More Cases, Less Autonomy? The Paradox of Modern Orthopaedic Residency Training.

Orthopaedic residents may be logging more operations than prior generations, but concerns regarding their readiness for independent practice persist. This apparent contradiction reflects a limitation of case counts: participation does not measure autonomy, clinical ownership, judgment, or the ability to manage complications. The COVID-19 pandemic exposed the vulnerability of surgical training, but declining operative autonomy predates the pandemic. Simultaneously, reimbursement pressure, throughput demands, expanding team-based care, and increasing subspecialization have changed how residents encounter patients and operations. A consequence is increasingly apparent in fellowship, where faculty may need to teach foundational surgical skills before they can teach the intended nuances of subspecialty practice. These changes are not inherently harmful, but without deliberate educational design, they can remove experiences that convert exposure into competence. Case counts should be supplemented by competency-based measures of entrustment, autonomy, and longitudinal clinical ownership. Residency should ultimately be judged by whether graduates can independently evaluate, operate on, and longitudinally care for appropriate orthopaedic patients, with fellowship reserved for subspecialty refinement rather than completion of core surgical training.