Teaching in the OR: New lessons for training surgical residents

“See one, do one, teach one” has been the principle applied in passing down operative techniques from one generation to the next for decades. Learning in this manner, known as the Halstedian training model, the surgeons who now serve as mentors to the present generation of surgery residents were able to accept increased responsibility in the operating room (OR) as they progressed through their years of training.1

For the past decade, however, changes in surgical residency have brought to light the need for innovative teaching methods in the OR. Today’s residents are seeing a greater variety of surgical procedures during their training—for example, operative volume for graduates increased 21 percent from 2005 to 2010.2 Nonetheless, the number of specific operations performed more than 10 times during residency has not changed.2

The evolution in surgical education has raised concerns about whether residents have sufficient time to master surgical techniques. A national survey published in 2009 highlighted these concerns, indicating that 27.5 percent of residents are concerned they will not feel confident performing procedures independently once in practice, which was magnified by the implementation of duty-hour regulations in 2003 and again in 2011 by the Accreditation Council for Graduate Medical Education.3 This imbalance between the increased scope of education and a reduced number of work hours in which to provide this training highlights the need for more efficient and structured intraoperative teaching by faculty surgeons.4,5 A variety of different educational strategies, each implemented with the aim of updating operative skills assessment and instruction, have recently been described in the literature. Effective use of these novel educational tools by surgical educators may serve to improve the quality and efficiency of intraoperative resident education.

Preoperative briefing, postoperative debriefing

The utility of briefing and debriefing tools in the OR has been well established, both in quality improvement endeavors and as a means of promoting a culture of safety in surgery.6-8 Additionally, this strategy has value as an educational tool. The preoperative briefing and postoperative debriefing educational model has been shown to vastly improve the intraoperative learning experience for surgical trainees when combined with residents’ preoperative identification of learning objectives.4 Clearly identifying learning objectives before a case and integrating them with educational briefings and debriefings facilitates a guided learning process for the trainees, as well as a structured, targeted teaching model for the surgeon.

A study published in 2013 specifically examined the effect that incorporating perioperative briefings and debriefings into surgical education and training had on achieving previously identified resident learning goals. This study, which used direct observation within the OR as well as pre- and post-implementation surveys from resident learners, demonstrated a significant change in communication styles between faculty and learners. Also observed was a decrease in idle and unstructured conversation between the learner and educator in operative cases.4

Before the initiation of briefing and debriefing interventions, surgical residents in this study of 263 operative cases reported a significantly higher frequency of faculty description of procedural steps and evaluation of their personal performance. When comparing baseline communication styles with those used after the initiation of briefings and debriefings, there were significantly increased observed demonstrations of surgical techniques (from 45.2 percent to 88.4 percent), encouragement of trainees (48.4 percent to 76.8 percent), use of nonverbal teaching (from 3.2 percent to 23.2 percent), warnings given (from 24.2 percent to 75.8 percent), and use of constructive feedback (from 33.9 percent to 63.2 percent).4 Following implementation of this teaching model, surveyed trainees were significantly more likely to agree with the following statements about the attending surgeon: “describes steps if I am unfamiliar with steps,” “asks me to describe critical/key points,” “provides frequent verbal feedback,” “provides frequent nonverbal feedback,” “confirms I understood the procedure,” and “provides clear feedback on my performance.”4

In an unstructured environment, trainees inconsistently recognize educational experiences.9 Preoperative self-identification of learning objectives reminds the trainees of specific tasks to work toward successfully completing. In addition, discussing these goals preoperatively with faculty reinforces their role during the instruction process. Combining structured educational briefings and debriefings with preoperative resident identification of learning objectives focuses faculty on resident needs and reinforces to the resident what he or she needs to learn.

The Zwisch model

Joseph (Jay) Zwischenberger, MD, FACS, developed a model at the University of Kentucky, Lexington, to aid in the training and assessment of his residents to achieve operative independence.10 The goal of the so-called Zwisch model is to provide both faculty and residents with specific stages of supervision allowing for adequate, safe training in a graduated manner to develop fully trained surgeons.

The four stages of the Zwisch model of supervision are as follows:10

  • Show and tell
  • Smart help
  • Dumb help
  • No help

Each stage identifies the manner in which the attending surgeon behaves and teaches during the case, as well as the expectations of the operating resident. In the show-and-tell stage, the attending surgeon performs the critical portions of the operation while explaining each step to the resident. The smart help stage involves the attending surgeon actively guiding the resident through the critical portions of the procedure. In the dumb help stage, the resident performs critical portions of the operation independently while the attending surgeon passively provides skilled assistance, intervening only when necessary. At the most advanced level, the no help stage, the attending surgeon is present only to guarantee patient safety while the resident performs the operation independently with a less-skilled assistant. (See Table 1.10)

Table 1. The Zwisch model

Zwisch stage Attending surgeon behaviors Resident learner behaviors
Show and tell
  • Performs key portions of procedure
  • Narrates the case (“thinks out loud”)
  • Demonstrates key steps and anatomy
  • Performs opening and closing of procedure
  • Acts as first assistant and observes procedure
Smart help
  • Shifts roles between surgeon and first assistant
  • When first assisting, leads resident in surgeon role
  • Optimizes the field and exposure
  • Coaches on next steps of procedure
  • Shifts roles between surgeon and first assistant
  • Demonstrates increasing ability to perform key steps of procedure with attending assistance
  • Is knowledgeable of all the component technical skills
Dumb help
  • Follows lead of the resident
  • Coaches regarding refinement of technical skills
  • Accomplishes the next step of the procedure with increasing efficiency
  • Recognizes critical transition point issues
No help
  • Provides no unsolicited advice
  • Monitors progress
  • Ensures patient safety (as during all stages)
  • Performs the procedure with an experienced first assistant
  • Safely completes the procedure without faculty
  • Recovers from most errors
  • Recognizes when to ask for help or advice

Adapted from: DaRosa DA, Zwischenberger JB, Meyerson SL, et al. A theory-based model for teaching and assessing residents in the operating room. J Surg Educ. 2013;70(1):24-30.

A major benefit of the Zwisch model is the simplicity with which it can be implemented and used to train and assess residents in the OR. In fact, many attending surgeons may feel they already use this teaching modality. Additionally, since the publication of the Zwisch method in 2013, other studies have shown the benefits of using this model in assessing residents, residency programs, and faculty development.10-12 In particular, this tool can provide residents with a specific measurement of their expected level of competence for a specific operation. It allows assessments to be more concrete, thus pointing out residents’ strengths and potential areas of improvement. It also can be used as a method of resident evaluation, as procedure-specific expectations for certain Zwisch stages can be established for each postgraduate year level.

As mentioned previously, the Zwisch model also may be used for faculty development through analysis of faculty consistency and adjustment of behavior in the OR depending on a resident’s stage.10 This model provides faculty with a structured means of teaching in the present-day culture that emphasizes increased productivity, litigation concerns, and patient safety regulations. Additionally, attending surgeons may appreciate a sense of accomplishment by systematically witnessing a resident’s progress from internship to their chief year using this model.

Teachable moments

Identifying specific learning objectives before operative cases is helpful in maximizing surgical education. However, many opportunities for education are unplanned. These teachable moments may arise from either technical errors by the learner or demonstrated knowledge deficits within the case.13 When these events occur, the resultant interactions between teachers and learners may take on a variety of forms. Some interactions focus on correcting learner actions, thereby ensuring a successful patient outcome, while other interactions focus on improving a learner’s knowledge base or understanding of a case.

A recent study by Roberts and colleagues sought to optimize operative teaching opportunities by looking specifically at how surgeons interact with residents during an operation.13 In this study, intraoperative verbal communication was observed during four videotaped surgical procedures. Each of the 1,306 observed interactions was categorized into one of four main types: instrumental, pure teaching, instrumental and teaching, and banter.

Interactions were described as instrumental when their purpose was solely to move the operation forward successfully. This descriptive name is derived from the sociologic concept of instrumental action, which centers on how behaviors, needs, and perceptions are shaped by specific goal-directed activities.14 With this form of interaction, educators make specific requests of the learner that, when performed, will result in a positive patient outcome. The burden here, though, is on the resident to translate these specific tasks into a broader understanding of surgical technique and decisions. These discrete, goal-oriented interactions were viewed as the most basic level of instruction.13

Conversely, pure teaching represented the opposite extreme of observed interactions. These communications provided education to the trainee, shaped judgments, or enhanced resident performance without directly affecting the outcome of the current surgical case.13 In instrumental and teaching interactions, educators balance both approaches in one exchange. These interactions provide specific instruction germane to the case at hand but also support the instruction with a broader explanation of the situation. Such a strategy moves a case forward and also increases the resident’s broader understanding of the operation. This combination of directed action with accompanying explanation increases the likelihood of that experience producing long-term changes to the learner’s thinking and practices.13 Banter, described in this study as discussion unrelated to the operation or disease process, may at first appear less educational than other intraoperative interactions. However, banter can humanize the parties involved in the case, thereby creating an environment that is more conducive to both teaching and learning.13

Most teaching events were prompted by resident performance errors.13 High-acuity situations often demand instrumental interactions without additional communications to ensure patient safety. Banter and pure teaching help to set the tone in the OR and provide lasting educational lessons, respectively. Being mindful of these different forms of operative interactions and striving to balance their use can enhance the learning experience in the OR.

Operative performance assessments

A variety of rating scales, procedure-specific checklists, and indices of surgical competency have been developed in the last few decades and provide a standardized means of assessing learner performance. Examples include the Objective Structured Assessment of Technical Skills and the Global Operative Assessment of Laparoscopic Skills.15

Although many assessment scales focus primarily on technical skills, the mark of a proficient surgeon includes not only mastery of the technical elements but also an ease and efficiency of movement and a situational awareness that promotes the efficiency of the entire surgical team. Therefore, scoring systems, which aim to evaluate overall surgical competence and incorporate all of these elements, are an ideal tool for this setting. One example is the Ottawa Surgical Competency Operating Room Evaluation (O-SCORE), which evaluates residents’ pre-procedure plan, case preparation, knowledge of specific procedural steps, technical performance, visuospatial skills, post-procedure planning, efficiency and flow, and communication with the surgical staff. When this tool was piloted in the division of orthopaedic surgery at the University of Ottawa, ON, faculty indicated that the tool made trainee assessment easier. Post-hoc analysis proved that the tool was able to differentiate between junior and senior residents, thereby validating the model.16 As objective measures of resident competence become increasingly important in education, models such as the O-SCORE may take a central role in resident assessment and teaching.

Video-based assessments

Video-based post-procedural analyses of residents’ operative performances provide yet another method for assessing residents’ surgical competence and for providing instructive feedback. Video assessments add flexibility to both the evaluation and the instruction process. Skills, performance, and operative technique may be viewed and rated at a later date, allowing for more extensive debriefing and analysis.

A video assessment system has been implemented recently at a tertiary care training institution in Pennsylvania. In this model, residents are videotaped while performing selected index cases. Feedback is given in the form of two separate rating systems, assessing both the residents’ performance and level of autonomy in the OR using the Zwisch model, as well as nontechnical criterion including situational awareness, decision making, communication and teamwork, and leadership.10,17 Such models, which evaluate multiple aspects of overall surgical competence, are another way to facilitate resident development.


Surgical training and education has evolved substantially over the last several decades in response to new technologies, regulations, and practices. In an effort to address these changes, a multitude of teaching and assessment methods were created to maximize teaching opportunities in the OR. Educators and institutions that embrace these new methods of teaching place themselves in an optimal position to train the next generation of surgeons. Each of these methods varies in terms of focus and mode of implementation, but they all share a common goal of maximizing the development of the surgical resident by encouraging proficiency in surgery.


  1. Polavarapu HV, Kulaylat AN, Sun S, Hamed OH. 100 years of surgical education: The past, present, and future. Bull Am Coll Surg. 2013;98(7):22-27. Available at: bulletin.facs.org/2013/07/100-years-of-surgical-education/. Accessed April 16, 2015.
  2. Malangoni MA, Biester TW, Jones AT, Klingensmith ME, Lewis FR Jr. Operative experience of surgery residents: Trends and challenges. J Surg Educ. 2013;70(6):783-788.
  3. Yeo H, Viola K, Berg D, et al. Attitudes, training experiences, and professional expectations of U.S. general surgery residents: A national survey. JAMA. 2009;302(12):1301-1308.
  4. Anderson CI, Gupta RN, Larson JR, et al. Impact of objectively assessing surgeons’ teaching on effective perioperative instructional behaviors. JAMA Surg. 2013;148(10):915-922.
  5. Nasca TJ, Day SH, Amis ES Jr, ACGME Duty Hour Task Force. The new recommendations on duty hours from the ACGME Task Force. N Engl J Med. 2010;363(2):e3.
  6. Kwok AC, Funk LM, Baltaga R. Implementation of the World Health Organization surgical safety checklist, including introduction of pulse oximetry, in a resource-limited setting. Ann Surg. 2013;257(4):633-639.
  7. Hicks CW, Rosen M, Hobson DB, Ko C, Wick EC. Improving safety and quality of care with enhanced teamwork through operating room briefings. JAMA Surg. 2014;149(8):863-868.
  8. Kuy S, Romero R, Cypher E. Shreveport: A success story. U.S. Department of Veterans Affairs. Available at: www.patientsafety.va.gov/features/Shreveport_A_Success_Story.asp. Accessed June 4, 2015.
  9. Butvidas LD, Anderson CI, Balogh D, Basson MD. Disparities between resident and attending surgeon perceptions of intraoperative teaching. Am J Surg. 2011;201(3):385-389.
  10. DaRosa DA, Zwischenberger JB, Meyerson SL, et al. A theory-based model for teaching and assessing residents in the operating room. J Surg Educ. 2013;70(1):24-30.
  11. George BC, Teitelbaum EN, Meyerson SL. Reliability, validity, and feasibility of the Zwisch scale for the assessment of intraoperative performance. J Surg Educ. 2014;71(6):e90-e96.
  12. Meyerson SL, Teitelbaum EN, George BC, et al. Defining the autonomy gap: When expectations do not meet reality in the operating room. J Surg Educ. 2014;71(6):e64-e72.
  13. Roberts NK, Brenner MJ, Williams RG, Kim MJ, Dunnington GL. Capturing the teachable moment: A grounded theory study of verbal teaching interactions in the operating room. Surgery. 2012;151(5):643-650.
  14. Honneth A. Work and instrumental action. New German Critique. 1982;26(Spring-Summer):31-52.
  15. van Hove PD, Tuijthof GJ, Verdaasdonk EG, Stassen LP, Dankelman J. Objective assessment of technical surgical skills. Br J Surg. 2010;97(7):972-987.
  16. Gofton WT, Dudek NL, Wood TJ, Balaa F, Hamstra SJ. The Ottawa Surgical Competency Operating Room Evaluation (O-SCORE): A tool to assess surgical competence. Acad Med. 2012;87(10):1401-1407.
  17. Yule S, Rowley D, Flin R, Maran N. Experience matters: Comparing novice and expert ratings of non-technical skills using the NOTSS system. ANZ J Surg. 2009;79(3):154-160.

Tagged as: , ,


Bulletin of the American College of Surgeons
633 N. Saint Clair St.
Chicago, IL 60611


Download the Bulletin App

Get it on Google Play