Training

How to get your attending to let you do more

Omar Samara · 2026-09-14 · 5 min read

You know the step. You have watched it forty times. The attending takes the driver back anyway, and you spend the rest of the case holding a retractor and quietly disagreeing.

Maybe you are right. The research suggests you are probably less right than you think, and so are they.

You are not watching the same case

One orthopaedic programme ran this on a single operation. Twenty-one residents and seven attendings each filled in the same survey after arthroscopic rotator cuff repairs, for 71 cases across a year.

Residents said they could have done the whole case on their own 52% of the time. Their attendings said 15%.

The gap got wider with seniority, not narrower. For junior residents it was 28 points. For seniors it was 50.

When the resident could not finish alone, the two sides disagreed about why. Attendings named technical skill in 72% of those cases. Residents named it in 30%.

It cuts the other way too. Attendings believed they were handing over about 70% of the key steps. Residents felt they were getting about 54%.

So each side overrates its own half. The resident overrates the skill. The attending overrates the opportunity. One programme, one procedure, so treat it as a hint. It is a very consistent hint.

Each side blames the other half

A survey at a general surgery programme asked 60 attendings and 38 residents what decides entrustment.

Attendings put demonstrated skill and resident reputation at the top. Residents put more weight on things outside their control: the push for efficiency, limited block time, malpractice worry.

The clearest split was on barriers. 58% of residents named low attending confidence. 17% of attendings did. 72% of attendings named resident skill. 32% of residents did.

An older survey of 116 attendings across seven institutions landed in the same place. The two biggest factors were the resident's observed clinical skill and the attending's own confidence with the operation.

Look at the word observed. Skill you have and they have not seen does not count. Reputation is just observed skill that travelled ahead of you.

The gap is not only in your head

It would be easy to read all of this as "residents are overconfident". That is not the full picture.

In one general surgery study, faculty and residents mostly agreed on how much autonomy a resident should have in each year. Then real operating room ratings came in. For all ten of the most common procedures, residents fell short of that shared expectation in at least one training year.

A larger study pooled 10,130 rated cases across 14 programmes. In the final six months of training, residents doing the five most common core operations were rated "supervision only" a third of the time.

Both of those are general surgery, not orthopaedics. But the shape is clear. Everybody agrees you should be doing more. It is not happening. Some of that is you, and some of it is not.

What trust looks like in the room

A national interview study spoke to 37 faculty and 59 residents about how entrustment actually builds during a case. Two of the themes were leadership opportunities for the resident, and a "safe struggle" when it is appropriate.

The same research group then built a tool to observe it live. Observers in the room scored five things: the type of questions asked, the operative plan, instruction, problem solving, and leadership.

How much the attending entrusted and how entrustable the resident looked moved almost in lockstep. The correlation was R² = 0.91. The attending's years of experience made no difference.

The authors read that as the attending's behaviour driving it. That is fair, and it was one institution. But notice that every one of the five is something you can show as well as receive.

A third study asked 38 residents how they actually got autonomy. They described three stages: build rapport, build trust both ways, then get handed the case. The strategies they named were smart communication, attention to attending preferences, helpful allies, and what the authors called visible attributes.

What this means on a Tuesday morning

• Say the plan before the case. Out loud, in order, with what could go wrong. The operative plan is one of the five things observers score. It is also the cheapest way to make preparation visible. Rehearsing the case the night before is how you get the plan into words.
• Ask for one step, by name. "Can I do the releases today?" is a question an attending can say yes to. "Can I do more?" is not. The orthopaedic study tracked five named steps. A named step is something you can both agree you did.
• Know this attending's version. Their order, their tools, the moment they usually take over. Attention to preferences was one of the four strategies residents named.
• Show your reasoning. "I am going to do this next, because of that" gives them something to judge. "What do you want next?" gives them nothing.
• After the case, ask one question. "What would you need to see before you let me do that step?" It turns "technical skill" from a verdict into a list.

The last answer is worth writing down the same day. Next time you scrub with that attending, it is the first thing you want to see.

OrthoVaultOS keeps a preference card for each attending and notes against each procedure. Put the step you asked for and what they said they need to see there. Then the ask is ready before the next case, not remembered halfway through it.