American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

The Language of Progressive Autonomy: Using the Zwisch Scale for More Than Just Assessment

Dr. GeorgeA recurring complaint among surgical residents is the lack of autonomy they achieve in the operating room. Sometimes this viewpoint represents unrealistic expectations on the part of the residents, but more typically it reflects a genuine concern about their readiness for independent practice. This same concern is now being voiced at the national level by surgical educators1,2, many of whom share the residents’ concerns about diminished resident operative autonomy.

There are many barriers to achieving meaningful resident autonomy in the operating room. The most obvious is a concern for patient safety, which must always remain paramount. But even with that consideration, there are other elements that can be improved. One element, faculty teaching skills, is the topic of this article.

I present here a framework for teaching faculty how to safely grant more autonomy to residents. The framework provides both faculty and residents a lexicon with which to discuss the expected role of the resident in an upcoming case. It also provides a structure that faculty can use to adjust their guidance behaviors during a case. And the same framework also provides residents with a roadmap for how they should be progressing during training.

This framework is based on the “Zwisch” scale, a conceptual model that was originally used by Joseph Zwischenberger, MD, FACS, a thoracic surgeon and the chair of the department of surgery at the University of Kentucky3. This model has been refined over the past several years, and now consists of four levels named “Show & Tell,” “Active Help,” “Passive Help,” and “Supervision Only.” Each level describes the amount of guidance provided by faculty to residents:

Zwisch Scale Level

Attending Behaviors

Resident Behaviors

Show & Tell

Performs >50% of critical portion; demonstrates key concepts, anatomy, and skills; explains case (narrates)

Opens and closes; observes and listens during critical portion

Active Help

Leads the resident (active assist) for >50% of the critical portion; optimizes the field/exposure; demonstrates plane/structure; coaches technical skills; coaches next steps; identifies key anatomy

The above, plus actively assists (i.e. anticipates surgeon’s needs); practices component technical skills

Passive Help

Follows the lead of the resident (passive assist) for >50% of the critical portion; acts as a capable first assistant; coaches for polish, refinement of skills, and safety

The above, plus can “set up” and accomplish next steps; recognizes critical transition points

Supervision Only

Provides no unsolicited advice for >50% of the critical portion; monitors progress and patient safety

The above, plus mimics independence; can work with less experienced assistant; can safely complete case without faculty guidance; recovers from most errors; recognizes when to seek advice/help

You may already be familiar with the BID Model which describes three phases of operative teaching: Briefing, Intra-operative Teaching, and Debriefing4. The Zwisch scale can be used in each of those phases.

Briefing: This phase occurs before the case and is typically a short interaction between learner and teacher. The purpose of the briefing phase is to “assess the needs of the learners, to cause the learner to assess her own learning needs, and to jointly establish learning objectives to guide both learner and teacher.” The Zwisch scale can help with all of these elements. While a learner may have several learning goals specific to that case, a universal goal is for the trainee to make progress towards safe independence. This goal can and should be explicitly discussed for every case. To do so, the teacher and learner can use Zwisch to identify the trainee’s prior requirements for guidance with similar cases and to set expectations around guidance for the case they are about to do. For example, if the resident is hoping to do a certain portion of the case, I talk explicitly about how much guidance the resident should expect. This assessment is based on numerous factors, including their prior experience, skill, and how much trust I have in them. We might also discuss which Zwisch levels are appropriate for different parts of the case, effectively negotiating a teaching plan that we can use to reduce friction and improve learning in the operating room.

Intra-Operative Teaching: While doing a case, the focus of most of the didactic talk should be the learning objectives defined during the briefing phase. Since all learners should be attempting to make incremental progress towards safe independence, the teacher can use the Zwisch language to identify those behaviors that accord with higher or lower Zwisch levels. It can also provide the teacher with a framework for selecting level-appropriate teaching behaviors. For example, while I always plan to target my guidance to the highest Zwisch level that does not compromise patient safety, I often find it challenging to relinquish control (i.e. teach at a higher Zwisch level). Keeping the target Zwisch level in mind helps me to remember the guidance behaviors appropriate to that learner and to regulate my own behavior. For those times when a resident needs more guidance than the original target, I explicitly tell them that I am temporarily switching levels and I explain why. While they are rarely happy to lose autonomy I find that using the language of Zwisch facilitates a rapid recalibration of expectations.

Debriefing: After the operation is finished the teacher and the learner should discuss the case, ideally in reference to the goals set out during the briefing phase. This debriefing conversation should consist of four elements: reflection, rules, reinforcement, and correction. Zwisch is useful here, too. Since at least some of the briefing goals should be related to guidance (i.e. Zwisch level), you can ask the learner to reflect on whether they achieved the expected Zwisch level. Either way, the teacher can highlight and reinforce those general rules that help the trainee progress towards safe independence. I also typically discuss specific skills the learner needs to improve in order to move up a Zwisch level.

The most important way to support progressive resident autonomy in the operating room is to get the faculty and residents talking about it. The Zwisch scale provides a language with which to have that conversation.