Assessment of surgical autonomy: in support of aspirational goals

Drawing on key principles of adult learning theory, a number of surgical autonomy assessment scales have been developed for use in resident evaluation. These assessment scales allow graded autonomy in resident surgical education, balancing patient safety with the need for achieving resident competency during training. The main scales used, the Zwisch scale and the Dreyfus scale, differ only in the inclusion of an "expert" level, and there is controversy in surgical education on whether inclusion of these types of aspirational goals is appropriate. This clinical opinion article reviews key aspects of adult learning theory that pertain to surgical skill acquisition and use of aspirational goals in education, and situates existing surgical autonomy assessment scales within this context. Existing evidence argues for the continued inclusion of aspirational goals in surgical education, but with a concomitant update to the surgical autonomy assessment scales to more closely align with the typical progression of surgical skills during residency. The current process for milestone evaluation put forth by the Accreditation Council for Graduate Medical Education provides an example of a potential framework that could be adapted for use in surgical skill assessment.