Identification of teaching excellence in operating room and clinic settings

Efforts to enhance operating room teaching

OBJECTIVE

To identify the learning needs of faculty members who are not perceived by residents as outstanding teachers in the operating room.

DESIGN

General surgery residents electronically evaluated each faculty surgeon with whom they had significant contact upon completion of each clinical rotation between July 2005 and October 2006. Evaluation forms requested global ratings (1-5 scale ranging from poor to excellent) in 10 separate teaching-related areas, 1 of which was operating room teaching. Residents also rated faculty on 10 specific operating room teaching behaviors identified during a previous observational study.

RESULTS

In total, 134 faculty surgeons were evaluated by 63 residents. Faculty who were evaluated by at least 5 residents (n = 99) were included in the study (mean = 21.9; range, 5-118 evaluations). The ratings of overall operating room teaching (M +/- SD: 4.46 +/- 0.52) correlated significantly (p < 0.001) with ratings of overall performance (r = 0.80) and each of the 10 teaching behaviors (range, r = 0.65 {confident in role as teacher and surgeon} to r = 0.85 {teaches with enthusiasm}). Stepwise multiple regression analysis (R2 = 0.76, p < 0.01) identified ratings of the following teaching behaviors as independently significant predictors (p < 0.05) of global ratings of operating room teaching: allows learners to "feel pathology" (B = 0.38), teaches with enthusiasm (B = 0.31), and remains calm and courteous (B = 0.17).

CONCLUSIONS

Resident perceptions of operating room teaching by faculty surgeons are strongly associated with overall perceptions of the surgeon and with perceptions of specific teaching behaviors exhibited in the operating room. Regression analysis suggests that approximately 76% of the variability in resident evaluations of operating room teaching may be associated with the extent to which a surgeon demonstrates a positive attitude toward teaching, remains calm and courteous, and provides a "hands on" learning experience. Faculty development efforts aimed at operating room teaching that focus on reinforcing or modifying these behaviors may contribute to improved overall perceptions of faculty by residents.

What makes a good clinical teacher in medicine? A review of the literature

PURPOSE

The authors perform a review of the literature pertinent to the question, "What makes a good clinical teacher in medicine?"

METHOD

After framing the question, based on discussions of their own experiences with clinical teachers, the authors performed a search of the literature pertinent to the question, "What are the qualities of a good clinical teacher in medicine?" Between July and December, 2006, they reviewed titles from Index Medicus (1909-1966), PubMed (1966 to the present), PubMed Related Articles, and referenced articles. The initial selections were chosen by scanning pre-1966 Index Medicus title lists and post-1966 abstracts. Chosen articles were then read in their entirety, and those which described specific characteristics of clinical teachers were selected for inclusion. Qualitative analysis was used to identify themes.

RESULTS

From 4,914 titles, 68 articles were selected for analysis-26 published before 1966, and 42 published after 1966. Four hundred eighty descriptors were identified and grouped into 49 themes, which were clustered into three main categories: physician, teacher, and human characteristics. Echoing the authors' intuitive descriptions, noncognitive characteristics dominated the descriptions and themes.

CONCLUSIONS

Excellent clinical teaching, although multifactorial, transcends ordinary teaching and is characterized by inspiring, supporting, actively involving, and communicating with students. Faculty development programs and future research should focus on development of the noncognitive attributes of clinical teachers, as well as the knowledge and skills associated with effective teaching.

How can we prepare medical students for theatre-based learning?

CONTEXT

The quality of medical undergraduate operating theatre-based teaching is variable. Preparation prior to attending theatre may support student learning. Identifying and agreeing key skills, competences and objectives for theatre-based teaching may contribute to this process of preparation.

METHODS

We carried out a cross-sectional survey of consultant surgeons and students using a forced choice questionnaire containing 16 skills and competences classified as 'essential', 'desirable' or 'not appropriate', and a choice of 6 different teaching methods, scored for perceived effectiveness on a 5-point Likert scale. Questionnaire content was based on the findings from an earlier qualitative study.

RESULTS

Comparative data analyses (Mann- Whitney and Kruskal-Wallis tests) were carried out using SPSS Version 14. A total of 42 consultant surgeons and 46 students completed the questionnaire (46% and 100% response rates, respectively). Knowledge of standard theatre etiquette and protocols, ability to scrub up adequately, ability to adhere to sterile procedures, awareness of risks to self, staff and patients, and appreciation of the need for careful peri-operative monitoring were considered 'essential' by the majority. Student and consultant responses differed significantly on 5 items, with students generally considering more practical skills and competences to be essential. Differences between students on medical and surgical attachments were also identified.

CONCLUSIONS

Consultant surgeons and medical students agree on many aspects of the important learning points for theatre-based teaching. Compared with their teachers, students, particularly those on attachment to surgical specialties, are more ambitious - perhaps overly so - in the level of practical skills and risk awareness they expect to gain in theatre.

Objective surgical skill assessment: the diagonal operating matrix☆

There is an urgent need for structured surgical training and assessment due to the reduction in the training duration with the European Working Time Directive (EWTD). We propose a model for objective skill assessment, the PAR-Diagonal Operating Matrix (PAR-DOM) which breaks down the task of vascular anastomosis into clearly defined skills. The PAR-DOM is made up of a 3x5 table and progress is made along vectors defined on the x-axis as PAR and on the y-axis as four levels. PAR defines three skills at each level. Each skill is graded from 1-3 (this may be taken as below average, average, above average). The skills at various levels are: Level 0 - Posture, Address, Relaxation; Level 1 - Pick-up, Airtime, Rotation; Level 2 - Placing, Angles, Rhythm; Level 3 - Precision, Adaptability, Reproducibility; Level 4 - Pace, Awareness, Relations. The PAR-DOM matrix provides a graphic representation of the progress of trainees over their training period assigned for them to stay with the trainer and also help identify individual strengths and weaknesses.

Facilitating learning in the operating theatre and intensive care unit

Almost every aspect of anaesthetic and intensive care practice can be taught within the operating theatre and intensive care unit. This includes knowledge in the areas of medicine, anatomy, pharmacology, physiology, measurement and statistics, invaluable psychomotor and global skills and abilities, as well as the many important non-clinical aspects of anaesthesia and intensive care including effective communication, leadership, management, ethics and teaching. The operating theatre and intensive care unit offer many advantages and pose numerous challenges to education. This paper briefly discusses what can be taught in the operating theatre and intensive care unit, the educational challenges and benefits of teaching in these unique environments, implications for teaching and what consultants and trainees can do to positively influence the educational activity. The paper concludes with suggestions for facilitating learning in the operating theatre and intensive care unit including the Soldier's Five, practice vivas, skills training, endoscopic dexterity, interesting article exchange, in-service sessions, electronic resources and use out of hours.

Technology-Enhanced Interactive Surgical Education

BACKGROUND

Our goal was to create surgical resident centered, interactive teaching modules rich in basic science and clinical content directly pertinent to patient care and surgical techniques that would facilitate education in the 80-h work week environment.

METHODS

A systematic evaluation of available instructional tools determined that a technology-enhanced approach can effectively and efficiently address the new requirements for resident learning. An extensive evaluation of available technology determined the technology best suited to teaching the adult surgical learner.

RESULTS

An on-line, multimedia-based surgical education environment using WebCT Vista (WebCT, Inc., Lynnfield, MA) and Macromedia Breeze (Adobe Systems, Inc., San Jose, CA) software packages was implemented. The concept was constructed on tenets of adult learning theory and based on the APDS curriculum and ACGME core competencies. WebCT Vista serves as virtual scaffolding, and Macromedia Breeze functions to deliver content rich multimedia audio and visual presentations. Core subdiscipline teaching modules were created, comprised of individual lecture packets developed by faculty. Components for testing pre/post module knowledge, feedback and evaluations are built-in. The online nature allows for 24-h access at locations that are convenient to the resident.

CONCLUSIONS

Teaching modules enable maximal trainee and instructor flexibility, which translates into optimal adult learning and teaching. Lecture packets can be conveyed to all residents with unlimited availability in the virtual domain. Further refinement and continued implementation will help fill the void in direct didactic teaching left by mandated work hour restrictions, allowing for more efficient learning and teaching. There is great potential for broad application of the concept and technology to other training programs.

Medical students' perceptions of resident teaching: have duty hours regulations had an impact?

OBJECTIVE

This study describes medical students' perceptions about resident teaching on a surgery clerkship and examines student perceptions before and after the implementation of duty hours regulations (DHR).

SUMMARY BACKGROUND DATA

There has been much discussion about the impact of DHR on surgical education. One area that merits evaluation is the effect that DHR have had on student education. Learners perceive the clinical teacher role as comprised of 4 roles: teacher, person, physician, and supervisor. This model served as the basis for examining resident teaching before and after DHR.

METHODS

Students completed end-of-rotation evaluations about residents' teaching effectiveness, amount of feedback, and quality of interactions. Student comments were compiled into individual resident reports, and reports were collected from pre- (2002-2003) and post- (2003-2004) DHR. A coding scheme was developed to describe resident performance in 4 roles: teacher, person, physician, and supervisor. Three coders independently reviewed 124 resident reports maintaining an interrater agreement of 80%. Analyses of variance were conducted to compare data from pre- and post-DHR.

RESULTS

After implementation of DHR, there were significantly more negative comments (P = 0.005), including comments about residents as supervisor (P = 0.001), teacher (P = 0.027), and teaching activities (P = 0.001). Positive comments about bedside teaching decreased (P = 0.007). Although total positive comments about resident as person increased (P = 0.01), total negative comments about resident as person also increased (P = 0.02).

CONCLUSIONS

Findings of this study indicate that DHR have had a negative impact on medical students' perceptions of resident teaching. Surgical educators must develop programs that address resident teaching skills in a different environment.

A model of teaching and learning in the operating theatre

INTRODUCTION

This paper extends the work of an earlier publication by the same author which reported the findings of a case study designed to investigate how medical students learn and are taught in the operating theatre. The earlier paper was descriptive in nature, examining the challenges students face as learners in theatres. These were conceptualised around 3 key domains: the challenge posed by the physical environment; the challenge of the educational task, and the challenge of managing and negotiating a role as a participant in the professional workplace of theatres. This paper focuses exclusively on the third domain. It presents an interpretive model of teaching and learning in the operating theatre, drawing largely on conceptual frameworks developed within the literature on learning in work-based settings.

METHODS

A multimethod strategy included observation in theatres, interviews with students and surgeons, and a student survey. The themes that characterised the case were identified and the relationships among these themes were explored, leading to the development of the model. Symbolic interactionism provided the underlying theoretical framework.

CONCLUSION

In any particular theatre session, the way in which learning evolves or is obstructed for any student, and the shape that teaching takes, depends on the interpretations that the student and the surgeon make in 'sizing up' the teaching and learning environment. How surgeons and students interpret and respond to each others' behaviour, style, attitude and even demeanour, has consequences for the way teaching and learning develop. The concepts of legitimacy and trust underpin these interpretations and are central to understanding the processes of teaching and learning in this setting.

Surgical teaching: how should neurosurgeons handle the conflict of duty to today's patients with the duty to tomorrow's?

The author examines the problem of tension in neurosurgical teaching between the duty to train residents by providing various levels of unsupervised surgery and the duty to patient care. The duty to train the residents also translates into ensuring the provision of good care for patients of tomorrow by producing competent surgeons. The author contends that both duties can be fulfilled simultaneously, but the surgical tension inherent in this situation must not be ignored or taken for granted.