See Article page XXX. Commentary: Supervised autonomy does no harm Danial Ahmad, MD, and Vakhtang Tchantchaleishvili, MD Escorel Neto and colleagues 1 present an important meta- analysis comparing outcomes between cardiac procedures performed by consultant/attending cardiac surgeons and those performed by trainees under their supervision. The authors found longer time on cardiopulmonary bypass (CPB) and longer aortic crossclamp time (AXC) but reduced mortality in trainee-led cases. The longer CPB and AXC time did not lead to longer lengths of stay. Other outcomes such as renal and sternal complications were comparable between the groups as well. 1 In essence, with their data the authors have added more evidence to the notion that supervised resident physician autonomy in the operating room does not translate to worse outcomes. 2,3 The results are also encouraging because they indicate that current and previous resident physicians have been able to safely operate under supervision. From this standpoint, longer CPB and ACX times likely represent sur- rogates of safety, implying that resident physicians are not being rushed to complete their tasks by potentially compro- mising on quality. Therefore, programs and attending phy- sicians should be encouraged to let resident physicians take on increasingly complex and leading roles in surgeries, pro- vided the trainees have been displaying increasing compe- tency (Figure 1). Simulation training may also enhance learning by equipping resident physicians with the skills necessary to take on greater roles in the operating room. 4 The responsibility is also on the trainees to utilize whatever resources are at their disposal to meet expectations in the operating room. This study also raises an interesting question about what a trainee-led case really is. There is discrepancy between programs relating to degree of resident autonomy and the type of cases they perform. The definition of autonomy Competent surgeons No patient harm Supervised resident autonomy Encourage programs Incentivize attendings FIGURE 1. Determinants and benefits of supervised resident autonomy. From the Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pa. Disclosures: The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. Received for publication Dec 21, 2021; revisions received Dec 21, 2021; accepted for publication Dec 22, 2021. Address for reprints: Vakhtang Tchantchaleishvili, MD, Division of Cardiac Surgery, Thomas Jefferson University, 1025 Walnut St, Suite 607, Philadelphia, PA 19107 (E-mail: Vakhtang.Tchantchaleishvili@jefferson.edu). J Thorac Cardiovasc Surg 2022;-:1-2 0022-5223/$36.00 Copyright Ó 2022 by The American Association for Thoracic Surgery https://doi.org/10.1016/j.jtcvs.2021.12.041 Competent surgeons No patient harm Supervised resident autonomy Encourage programs Incentivize attendings Determinants and benefits of supervised resident autonomy. CENTRAL MESSAGE Cardiothoracic surgery trainees can safely perform surgeries un- der attending supervision. This supervised autonomy is essential for training competent cardio- thoracic surgeons of the future. The Journal of Thoracic and Cardiovascular Surgery c Volume -, Number - 1 Ahmad and Tchantchaleishvili Commentary