwest (51.9 to 58.3%, P = .039), Midwest (36.9 to 43.3%, P = .006), and Southwest (35.8 to 47.5%, P = .027). A significant increase in black residents was only noted in the Northwest (0 to 15.8%, P = .031). The proportion of white residents decreased nationally by 8.9% and in the Mid-Atlantic, Southeast, and Southwest between 5.5 and 15.9% (P < .05). DISCUSSION: In an increasingly diverse society, expanding the numbers of underrepresented surgeons in training, and ultimately in practice, is a necessity. This study shows that there are region-specific increases in diversity, despite minimal change on a national level. This finding may suggest the need for region-specific DEI strategies and initiatives. Future studies will seek to evaluate individual programs with DEI plans and determine if there is a correlation to changing demographics.

American Board of Surgery Entrustable Professional Activities (EPAs): Assessing Graduating Residents' Perception of Preoperative Entrustment.

OBJECTIVE: To determine if graduating surgical residents are achieving entrustment of surgical entrustable professional activities (EPAs). We hypothesize that postgraduate year 5 (PGY5) residents are achieving evaluation and management entrustment in the selected EPAs. DESIGN: In January 2020, surgical residents completed a survey following the American Board of Surgery In-Training Examination (ABSITE) to measure their levels of entrustment in 4 of the 5 ABS-selected EPAs. A Resident Entrustability Index (REI) score was developed to ascertain PGY5 residents' levels of entrustment (range 1-5). Residents indicated how often their assessments and operative plans were modified in the prior 6 months for each EPA (1=Always, 2=Frequently, 3=Occasionally, 4=Rarely, 5=Never). An independent clinical decision-making score (ICDM) was developed with subsequent evaluation of its relationships to intrinsic, resident-related and extrinsic, program-dependent factors. SETTING: A national post-ABSITE survey. PARTICIPANTS: All general surgery residents participating in ABSITE were invited to participate. Of the 1367 PGY5 residents that completed the survey, 1049 residents (76.7%) responded to the surgical EPA items. RESULTS: Residents achieved an average REI of 4, indicating rare modification of assessments and operative plans for the 4 EPAs assessed. Complete entrustment was reported for inguinal hernias and penetrating abdominal trauma (Median REI = 5, IQR 4, 5) indicating assessments and operative plans were never modified. Lack of entrustment (REI ≤3) was reported by a minority of residents (ranging from 8.6% for operative plan of right lower quadrant pathology to 12.8% for operative plan of blunt abdominal trauma). Significant resident-related and program-dependent factors associated with achievement of expected ICDM was socializing with a co-resident (p = 0.001), while training in one's hometown (p < 0.001) and policies that mandate attendings be scrubbed in (p = 0.022) were associated with decreased achievement of expected ICDM. Overall, 89.2% and 90.3% of PGY5 residents are attaining appropriate levels of entrustment and ICDM abilities, respectively, within 6 months of graduating. CONCLUSIONS: Of the EPAs evaluated, PGY5 residents are achieving appropriate levels of entrustment in evaluation and management. Although this is the case for a vast majority of PGY5 residents, there is still work to be done to ensure that all PGY5 residents are attaining entrustment prior to graduation. Our study also provides content validity for the surgical EPAs in assessing levels of entrustment in PGY5 residents.

Validity Evidence for Vascular Skills Assessment: The Feasibility of Fundamentals of Vascular Surgery in General Surgery Residency.

OBJECTIVE: As the Fundamentals of Laparoscopic Surgery (FLS) and Fundamentals of Endoscopic Surgery (FES) have been used for general surgery assessment, the Fundamentals of Vascular Surgery (FVS) has recently been developed to evaluate core operative skills for vascular trainees. This study examines the 3 year implementation of FVS for general surgery residents and it gathers validity evidence using Messick's framework. We hypothesized that the curriculum and assessment tool enhance general surgery resident training and assessment. DESIGN: This is a retrospective review of FVS assessments of residents using descriptive and multivariate analyses. SETTING: This study was conducted at an academic institution, where simulation-based teaching sessions occur in coordination between the general surgery and the integrated vascular surgery residency programs. PARTICIPANTS: Seventeen general surgery residents were assessed in FVS skills by an expert rater from 2018 to 2020. RESULTS: Overall, 86 assessments were completed. CONTENT: Assessment focuses on 3 open vascular skills (End-to-Side Anastomosis, Patch Angioplasty and Clockface Suturing). Response Process: 7 items comprise a graded rating for a skills score. Additionally, a global summary score is designated. Internal Structure: The assessment tool has a Cronbach's alpha of 0.87, demonstrating good internal consistency. Addition of the second rater correlated with Cohen's kappa -0.69 (p < 0.001), indicating poor interrater reliability. Relationships to other variables: The most significant improvement occurred in total scores between PGY2s (17.4 ± 2.37) and PGY4s (23.2 ± 3.00), p < 0.001, indicating adequate level discernment. CONCLUSIONS: The validity evidence of FVS assessment in this study supports its use in general surgery residency at a time when opportunities for open vascular skills assessment may be decreasing due to case availability and shifting paradigms. Further study into quality rater training is needed to optimize national implementation of FVS and ensure consistency in grading.

Isolating steps instead of learners: Use of deliberate practice and validity evidence in coronavirus disease (COVID)-era procedural assessment.

BACKGROUND: In surgical training, assessment tools based on strong validity evidence allow for standardized evaluation despite changing external circumstances. At a large academic institution, surgical interns undergo a multimodal curriculum for central line placement that uses a 31-item binary assessment at the start of each academic year. This study evaluated this practice within increased in-person learning restrictions. We hypothesized that external constraints would not affect resident performance nor assessment due to a robust curriculum and assessment checklist. METHODS: From 2018 to 2020, 81 residents completed central line training and assessment. In 2020, this curriculum was modified to conform to in-person restrictions and social distancing guidelines. Resident score reports were analyzed using multivariate analyses to compare performance, objective scoring parameters, and subjective assessments among "precoronavirus disease" years (2018 and 2019) and 2020. RESULTS: There were no significant differences in average scores or objective pass rates over 3 years. Significant differences between 2020 and precoronavirus disease years occurred in subjective pass rates and in first-time success for 4 checklist items: patient positioning, draping, sterile ultrasound probe cover placement, and needle positioning before venipuncture. CONCLUSION: Modifications to procedural training within current restrictions did not adversely affect residents' overall performance. However, our data suggest that in 2020, expert trainers may not have ensured learner acquisition of automated procedural steps. Additionally, although 2020 raters could have been influenced by logistical barriers leading to more lenient grading, the assessment tool ensured training and assessment integrity.

A 20-year review of surgical training case logs: Is general surgery still general?

BACKGROUND: Surgical training has undergone many facets of restructuring over the most recent decades, with critiques of the quality and variability of training as well as the competency of recent graduates. This study examines the changes in surgical training in operative volume and breadth in the past 2 decades. METHODS: The Accreditation Council for Graduate Medical Education Case Log Statistics Reports from 1999 to 2019 were reviewed. Case logs were grouped into defined case categories and group levels of postgraduate training. Descriptive analyses and multiple linear regressions were performed. RESULTS: General surgery residents are graduating with 10.7% more cases, owing to increases in mostly junior year cases (P < .001). The breadth of specialty cases has decreased, while there was an increase in alimentary and abdominal cases to 58.4% from 47.2% 20 years ago. A decrease in vascular surgery cases from 19.9% to 10.7% of all cases was noted. Analysis of the distribution of defined categories showed right skewness in many categories with mode being much lower than reported mean. CONCLUSION: Evaluation of trends, despite residents graduating with higher case volume than the minimum required, shows that the breadth and variety of cases has narrowed significantly in the past 20 years, providing a case for general surgery training restructuring.

Defining the Deficit in US Surgical Training: The Trainee's Perspective.

BACKGROUND: Self-efficacy is the personal judgment of how well one can successfully complete a task. The goal of this study was to assess self-efficacy of PGY5 residents for common general surgery operations. We hypothesized there are deficits in self-efficacy of PGY5 residents, and self-efficacy of a given operation correlates with experience performing the operation without attending assistance (independently) and teaching the operation from start to finish. METHODS: A survey was linked to the 2020 American Board of Surgery In-Training Examination. From the ACGME case log's 15 most commonly performed surgeon-chief operations and AHRQ's 15 most common operations, 10 operations were selected. Residents evaluated their ability to perform these operations independently using a 5-point self-efficacy scale. Residents were asked whether they had experience performing these operations independently or teaching the operation from start to finish. Descriptive statistics and Pearson correlation were used to examine the relationship between self-efficacy and operative experience. RESULTS: In all, 1,145 of 1,367 PGY5 residents (84%) responded. Highest self-efficacy was in performing wide-local excision (90.24%) and lowest was in performing open thyroidectomy (19.58%). Eighty-eight (7.7%) reported self-efficacy in all procedures. Statistically significant positive correlations were identified between experience and self-efficacy for cases performed without assistance (r = 0.98, p < 0.01) and cases taught (r = 0.91, p < 0.01). CONCLUSIONS: With 5 months left in training, 92.3% of residents report deficits in preparation for practice, as defined by self-efficacy to complete common procedures independently. Resident self-efficacy increased in direct relation to performed cases and cases taught.