Developing autonomy is a critical component of becoming an attending surgeon. General surgery training has evolved in recent decades, however, leaving residents less time to work with attendings to establish entrustment. Limited entrustment can impact resident learning and engagement.

A constructivist grounded theory approach was used to guide interviews of 12 general surgery residents and 10 attendings.

Engagement in the OR is perceived by both residents and attendings as fundamental to achieving autonomy. Our study uncovered three key tensions: 1. Residents and attendings both occupy dual roles in the OR; 2. System demands put those roles in tension and opposition constantly; 3. Residents and attendings do deploy strategies to seek balance in those tensions.

In an academic OR setting, competing priorities can negatively impact resident engagement. Participants described some strategies for helping residents and attendings prioritize learning and teaching to better prepare residents for future practice.