Documenting Resident Progression towards Independence in the Operating Room

Jonathan Fryer, M.D.

Northwestern University

National recommendations have emphasized that “if residents are not provided sufficient independence or authority for patient care, they may be delayed in developing essential skills, particularly decision-making and technical skills, and may lack confidence in the competencies they have achieved.” (Josiah Macy Jr. Foundation 2011) Progression to independent operative competence is arguably the single most important criterion for determining if a surgical resident is ready to enter independent clinical practice. We developed a tool for documenting and monitoring residents’ stages of operative development throughout their residency. Our evaluation tool (referred to as “Zwisch”, named after its concept originator) is designed to assess the amount of supervision or guidance provided in the operating room.  Zwisch includes a four level supervision scale that describes progressive levels of autonomy. The first level, “show and tell”, occurs when the faculty surgeon performs the entire operation describing the steps and corresponding thought processes and sharing tips on technique while the trainee observes. In the second level, “active help”, the attending guides the resident through the procedure. The resident can perform many of the technical steps but requires significant guidance and intervention to hone technique and maintain the flow of the operation. The third level, “passive help”, occurs when the resident guides the flow of the operation, but still needs an experienced attending for assistance and guidance. The fourth level, “supervision only”, mimics independent practice and applies to surgical procedures that are performed entirely by the trainee. At this stage, the resident is capable of doing the operation with a less experienced assistant. The faculty surgeon is still present to supervise as appropriate, but remains quiet and only intervenes to give “fine tuning” tips or as needed for patient safety purposes.   This presentation will describe how the tool works and its potential applications at local, national, and international levels.