Research Article | | Peer-Reviewed

Assessment of Operative Experience of General Surgery Residents of Yekatit 12 Hospital Medical College, Addis Ababa, Ethiopia

Received: 2 April 2024     Accepted: 19 April 2024     Published: 14 June 2024
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Abstract

Background: The Zwisch Score is a recognized tool for objectively assessing resident competency, particularly in measuring faculty guidance. However, there hasn't been a study in Ethiopia yet to assess surgical residents' operative experience using this standardized objective method. Objective: To assess the operative experience of general surgery residents’ using Zwish score in Yekatit 12Hospital Medical College. Methods: A cross-sectional study design was employed, involving all general surgery residents enrolled in the residency program at Yekatit 12 Hospital Medical College from January 2020 to January 2023. Primary data collection utilized online shared questionnaires, with data entry and analysis conducted using SPSS. Result: In Yekatit 12Hospital Medical College, there are 18 Surgeons and 44 surgery residents. Senior residents tend to give junior residents scores of show and tell (33.3% for year 1, 50% for year 2), while year 1 residents most commonly rate themselves as providing active help (18.4%), and year 2 residents rate themselves as show and tell (59.3%). When comparing senior residents' scores with their own, seniors commonly rate themselves as providing passive help (30% for year 3, 65.4% for year 4), and residents rate themselves similarly (31% for year 3, 62.1% for year 4). Conclusion: There are variations between scores given by junior residents and seniors, but senior residents' self-assessments align closely with those of the seniors. This suggests that residents tend to accurately evaluate their skills as they progress through their residency.

Published in Journal of Surgery (Volume 12, Issue 3)
DOI 10.11648/j.js.20241203.14
Page(s) 83-91
Creative Commons

This is an Open Access article, distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution and reproduction in any medium or format, provided the original work is properly cited.

Copyright

Copyright © The Author(s), 2024. Published by Science Publishing Group

Keywords

Surgical Resident, Zwisch Score, Operative Experience, Resident Evaluation

1. Introduction
Surgical residency programs began in Germany in the late 1880s, later adopted by William Halsted in the US in 1889. Surgical education has evolved from exposure-based learning to structured curriculum. However, current discussions revolve around international concerns regarding work time constraints . Achieving sufficient operating volume and autonomy poses challenges for surgical residents. Each resident is expected to be actively involved and supervised during their operative experiences, maintaining a logbook monitored by the Department of Surgery education team to ensure fulfillment of requirements .
Assessing surgical residents objectively is challenging due to their varied operating experiences. The Zwisch score standardizes this assessment, reliably measuring operative autonomy. It consists of four stages. Show and tell, Active help, Passive help, and supervision only, indicating levels of resident autonomy and surgeon involvement during procedures. This model offers precise evaluations, identifies strengths and areas for improvement, and sets procedure-specific expectations across different postgraduate year levels .
In Ethiopia Uniform, simple evaluation methods for surgical residents across the country are lacking and this study employed questionnaires to assess Procedural Autonomy and Supervision System, aiming to evaluate resident performance based on the Zwisch scale with minimal workflow disruption.
2. Method and Materials
2.1. Study Area and Study Period
This study is conducted in Y12HMC, general surgery department which is found in the centre of the Addis Ababa, Ethiopia. The study was carried out between Jan 2022 to May 2023.
2.2. Study Design
Cross sectional study was conducted on operative experience of general surgical residents attending residency program at Y12HMC.
2.3. Source and Study Population
All surgical residents of Y12HMC attending residency program from Jan, 2020 to Jan, 2023 where considered as source and study population.
2.4. Inclusion and Exclusion Criteria
All general surgery residents of Y12HMC attending residency program from Jan, 2020 to Jan, 2023 were included in the study where as general surgery residents from other Hospitals and attaching residents from other departments were excluded from the study.
2.5. Study Variables
Dependent variables-Operative experience.
Independent variables-Sex, Year of residency, Specialty, Type of procedure, Complexity of procedure.
2.6. Operational Definition
Operative experience- The level of surgical skill of resident on handling surgical procedures measured by Zwisch score.
Surgery- Medical specialty that uses operative manual and instrumental techniques on a person to investigate or treat a pathological condition.
Surgical Resident- A doctor who has completed medical school and in active training for surgical specialty.
Resident Evaluation- The act of forming an opinion of the amount, value or quality of resident’s work or progress after careful follow up by the senior or by the resident him self.
Zwisch Score- scoring system used to evaluate Operative experience and Autonomy of Surgery resident in quantitative measure.
2.7. Data Collection and Quality Control
First training was given to the consultants and resident who were involved in the study. Data was collected using online questionnaires in English language. The questionnaires include questions about year of residency, the type of procedure done and Zwisch scoring of the surgical residents. The questionnaires were shared online to general surgical residents and the senior involved in the procedure after the end of each procedure in the OR and the questionnaires were filled in the OR, and the online filled questionnaires were collected by the data collector personnel. The principal investigator had ongoing supervision each day during data collection to ensure the quality of data by checking filled format for their completeness and consistency. And incomplete questionnaires are discarded.
2.8. Data Processing and Analysis
Once data completeness was ensured, it was inputted into SPSS Version 24 for analysis. Descriptive statistical methods were employed to ascertain frequencies, means, and standard deviations of both dependent and independent variables.
3. Results
There are 44 General surgery residents 11 in each year of residency from year one to year four in which 81.8% are male residents and 18.2% female residents. Eleven residents in each year of residency from year one to year four. There are 8 (18.2%) female surgical residents, two in each year of residency and 36 (81.8%) male residents (Table 1).
Table 1. Socio-demographic characteristics of general surgery residents of Y12HMC from January, 2020 to January, 2023.

Variable

Frequency

Percent

Sex

Male

36

81.8%

Female

8

18.2%

Year of residency

PGY 1

11

25%

PGY 2

11

25%

PGY 3

11

25%

PGY 4

11

25%

Age

< 30 years

14

31.8%

≥30 years

30

68.2%

There are a total of 18 Surgeons including General Surgeon 8, Urologic surgeon 3, Neurosurgeon 3, HBP Surgeon 1, Pediatrics Surgeon 2, and Cardiothoracic Surgeon 1 (Table 2).
Table 2. Number of attending physicians in Y12HMC and their specialty.

Specialty

Number

Percent

General Surgeon

8

44%

Urologic surgeon

3

16.6%

Neurosurgeon

3

16.6%

Hepatobiliary Surgeon

1

5.5%

Pediatrics Surgeon

2

11%

Cardiothoracic Surgeon

1

5.5%

Total

18

100%

The common procedures done during the study were open cholecystectomy 25.1% followed by Laparoscopic cholecystectomy followed by thyroidectomy and tissue hernia repair 8.8% each.
Table 3. Frequencies of surgical procedures done at Y12HMC during the study period that are filled on the questionnaire.

Surgical procedures

Frequency

Percent

Thyroidectomy

13

8.8%

MRM

9

6.1%

Open Cholecystectomy

37

25.1%

Laparoscopic Cholecystectomy

15

10.2%

Mesh Repair

7

4.7%

Orchidopexy

9

6.15

PPV ligation

12

8.1%

Colon REEA

2

1.3%

Colostomy reversal

3

2%

Tissue Hernia repair

13

8.8%

Hemorrhoidectomy

2

1.3%

Others

25

17%

Based on Zwisch scale for residents the commonest score given by the senior for year 1 resident is 1 (show and tell) 10 (33.3%). For year 2 residents the commonest score given by the senior is also 1 (show and tell) 15 (50%). For year 3 and 4 residents the commonest score given is 3 (passive help) 16 (30%) and 34 (65.4%) consecutively (Table 4).
Table 4. Year of residency with Zwisch scale of senior Cross tabulation.

Zwisch scale of senior

Total

1

2

3

4

Year of residency

1

Frequency

10

1

0

0

11

%

33.3%

2.4%

0.0%

0.0%

7.1%

2

Frequency

15

13

2

9

39

%

50.0%

31.7%

3.8%

28.1%

25.2%

3

Frequency

1

11

16

8

36

%

3.3%

26.8%

30.8%

25.0%

23.2%

4

Frequency

4

16

34

15

69

%

13.3%

39.0%

65.4%

46.9%

44.5%

Total

Frequency

30

41

52

32

155

%

100.0%

100.0%

100.0%

100.0%

100.0%

From theZwisch score given by the residents for themselves the commonest score given by year 1 residents is 2 (active help) 7 (18.4%). The commonest score given by year 2 residents is 1 (show and tell) 16 (59.3%). For year 3 and 4 it is 3 (passive help) 18 (31%) and 36 (62.1%) consecutively.
Table 5. Year of residency with Zwisch scale of resident Cross tabulation.

Zwisch scale of resident

Total

1

2

3

4

Year of residency

1

Frequency

4

7

0

0

11

%

14.8%

18.4%

0.0%

0.0%

7.1%

2

Frequency

16

10

4

9

39

%

59.3%

26.3%

6.9%

28.1%

25.2%

3

Frequency

2

8

18

8

36

%

7.4%

21.1%

31.0%

25.0%

23.2%

4

Frequency

5

13

36

15

69

%

18.5%

34.2%

62.1%

46.9%

44.5%

Total

Frequency

27

38

58

32

155

%

100.0%

100.0%

100.0%

100.0%

100.0%

From tables 4 and 5 It’s observed that comparison between senior and resident Zwisch score, when we see the score given by the senior to year 1 resident the commonest score is 1 show and tell (33.3%) but the score given by the residents for themselves the commonest score is 2 active help (18.4%). Comparison between senior score to year two resident the commonest score given by the senior is 1 show and tell (50%), the commonest score given by the year 2 residents to themselves is also 1 show and tell (59.3%). Comparison between senior and year 3 resident, the commonest score given by the senior is 3 passive help (30%) and the commonest score given by residents for themselves is also 3 passive help (31%). Comparison between senior and year 4 residents the commonest score given by the senior is 3 passive help (65.4%) and also the score given by the resident for themselves is 3 passive help (62.1%). And also this study shows that the procedures given score of 4 observation only mostly are done by year 4 residents (46.9%), followed by year 2 resident (28.1%) and followed by year 3 residents (25%).
Most of the procedures encountered by year 4, year 3 and year 2resident are average (59.4%, 58.3% and 43.6% respectively) for year 1 residents most of the procedures encountered are easy 81.8% in this case it should be remembered that year 1 resident are involved in less complex surgeries which is described below (Table 6).
Tabulatione shows that none of year 1 residents are given major t. And the commonest role for year two resident is as assistant resident (37.9%), for year 3 and year 4 residents the commonest role on surgical procedure is operating resident (28.1%) and (56.2%) respectively.
Table 6. Procedure Complexity Scale filled by Senior * Year of residency Cross.

Year of residency

Total

1

2

3

4

Procedure Complexity Scale filled by Senior

Average

Frequency

2

17

21

41

81

%

18.2%

43.6%

58.3%

59.4%

52.3%

Difficult

Frequency

0

8

4

9

21

%

0.0%

20.5%

11.1%

13.0%

13.5%

Easy

Frequency

9

14

11

19

53

%

81.8%

35.9%

30.6%

27.5%

34.2%

Total

Frequency

11

39

36

69

155

%

100.0%

100.0%

100.0%

100.0%

100.0%

Table 7. Year of residency and Role of resident Cross tabulation.

Role of resident

Total

Assistant Resident

Operating Resident

Year of residency

1

Frequency

11

0

11

%

16.7%

0.0%

7.1%

2

Frequency

25

14

39

%

37.9%

15.7%

25.2%

3

Frequency

11

25

36

%

16.7%

28.1%

23.2%

4

Frequency

19

50

69

%

28.8%

56.2%

44.5%

Total

Frequency

66

89

155

%

100.0%

100.0%

100.0%

The commonest procedure year 1 resident involved in from this study is PPV ligation (45%) followed by Orchidopexy (27.3%), The commonest procedure year 2 resident involved in from this study is Open cholecystectomy (25.6%) followed by laparoscopic cholecystectomy (23.1%) then PPV ligation (12.8%). The commonest procedure year 3 resident involved in from this study is open cholecystectomy (38.1%) followed by thyroidectomy and hernia tissue repair 11.1% each. The commonest procedure year 3 resident involved in from this study is open cholecystectomy (18.8%) followed by Thyroidectomy (15.8) followed by MRM (10%). The commonest procedures done by residents as operating resident are Open cholecystectomy (32.6%), Tissue repair (14.6%), MRM (9%), Thyroidectomy (6.7%) (Table 8).
Table 8. Procedure Name * Year of residency Cross tabulation.

Year of residency

Total

1

2

3

4

ProcedureName

Anatrophic Lithotomy

1.4%

0.6%

CBD Exploration

1.4%

0.6%

Chest tube insertion

9.1%

0.6%

Colostomy Reversal

4.3%

1.9%

Cystolithotomy

2.8%

0.6%

Debridement

1.4%

0.6%

FA Excision

1.4%

0.6%

Fistulectomy

1.4%

0.6%

Heller's Myotomy

1.4%

0.6%

Hemi thyroidectomy

2.9%

1.3%

Hemorrhoidectomy

2.9%

1.3%

Hydrocelectomy

2.6%

0.6%

Hypospadia Repair

9.1%

5.6%

1.9%

Ileostomy Reversal

1.4%

0.6%

Lap Cholecystectomy

23.1%

2.8%

7.2%

9.7%

Lipoma Excision

2.6%

1.4%

1.3%

MBR

4.3%

1.9%

Mesh Repair

5.1%

7.2%

4.5%

MRM

9.1%

2.8%

10.1%

5.8%

Multiple Ligation

2.8%

0.6%

Neck Mass Excision

2.8%

0.6%

NTT

1.4%

0.6%

Open Cholecystectomy

25.6%

38.9%

18.8%

23.9%

Orchiectomy

2.6%

2.8%

1.3%

Orchidopexy

27.3%

7.7%

8.3%

5.8%

Positive Margin Excision Post M

2.6%

0.6%

PPV Ligation

45.5%

12.8%

5.6%

7.7%

Pyloromyotomy

1.4%

0.6%

REEA

2.9%

1.3%

Roux en Y Choledochojejunostom

1.4%

0.6%

Roux en Y cystojejunostomy

2.6%

0.6%

Roux en Y Hepaticojejunostomy

1.4%

0.6%

RtHemi colectomy

1.4%

0.6%

STT

1.4%

0.6%

Thoracotomy and Bullectomy

2.6%

0.6%

Thyroid Lobectomy

2.9%

1.3%

Tissue Repair

7.7%

11.1%

4.3%

6.5%

Tracheostomy and Esophagostomy

2.8%

0.6%

TT

11.1%

7.2%

5.8%

TVP

2.9%

1.3%

UCF Repair

2.6%

0.6%

Varicose Vain Stripping

1.4%

0.6%

Total

100.0%

100.0%

100.0%

100.0%

100.0%

4. Discussion
This study shows the commonest score given by the senior to year 1 resident is 1, show and tell (33.3%) but the score given by the residents for themselves the commonest score is 2, active help (18.4%). Comparison between senior score to year two resident the commonest score given by the senior is 1 show and tell (50%), the commonest score given by the year 2 residents to themselves is also 1 show and tell (59.3%).
Comparison between senior and year 3 & 4 resident, the commonest score given by the senior is 3, passive help (30%) & (65.4%) and the commonest score given by residents for themselves is also 3, passive help (31%) & (62.1) respectively, so we can analyze that most of year 1 residents over estimate their surgical skill compared to the senior’s observation. For year two residents even though the highest score is the same compared with the senior the percentage of the score of the residents to score given by the senior is little bit higher so we can realize that some of year two residents over estimate their surgical skill compared the senior which is similar in some way to the finding in the study done at Northwestern University, Chicago, Illinois on which shows Resident and faculty expectations of resident operative autonomy were similar. For laparoscopic cholecystectomy, residents expected significantly more autonomy than the faculty did during the junior years but they agreed with the faculty for the chief year .
This finding is also similar to the result found on study done on Springfield, Massachusetts, USA which shows extremely close agreement on acceptance of credit (n=1,049 of 1,139; p <0.00001); where disparity existed, it was predominant in the first two postgraduate years (62% of 90 cases) .
This result is opposite to the finding on Study done at Harvard Medical School, Massachusetts General Hospital 46% trainees and faculty performance ratings were discrepant (r = 0.47), with 80% residents rating themselves lower than faculty in those cases .
The commonest procedure done on this study is open cholecystectomy 25.1% followed by Laparoscopic cholecystectomy followed by thyroidectomy and tissue hernia repair 8.8% each which is somehow comparable with the results found on Study done at Northwestern University, Chicago, Illinois The 10 most common procedures which include Laparoscopic cholecystectomy, Laparoscopic appendectomy, Open inguinal hernia, Wide local excision melanoma, Morbid obesity procedures, Hemorrhoidectomy, Thyroidectomy/parathyroidectomy, Laparoscopic partial colectomy, Simple excision soft tissue mass, Umbilical hernia accounted for 56.3% (827) of the cases .
Most of the procedures encountered by year 4, year 3 and year 2resident are average (59.4%, 58.3% and 43.6% respectively) for year 1 residents most of the procedures encountered are easy 81.8% in this case this result is comparable for year 2 residents to the result found on the study done on Springfield, Massachusetts, USA in 2007, which shows Sixty-five percent of procedures in the intermediate group were performed by first or second postgraduate year residents, in which this result is opposite for our year 1 residents .
This study shows through experience the residents analyze their actual experience and they are becoming more experienced on analyzing themselves.
From this study we can conclude that the responsibilities through different year of residency are appropriately distributed and senior residents are trained to be more independent and to handle procedures by themselves.
This study also shows the junior resident are being more exposed to laparoscopic surgery than the senior resident this shows that the advancement of Y12HMC surgical department on training surgical residents through the years.
5. Conclusion
Year 4 residents mostly receive observation-only scores, followed by year-two and year-three residents respectively. Senior residents commonly score junior residents as "show and tell" while year-one residents rate themselves as "active help" and year-two residents rate themselves as "show and tell". Seniors most often score themselves as providing "passive help", similarly, residents rate themselves likewise. Year 4, year 3, and year 2 residents mostly encounter average procedures 59.4%, 58.3%, and 43.6% respectively, while year 1 residents encounter mostly easy procedures (81.8%).
Abbreviations

CBD

Common Bile Duct

EC

Essential Common

EU

Essential-Uncommon

FACS

Fellow of the American College of Surgeons

FB

Fellow Bound

GI

Gastrointestinal

GS

General Surgery

GYN/OBS

Gynecology and Obstetrics

HERQA

Higher Education Relevance and Quality Agency

IP

Index Procedure

MD

Medical Doctor

MRM

Modified Radical Mastectomy

OR

Operating Room

PGY

Post graduate Year

QE

Qualifying Examination

REEA

Resection and End to End Anastomosis

SCORE

Surgical Council on Resident Education

TV

Truncal Vagotomy

UK

United Kingdome

USA

United States of America

Y12HMC

Yekatit 12 Hospital Medical Collage

Ethical Approval and Consent to Participants
Ethical clearance was obtained from the Institutional Review Board of Y12HMC (Protocol number 049/23; dated: 17/03/2022). Permission and written consent was taken from the college management. The information gained from the patients upon data collection was kept confidential by using codes for each card throughout the study. The procedures followed were by the ethical standards of the Helsinki Declaration.
Acknowledgments
We, the authors acknowledge all individuals involved in the comprehensive management of the patient. Furthermore, our gratitude extends to the administration of Yekatit 12 Hospital Medical College for granting permission to access and utilize the patients’ medical records in the preparation of this article.
Funding
There is no fund for this research article.
Data Availability Statement
All data supporting the case report is available with the crossspondance.
Conflicts of Interest
The authors declare no conflicts of interest.
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Cite This Article
  • APA Style

    Alemayehu, S., Mulatu, S., Amtataw, W., Endazenaw, G. (2024). Assessment of Operative Experience of General Surgery Residents of Yekatit 12 Hospital Medical College, Addis Ababa, Ethiopia. Journal of Surgery, 12(3), 83-91. https://doi.org/10.11648/j.js.20241203.14

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    ACS Style

    Alemayehu, S.; Mulatu, S.; Amtataw, W.; Endazenaw, G. Assessment of Operative Experience of General Surgery Residents of Yekatit 12 Hospital Medical College, Addis Ababa, Ethiopia. J. Surg. 2024, 12(3), 83-91. doi: 10.11648/j.js.20241203.14

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    AMA Style

    Alemayehu S, Mulatu S, Amtataw W, Endazenaw G. Assessment of Operative Experience of General Surgery Residents of Yekatit 12 Hospital Medical College, Addis Ababa, Ethiopia. J Surg. 2024;12(3):83-91. doi: 10.11648/j.js.20241203.14

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  • @article{10.11648/j.js.20241203.14,
      author = {Saron Alemayehu and Surafel Mulatu and Wondwossen Amtataw and Getabalew Endazenaw},
      title = {Assessment of Operative Experience of General Surgery Residents of Yekatit 12 Hospital Medical College, Addis Ababa, Ethiopia
    },
      journal = {Journal of Surgery},
      volume = {12},
      number = {3},
      pages = {83-91},
      doi = {10.11648/j.js.20241203.14},
      url = {https://doi.org/10.11648/j.js.20241203.14},
      eprint = {https://article.sciencepublishinggroup.com/pdf/10.11648.j.js.20241203.14},
      abstract = {Background: The Zwisch Score is a recognized tool for objectively assessing resident competency, particularly in measuring faculty guidance. However, there hasn't been a study in Ethiopia yet to assess surgical residents' operative experience using this standardized objective method. Objective: To assess the operative experience of general surgery residents’ using Zwish score in Yekatit 12Hospital Medical College. Methods: A cross-sectional study design was employed, involving all general surgery residents enrolled in the residency program at Yekatit 12 Hospital Medical College from January 2020 to January 2023. Primary data collection utilized online shared questionnaires, with data entry and analysis conducted using SPSS. Result: In Yekatit 12Hospital Medical College, there are 18 Surgeons and 44 surgery residents. Senior residents tend to give junior residents scores of show and tell (33.3% for year 1, 50% for year 2), while year 1 residents most commonly rate themselves as providing active help (18.4%), and year 2 residents rate themselves as show and tell (59.3%). When comparing senior residents' scores with their own, seniors commonly rate themselves as providing passive help (30% for year 3, 65.4% for year 4), and residents rate themselves similarly (31% for year 3, 62.1% for year 4). Conclusion: There are variations between scores given by junior residents and seniors, but senior residents' self-assessments align closely with those of the seniors. This suggests that residents tend to accurately evaluate their skills as they progress through their residency.
    },
     year = {2024}
    }
    

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  • TY  - JOUR
    T1  - Assessment of Operative Experience of General Surgery Residents of Yekatit 12 Hospital Medical College, Addis Ababa, Ethiopia
    
    AU  - Saron Alemayehu
    AU  - Surafel Mulatu
    AU  - Wondwossen Amtataw
    AU  - Getabalew Endazenaw
    Y1  - 2024/06/14
    PY  - 2024
    N1  - https://doi.org/10.11648/j.js.20241203.14
    DO  - 10.11648/j.js.20241203.14
    T2  - Journal of Surgery
    JF  - Journal of Surgery
    JO  - Journal of Surgery
    SP  - 83
    EP  - 91
    PB  - Science Publishing Group
    SN  - 2330-0930
    UR  - https://doi.org/10.11648/j.js.20241203.14
    AB  - Background: The Zwisch Score is a recognized tool for objectively assessing resident competency, particularly in measuring faculty guidance. However, there hasn't been a study in Ethiopia yet to assess surgical residents' operative experience using this standardized objective method. Objective: To assess the operative experience of general surgery residents’ using Zwish score in Yekatit 12Hospital Medical College. Methods: A cross-sectional study design was employed, involving all general surgery residents enrolled in the residency program at Yekatit 12 Hospital Medical College from January 2020 to January 2023. Primary data collection utilized online shared questionnaires, with data entry and analysis conducted using SPSS. Result: In Yekatit 12Hospital Medical College, there are 18 Surgeons and 44 surgery residents. Senior residents tend to give junior residents scores of show and tell (33.3% for year 1, 50% for year 2), while year 1 residents most commonly rate themselves as providing active help (18.4%), and year 2 residents rate themselves as show and tell (59.3%). When comparing senior residents' scores with their own, seniors commonly rate themselves as providing passive help (30% for year 3, 65.4% for year 4), and residents rate themselves similarly (31% for year 3, 62.1% for year 4). Conclusion: There are variations between scores given by junior residents and seniors, but senior residents' self-assessments align closely with those of the seniors. This suggests that residents tend to accurately evaluate their skills as they progress through their residency.
    
    VL  - 12
    IS  - 3
    ER  - 

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