Surgical trust is built over time, not by a single score

A broad review of 122 studies concludes that surgical supervisors rarely decide that a resident is ready to operate independently through one examination, checklist or procedure count. Instead, they build trust through continuous observation, prior knowledge of the learner, the quality of the supervisor–resident relationship and the circumstances of each case. The mapping study identified 31 assessment tools and frameworks, revealing a field that has shifted away from counting procedures toward judging competence but has not settled on a shared way to measure the decision that matters most: how much responsibility a resident can safely carry.

The scoping review, published in Global Surgical Education, searched PubMed, Embase, PsycINFO, Web of Science and Scopus for empirical studies examining how clinical supervisors assess residents’ readiness for independent surgical performance. The final database search was conducted in June 2024. After 2,727 records remained following removal of duplicates, 162 reports underwent full-text screening and 122 met the inclusion criteria. Qualitative and quantitative studies were both accepted, but the analysis was descriptive rather than a pooled estimate of effectiveness, and the authors did not formally appraise methodological quality.

Most of the evidence came from a narrow section of global surgical education. Eighty-eight and a half percent of the included studies were conducted in the United States, followed by Canada at 5.7 percent and the Netherlands at 1.6 percent, while the remainder came from New Zealand, Norway, the United Kingdom, Kenya and Ethiopia. General surgery and its subspecialties accounted for 64.7 percent of the literature, and 94 percent of studies did not integrate multiple surgical specialties. The findings therefore provide a detailed map of predominantly North American general-surgery assessment, but they should not be treated as a universal description of readiness across countries, specialties or training systems.

Quantitative methods dominated: 110 studies, or 90 percent, used quantitative designs, and 12 used qualitative interview methods. Three mixed-methods studies were classified with the assessment-tool literature. The tools could be grouped into five broad approaches: recording the level of supervision; combining supervision with summative or formative performance judgments; combining technical and non-technical skills with those judgments; combining tools with broader assessment frameworks; and asking supervisors for subjective judgments, often described in the review as “gut feeling.” One of the most frequently used instruments was the Zwisch Autonomy Scale, which grades progression from “show and tell” through “active help,” “passive help” and “supervision only.”

Other instruments sampled different parts of performance. SIMPLE combined a Zwisch-type supervision measure with ratings of performance and case complexity, while OpTrust and GOALS incorporated structured assessment of operative work. The Ottawa Surgical Competency Operating Room Evaluation, or O-SCORE, extended assessment to pre- and post-procedure planning, preparation, knowledge, technical steps, visuospatial ability, efficiency, flow and communication. Other systems targeted technical skills, such as the Objective Structured Assessment of Technical Skills and the Global Operative Assessment of Laparoscopic Skills, or non-technical skills through the Non-Technical Skills for Surgeons. A further group relied on thresholds for primary and autonomous primary operating, console time, whether the attending surgeon was scrubbed, or combinations of existing instruments with milestones and educational time-outs.

Although more comprehensive tools can capture facets of competence that brief autonomy scales miss, their value is constrained by practical conditions in clinical training. Operating-room schedules are pressured by limited staffing, restricted work hours, productivity demands and the need to maintain patient safety. Detailed assessments can also be burdensome when a supervisor must make decisions during a live procedure. The Zwisch scale is comparatively simple, which may explain its appeal, but simplicity also restricts the context that can be considered. More broadly, the authors caution that instruments created under one generation’s training norms may not age well as clinical practice, supervision patterns and the structure of residency work change.

The 12 qualitative studies offer the clearest account of how entrustment decisions are actually formed. Across these interviews, trust emerged as an ongoing, multidimensional and prospective process extending before, during and after surgery. Supervisors gathered information about medical knowledge, technical skill, communication, decision-making, prior operative experience and the resident’s general learning trajectory. Their judgments were often substantially formed before the procedure began, making a pre-case time-out more than a pause for safety checks: it could be an important point at which the attending surgeon decided how much autonomy to permit.

Observable behaviour then supplied cues for intervention. Hesitancy, lack of confidence, failure to anticipate the next procedural step, unsafe manoeuvres and bleeding were described as warning signs. At the same time, supervisors did not merely note errors. They looked for evidence that a resident could maintain control, communicate appropriately, make sound decisions and respond effectively when the case changed. These judgements were relational: familiarity with a resident, opportunities to practise without excessive direction, visible engagement in self-regulated learning and open discussion of educational goals could strengthen trust. The resident’s willingness to reason through a difficult step, rather than simply waiting for instruction, was itself relevant to the supervisor’s confidence.

The review also places entrustment within an organisational setting. Supervisors and residents occupy overlapping roles as learners, workers and teachers, while systems must balance education, patient safety and efficiency. Structural conditions, institutional culture, supervisor characteristics, the patient, the procedure and the current state of the relationship may all matter. The authors note a useful distinction between relatively stable factors, such as the clinical environment or supervisor’s characteristics, and dynamic factors, including the particular resident, patient, procedure and supervisor–resident relationship. This distinction helps explain why a single general score is unlikely to reproduce the full basis of a supervision decision.

Conceptually, the review separates four related ideas that are often used loosely. Trust is a supervisor’s belief that a resident can safely perform a task; entrustment is the decision to transfer responsibility for that task; autonomy is the freedom to act with limited supervision; and independence is performance without direct supervision. Trust may support entrustment, which can enable autonomy and eventually independent practice, but the terms are not interchangeable. The large number of instruments has not produced a shared operational definition of this progression. Instead, quantitative tools often capture isolated observations, while qualitative evidence indicates that the decisive judgment is cumulative, contextual and forward-looking. A future evidence review would need to assess the validity and reliability of the tools themselves, and future instrument development could incorporate longitudinal information rather than treating each operation as a self-contained test.

Subject of Research: Assessment of surgical residents’ readiness for independent operative performance

Article Title: Assessing surgical residents’ readiness for independent surgical performance: a scoping review

Article References: Hesseldal, K. B., Haug, T., Jensen, R. D., & Madsen, A. H. (2026). Assessing surgical residents’ readiness for independent surgical performance: a scoping review. Global Surgical Education – Journal of the Association for Surgical Education, 5(1), Article 205. https://doi.org/10.1007/s44186-026-00616-1

Image Credits: AI Generated

DOI: 10.1007/s44186-026-00616-1

Keywords: surgical education, surgical residents, clinical competence, operative autonomy, entrustment, resident assessment, surgical supervision, patient safety, scoping review, medical training, Assessing, surgical