155surgery. The attending should assume the first assist role with the expectation that the
surgeon’s role is for the resident unless the attending can anticipate the development
of a problem. The coaching from the attending is fine adjustments of techniques,
alternative techniques, and taking note of teaching points and feedback.
The resident at the beginning levels of this stage that is goal oriented however
still relies on the passive actions of a skilled assistant in the attending. The resident
needs to lead the case, ask for appropriate instruments, set up adequate exposure,
anticipate needs, and communicate with operating room team regarding specimen,
medications, etc. In order for residents to take full advantage of the learning in this
stage, the attending needs to fight the temptation of continuous verbal and techni-
cal feedback. The residents should be allowed to safely struggle, refine their tech-
niques, and practice their problem-solving skills to gain confidence in their
abilities.
The resident need not only complete the requisite tasks but also be able to criti-
cally think through key transition points and guide the progress of the surgery.
When the resident is able to accomplish this with minimal input from attending,
then the graduating step has been reached.
No Help Stage [ 44 ]
The needs assessment of a resident at this stage would indicate that the resident is
able to perform the procedure independently without help. The resident may at this
stage advance into a teaching role for a junior resident. The attending does not need
to actively participate but be present. The coaching would be limited to refining
technique and reviewing higher levels of understanding, generating hypothesis, and
advanced treatment planning.
Limitations here would be that the no help stage may not be applicable to some
major operative cases. For example, we would not expect nor allow our residents
to perform a radical nephrectomy and caval thrombectomy independently. These
types of surgeries may incorporate various stages at different phases of the proce-
dure. The resident may be in “no help” phase during exposure of the retroperito-
neum, “dumb help” for lateral and inferior mobilization, “smart help” for hilar
dissection, and maybe “show and tell” for caval thrombectomy. Obviously, these
can vary.
Expectations in the operating rooms are often not stated. There is data that sup-
ports that often expectations of residents don’t match with expectations of attending
surgeons [ 46 ]. Residents often feel they don’t get enough feedback or that their
attendings “hog” the case so they don’t get enough independence to advance.
Attendings feel residents are too indifferent, come ill prepared, and don’t under-
stand the value of learning by observation and in stages.
An approach that assesses needs, sets expectations, follows an instructional
model which is clear, standardizes the vocabulary, and values the learning environ-
ment can align all involved toward patient safety and excellent training.
8 Teaching in the Operating Room