How to Be a Good Assistant

It was Friday and I was a chief resident with only a month left. My senior attending stood opposite me, silently assisting while I sutured in a mesh. Finally, he broke the silence: “You know you’ll never be as good as you are right now.” I chuckled. “Because when you graduate, you’ll never have me on the other side of the table.” I knew he was right. Exactly four months later, opposite a brand-new scrub tech, I thought of that conversation.

I would guess that these conversations take place every spring, echoes of the original exchange between William Halsted and his promising chief resident, Harvey Cushing. It so perfectly illustrates the life cycle of surgeons who teach surgeons. At the beginning of their training, interns know to ask for the retractor. It’s their instrument of learning; with it, they demonstrate that they can see what needs to be seen. Then there comes a moment when they ask for the scalpel instead. It’s their time. At the completion of a surgeon’s metamorphosis, they’ll once again ask for the retractor, finally realizing that it’s an instrument of learning and teaching.

The process of surgical education is vast and complex, and interesting. But it’s also tricky business. What happens across the table is nuanced, subjective, individualized, and yet programs are littered with models and metrics to standardize something, anything. While standardization can minimize risk and increase efficiency, it cannot capture and certainly cannot quantify the exchange of knowledge and experience that takes place during surgery. There is no substitute for consistency and investment on the part of both residents and faculty.

There are so many intangible nuances in surgery that resist standardization. But it’s these nuances that bring an art to surgical education and allow for creative teaching. As a young attending, I wanted to share some thoughts that I hope will generate conversation. For every resident and every operation, I consider three things:

1. Find and create discomfort. Learning to work through discomfort in the OR produces personal and professional growth. The role of autonomy in training is to find the right balance between creating stress and ensuring patient safety.
2. Break down operations into their components and slowly rebuild them. This means understanding the individual parts and how they create the whole. When residents learn to think of operations as a sum of its parts, their toolbox becomes more than just a list of surgeries.
3. Teach principles and not products. I am less interested in what brand name the resident wants, and much more interested in why they want a permanent suture or composite mesh.

PGY-1: ‘The Uncomfortable One’

When I was an intern, I was told that to be a good surgeon, I had to first be a good assistant. Good first assists are capable, teachable, and proactive—all traits that require skill and knowledge. An intern’s role in the OR can vary considerably, ranging from observer to primary surgeon. Years ago, the American Board of Surgery proposed using the Zwisch scale to help describe appropriate levels of staff involvement. The first year is aptly described as “show and tell.” My role is to ensure the intern sees what I see and feels what I feel. I talk constantly during these cases, verbalizing my inner monologue so I can give them insight into surgical decision-making. I ask them questions that lead into teaching points. “What do you worry about during this dissection?” Their contribution to the case is on the magnitude of tasks, such as “tie this” or “Bovie here.” Since the very act of operating is uncomfortable for them, I don’t think much about creating stress for this group. I just want them to be present and engaged.

PGY-2: ‘The Cautious One’

In the second year of training, residents are ready for higher level thinking. This is usually the first time they have their own room and get one-on-one time with faculty. The phrase “you don’t know what you don’t know” applies particularly well to this group. Coming out from under the weight of updating lists and discharging patients, they’re exposed to just how much knowledge they need to know. They are eager but struggle with where to focus (“cannot see the forest through the trees”). I think that these residents benefit most from discussing cases ahead of time, and I often start by asking them what part of the operation they want to focus on. That lets me know when to alternate between “operating speed” and “teaching speed.” As opposed to my interactions with interns, I try to not talk the entire time. In fact, I’ve found that creating stress or discomfort for this group is as easy as being silent. This forces them to consider which instrument to ask for, or what step is next as they translate a memorized dictation into real life. They naturally operate slowly, which is good. They have no concept of tissue handling, like how much tension with which to retract the gallbladder. I rarely bring up the topic of efficiency.

PGY-3: ‘The Frustrated One’

This is the year they put it all together. In the 1970s, Noel Burch from Gordon Training International created the Conscious Competence Ladder. When mastering a new skill, learners move from unconsciously to consciously unskilled, then from consciously to unconsciously skilled. PGY-3s, especially early in the year, are consciously unskilled. They are competent, but not efficient. They know the steps but struggle to seamlessly connect them. These limitations, combined with bigger cases and increased autonomy, create frustration.

Consider that for any skill or trade, there are two types of mastery: academic and experiential. Academic mastery is a product of will, not time. Residents who pore over surgical texts and journals will excel above their peers. Experiential mastery is a product of time, and not will. Spending hours memorizing images from Zollinger’s will not translate to the OR. It helps, but there’s no substitute for time operating. Experiential mastery requires experience and experience requires time—more time than just three years.

I have found that this group of residents will often use speed as a surrogate for experiential mastery; they operate quickly to demonstrate that they know how to perform the surgery. The old adage “slow is smooth and smooth is fast” applies well here. Creating discomfort means allowing them to sit with their inefficiency and struggle. The stress they feel comes from knowing what needs to be done, but not being able to do it. This is the year to talk about efficiency. “Why didn’t that movement work for you?” Instead of their dozen small spreads, what they really want to do is one well-placed spread. And that usually involves slowing down.

PGY-4 and -5: ‘The Comfortable One’

This is, far and away, the most difficult group to generalize. The Zwisch scale would associate this group with “supervision only.” Nearing the end of training, senior residents are generally capable of performing most cases independently, and even teaching them to interns or juniors. By this point, they understand the sequence of steps and can put everything together. They are generally efficient. They know the pitfalls to avoid. All in all, they are comfortable in the OR, and it can be more challenging to create discomfort.

To start, I ignore my case card. I want to know how they would do the operation. At this point, they’re building a practice pattern, and my role is to ensure that they can do it safely. Building the preference card shifts ownership of the case to them. Next is the question of autonomy. I ask myself, “How can I safely create discomfort for this particular senior resident?” For some, it means I sit on a stool in the corner. For others, I catch up on notes in my office. Of interest, teaching an intern or junior can be a safety net for chief residents. I would rather they do the case with a scrub tech since this will force them to think outside of the operation. I’ve discovered I can move the operation forward or give a word of caution just by talking with the medical student or intern. “See how the chief is taking small bites with the needle. What do you think is behind that? … The next thing they’re going to be looking for is the nerve.” I highly recommend this strategy. It lets me give input into the case while preserving autonomy and teaching the students. The trifecta.

It would be impossible to cover every practical and esoteric aspect of residency education. Instead, I chose to share some of my observations as I ease into this phase of my career. To that end, I obviously created generalizations even though this process is highly individualized. I am certainly not an expert. I prefer to think of myself as a surgeon learning how to become a better assistant.

Dr. Halgas is a general and burn surgeon in San Antonio. He is currently completing a fellowship in hand surgery.