From Data to Dialogue: A Mixed-Methods Study of Resident Confidence and Knowledge Gaps in Adrenal Surgery.

OBJECTIVE: To evaluate general surgery resident competence in adrenalectomy using national case log data and qualitative resident feedback to identify actionable training gaps. DESIGN: A mixed-methods analysis of Society for Improving Medical and Professional Learning (SIMPL) national case evaluations and semistructured interviews with general surgery residents. SIMPL data included faculty- and resident-reported assessments of performance, autonomy, and case complexity for laparoscopic and open adrenalectomies. Logistic regression modeled predictors of competent performance and meaningful autonomy. Interview transcripts were coded using content analysis to identify themes related to perioperative knowledge and skill gaps. SETTING: SIMPL data for quantitative analysis came from a national database, and semistructured interviews took place at a single academic center. PARTICIPANTS: For quantitative analysis of SIMPL evaluations, participants included general surgery residents across all residency programs participating in the SIMPL system from 2015 to 2023. For qualitative analysis of semistructured interviews, participants included postgraduate year (PGY)-3 to PGY5 residents. RESULTS: A total of 317 adrenalectomy cases (265 laparoscopic, 52 open) were analyzed, including 225 residents who completed an average of 1.4 adrenalectomies each (SD = 0.84). Competent performance was observed in 41.7% of laparoscopic and 32.6% of open cases, while meaningful autonomy occurred in 37.4% and 13.5%, respectively. PGY5 residents demonstrated a 47.2% predicted probability of competent performance and 45.9% probability of meaningful autonomy. Agreement between resident and faculty ratings occurred in 45.9% of competency and 58.2% of autonomy assessments, with residents underestimating their performance in 44.1% of cases. Fourteen resident interviews revealed limited exposure to adrenal surgery, variability in intraoperative autonomy, and persistent knowledge gaps in postoperative management-particularly steroid replacement and long-term surveillance. CONCLUSIONS: General surgery residents infrequently achieve competence or autonomy in adrenalectomy by graduation and often underestimate their abilities relative to faculty assessments. Resident-reported data highlight insufficient longitudinal exposure and perioperative management knowledge gaps. These findings underscore the need for resident-informed training interventions and support the role of fellowship training for surgeons intending to perform adrenal surgery independently.