“Look at every path closely and deliberately, then ask ourselves this crucial question: Does this path have a heart? If it does, then the path is good. If it doesn't, it is of no use.” ~Carlos Castaneda

Sunday, January 20, 2008

To be a good surgeon, you must first be a good first assistant ...

“You cannot teach a man anything; you can only help him discover it in himself.”
~Galileo Galilei

One of the first questions resident applicants ask is, "when will I get to operate?" For the most part, operating is the reason most people go into a surgical specialty. We understand that clinic is a necessary evil. Clinic is where the surgical decision making begins and the final outcomes are determined. It is a key element in surgical education, and for the most part, is hated by most residents.

So, when should a resident be the primary surgeon operating surgeon? Well, I truly believe that you must first be a good first assistant. Many may disagree with this statement. I hated when an attending would make the same statement to me. My response, in my head of course, would be, "I have prepared for it and I am ready." I will concede that holding a retractor in a 10 hour case is not a great learning experience; but like the unpopular clinic, first assisting is a vital tool in developing surgical skills.

Surgery is about pattern recognition. For a more experienced surgeon, watching another surgeon operate is like watching film to prepare for a game. S/he is looking for better or different ways of attacking a problem. When we see a certain pattern or obstacle, how should we approach it? The basic pattern is understood. Like Tom Brady reading a defense and changing the play to exploit a weakness, an experienced surgeon may change his/her techniques based on a recognized pattern. A young surgeon uses all his/her senses to orient themselves to a procedure. The anatomy never looks like the Netter drawings. Like a child experiencing the world, they need to feel, see, and taste everything. It is more information into the computer to be stored for future pattern recognition. In assisting, unknowingly the surgeon is increasing the data bank of patterns. Pattern recognition is what helps surgeons move effortlessly thorough procedures. "I have seen that before .... this is what worked before." It allows for almost reflexive responses to challenges and obstacles during a procedure.

Learning through observation, passive learning, is different than the learning through direct participation, active learning. As primary surgeon, the surgeon can "feel" the education occurring. The active learning is through brute force and improvements are almost palpable. For the experienced surgeon, observation, passive learning, is a vital tool in improving surgical skill and improving their currently used techniques. For the less experienced surgeon, the subtleties of the surgeon's techniques may be lost because so much energy is used to understand the basics of the procedure. Because the learning is more passive, it does not feel like learning has occurred. Fortunately, it increases the surgeon's data bank of patterns.

What is it about assisting that improves surgical skill? Being a good first assistant requires you to understand the case. It would be like the caddy's relationship to the golfer; the assistants role is to anticipate. It starts with room set up and patient positioning. You must be able to think steps ahead and obtain whatever is needed help the procedure run smooth with less delays. The assistant must know the instruments and have an understanding of how they are used. Although these little things seem unnecessary, they are all extremely important.

As a novice surgeon, the OR can be very overwhelming. Sometimes just remembering the approach is stressful enough. As an assistant, you don't have to think about the how and why during the procedure. Your role is to pay attention, to anticipate the next move, and to help his/her exposure and/or vision. To be a good first assist, you actually must understand the procedure and think steps ahead. For the novice surgeon, the assistant role allows them to absorb the information. Although you are thinking ahead in the case, you are not required to make critical decisions and therefore, it is less stressful.

With each case and surgeon, you will experience different ways of accomplishing the same goals. Some will use different instruments to perform similar tasks. You will begin to develop your own style or flare. You find what works for you. There will be instruments that you like and dislike. I am partial to the cobb. My residents have heard me say more than once that I could win Survivor with 2 good sharp cobbs. With each case, the young surgeon's repertoire of surgical approaches, positions, instruments, and retractors, increases. Their understanding of OR management from set up to time management improves.

The goal of residency is to create a complete surgeon. Technical skill is only one component. Like the decision making skills gained from clinic, assisting helps in rounding off the surgeon. Although many other specialties view orthopaedic surgeons as technicians, there is a lot more thought that goes into the treatment of musculoskeletal disorders. The easiest part of what we do is the technical part. The decisions are the hard part. So, when should a resident become primary surgeon? Well, my view is not until they are chiefs and almost ready to graduate. In my mind, the primary surgeon is not the one who is making the incisions; the primary surgeon is making the decisions. The primary surgeon has to decide who is an appropriate surgical candidate, what surgery is appropriate, and what techniques are to be used. The primary surgeon must think about OR setup (lights, bed position, c-arm position), patient positioning (supine, lateral), surgical approach, instrumentation type, surgical closure, and postoperative management. The primary surgeon must be complete.

As the attending surgeon, it is difficult to perform both roles, surgeon and first assistant. There are many days when I wish I had a first assistant instead of a resident. Someone who would concentrate on assisting and not trying to move into the role as primary surgeon. The assistant's role is to keep the surgery moving forward. As a resident, I remember finishing a case and believing I did a great job on it. In hindsight, I realized that is was my fist assistant (the attending) who made the case go so smoothly. The attending surgeon moved me through the case like a puppet. So what do I do today when I need an expert assistant, I ask one of my partners to assist.

“There are no failures - just experiences and your reactions to them.”
~Tom Krause


rlbates said...

I agree with you (especially now that I am so far out from my residency).

Midwife with a Knife said...

I mostly agree with you. I think that there is some learning that can only happen once you do the procedure (like how it feels to cut through the uterus so far and yet not too far, or how it feels to deliver a baby with forceps or a vacuum, how the pelvis tells you where to go). I also think that first assisting helps to develop muscles you'll need as you teach junior residents how to do the procedure: when the junior residents/med students muscles fatigue you'll have to be able to pick up the slack. Now, even though I'm not a great example of the human physique, I can retract for hours, if need be, and not loose the ability to do it (where as my muscles would fatigue when I was a fourth year medical student). I do, admittedly, occasionally get sore the next day, though.

Also, every surgeon needs a first assist, and most people who go into private practice will either first assist for their partners or tell a PA or resident how they want them to do things....

Someonect said...

rlbats: i realize this more and more the longer i am out.

MWWAK: well as you know, all of our residents are gym freaks ;). it is a prereq. for ortho.

i hope i didn't imply that first assisting is all one should do. i think it is important. typically in my OR the teaching physician (me) is the first assistant role. leading the operating surgeon through the case. i frequently second assist, putting my chief in the first assistant role with the junior resident in the operating role. when in the teaching or leading role, the thought process is different, your vision is different, and you have to understand the procedure better.

Unknown said...

all of our residents are gym freaks ;)

Aha! Couple of years ago I broke my hip. I met the surgeon for the first time later after surgery. He came in, sat in the chair next to the bed and when I asked what he did to fix the hip, he stood and moved to the blackboard in the room and drew the bones and the pins and plate. I was really struck by the grace and effortlessness of his movements, drugged as I was. When I got home I googled his name and discovered that he is an Iron Man Triathlon athlete, which did not surprise me. I admire athletic grace greatly, probably because I have a slight limp from childhood polio. Now, you're telling me orthopedic surgeons generally are really good athletes? Amazing. He did a great job on my hip, but he was also the best doctor I've ever had.

make mine trauma said...

There are many days when I wish I had a first assistant instead of a resident. Someone who would concentrate on assisting and not trying to move into the role as primary surgeon

Also applies to general surgery and trauma. I have often heard from docs that they prefer that I assist because when a partner assists they want to help too much. Of course in a technically challenging case another surgeon is the preference.

Jeffrey said...

fantastic post. can't agree more. start from the lowest, and learn every step of the way.

consider submitting to SurgeXperiences to be hosted this Sunday at Notes of an Anesthesioboist.

Jaspreet Singh said...

Agreed you should know the basic before you be surgeon

orthopaedic surgeon