Trust, Autonomy, and Teaching Dynamics in Robotic Surgery: A Mixed Methods Study

Purpose Compared to open or laparoscopic surgery, the configurational relationship between trainer and trainee in robotic surgery reduces face-to-face interaction and ability to directly co-manipulate the surgical field. To elucidate the impact of this environment on surgical training dynamics, we conducted a mixed-methods study examining dyadic trust, autonomy, teaching, communication, and feedback in robotic surgery. Methods Robotic procedures performed on a dual console system at a single academic center were included. Trainee console operative time, representing autonomy, was extracted from the robotic system. Bidirectional trust was measured via a modified Leader Member Exchange (mLMX) questionnaire at the end of each case. Correlation between autonomy and trust was analyzed utilizing Pearson’s coefficient. Procedures were video- and audio-recorded, capturing both endoscopic view and a broad view of the operating consoles with trainer/trainee interactions. Two researchers performed thematic analysis of the synchronized video and transcribed audio. Results Nine robotic procedures in colorectal, general surgery, urology, and thoracic surgery were included. Trainee console time was directly correlated with average trainer mLMX trust scores (r=0.54) but not trainee scores (r=-0.19). Average trainer mLMX trust score was 4.08 vs. 3.16 (p=0.038) for trainees with >50% vs. <50% console time; trainee mLMX was not significantly different between the same groups (p=0.74). Thematic analysis revealed major themes of effective teaching techniques, feedback “escalation,” and trust-fostering behavioral strategies. Conclusion Higher trainer trust is associated with higher resident autonomy, and trainers/trainees can use specific strategies for teaching, feedback, and fostering trust in the robotic operating room. These findings may improve communication and trainee autonomy in the robotic operating room, and inform future robotic surgical educational curricula.