153decision-making points of the procedure. The resident should be engaged in focused
observation and assists as the attending teaches:
- Instrument handling
- Exposure of pertinent anatomy and tissue planes
- Hand positioning with hand bracing and demonstration
- Tips and techniques
The resident should assist and anticipate the next steps of the procedure, verbal-
ize understanding, answer questions, and ask questions that demonstrate a higher
level of understanding.
Table 8.1 Model for teaching and assessment in the operating room [ 44 ]
Zwisch stage of
supervision Attending behaviors Resident behavior
Show and tell Performs majority of surgery
Narrates and articulates steps of
the case
Demonstrates key concepts,
anatomy, and skillsEngages as focused and active learner
First assists and observes
Opens and closesGraduating step Actively assists and anticipates
surgeon’s needs
Smart help Shifts between surgeon and
assistant
Leads resident as first assistant
when resident in surgeon role
Obtains and optimizes exposure
and identifies anatomical
landmark
Demonstrates planes and
structures
Coaches technical skills, next
stepsShifts between surgeon and assistant
Knowledgeable about all the
component technical skills
Demonstrates increasing ability to
perform key parts with attending
assistanceGraduating step Able to perform majority of steps
with attending assistance
Dumb help Assists and commits to follow
the lead of the resident
Coaches refining of techniquesAble to stage, set up, and accomplish
next step with increasing efficiency
Recognized critical transition points
Graduating step Can transition between all steps with
passive assistance
No help Monitor progress and patient
safety
Very little unsolicited adviceCan work with inexperienced first
assist
Safely complete procedure without
attending help
Can recover most errors
Recognizes when to seek help/advice8 Teaching in the Operating Room