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Schulze M, Streith L, Wiseman SM. Intraoperative teaching methods, models, and frameworks: A scoping review for surgical resident education. Am J Surg 2024; 231:24-40. [PMID: 38342713 DOI: 10.1016/j.amjsurg.2024.01.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 01/15/2024] [Accepted: 01/24/2024] [Indexed: 02/13/2024]
Abstract
BACKGROUND This review aimed to consolidate the existing literature on intraoperative teaching strategies and highlight areas for future research. OBJECTIVE The objective is to review the research conducted regarding the implementation of various teaching frameworks for surgical learners and to present their feasibility, benefits, and limitations within surgical residencies, as well as areas for future research. METHODS Two independent investigators searched MEDLINE, EMBASE, and ERIC and reviewed articles on intraoperative teaching strategies for surgical resident education. RESULTS 3050 abstracts were reviewed, and 66 studies (2.2%) were included. The most common study type was single cohort studies (33%), followed by survey studies (17%). The majority of articles were carried out in General Surgery (50%), or a combination of surgical specialties (17%). CONCLUSIONS The BID model encompasses perioperative teaching time points and suggests a universal organizational approach to intraoperative teaching that would likely be compatible with documented competency assessments for residents.
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Affiliation(s)
- Marie Schulze
- Department of Surgery, St. Paul's Hospital & University of British Columbia, Vancouver, Canada
| | - Lucas Streith
- Department of Surgery, St. Paul's Hospital & University of British Columbia, Vancouver, Canada
| | - Sam M Wiseman
- Department of Surgery, St. Paul's Hospital & University of British Columbia, Vancouver, Canada.
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Keuning MC, Lambert B, Nieboer P, Huiskes M, Diemers AD. Perceptions and Guiding Strategies to Regulate Entrusted Autonomy of Residents in the Operating Room: A Systematic Literature Review. JOURNAL OF SURGICAL EDUCATION 2024; 81:93-105. [PMID: 37838573 DOI: 10.1016/j.jsurg.2023.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 12/24/2022] [Accepted: 09/11/2023] [Indexed: 10/16/2023]
Abstract
OBJECTIVE To provide a systematic literature review of intraoperative entrusted autonomy for surgical residents. Specifically, perceptions from residents and supervising surgeons, supervising behavior and influencing factors on intraoperative teaching and learning are analyzed. BACKGROUND Increasing demands on surgical training and the need for effective development of technical skills, amplify the importance of making the most of intraoperative teaching and learning opportunities in the operating room. It is critical for residents to gain the greatest benefit from every surgical case and to achieve operative competence. METHODS A systematic literature search identified 921 articles from 2000 to 2022 that addressed surgical education/training, intraoperative supervision/teaching, autonomy and entrustment. 40 studies with heterogeneous designs and methodologies were included. RESULTS Four themes were established in the analysis: patient safety, learner, learning environment and supervising surgeon. The patient is identified as the primary responsibility during intraoperative teaching and learning. Supervisors continuously guard patient safety as well as the resident's learning process. Ideal intraoperative learning occurs when the resident has optimal entrusted autonomy during the procedure matching with the current surgical skills level. A safe learning environment with dedicated time for learning are prerequisites for both supervising surgeons and residents. Supervising surgeons' own preferences and confidence levels also play an important role. CONCLUSIONS This systematic literature review identifies patient safety as the overriding principle for supervising surgeons when regulating residents' entrusted autonomy. When the supervisor's responsibility toward the patient has been met, there is room for intraoperative teaching and learning. In this process the learner, the learning environment and the supervising surgeon's own preferences all intertwine, creating a triangular responsibility. This review outlines the challenge of establishing an equilibrium in this triangle and the broad arsenal of strategies supervising surgeons use to keep it in balance.
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Affiliation(s)
- Martine C Keuning
- Department of Orthopedic Surgery, University Medical Center Groningen, Groningen, The Netherlands.
| | - Bart Lambert
- Department of Orthopedic Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Patrick Nieboer
- Department of Orthopedic Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Mike Huiskes
- Center for Language and Cognition Groningen, University of Groningen, Groningen, The Netherlands
| | - Agnes D Diemers
- Lifelong Learning, Education and Assessment Research Network (LEARN), University Medical Center Groningen, Groningen, The Netherlands
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Raymond M, Studer M, Al-Mulki K. Supplementing Intraoperative Mastoidectomy Teaching With Video-Based Coaching. Ann Otol Rhinol Laryngol 2023; 132:440-448. [PMID: 35658718 DOI: 10.1177/00034894221098804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Video-based coaching might complement general surgery education, but little is known of its applicability for otologic microsurgical teaching. Our purpose was thus to evaluate the content and resident-perceived benefit of video-based coaching for mastoidectomy education. METHODS In this mixed-methods pilot design, mastoidectomies were recorded from operative microscopes and reviewed during 30-minute video-based coaching sessions at 2 tertiary care centers. Eight residents and 3 attendings participated. Ten-point Likert-type questionnaires on the extent to which attendings taught 12 topics through 8 techniques were completed by residents after surgical and coaching sessions. Coaching sessions and structured interviews with residents were audio-recorded, transcribed and iteratively coded. RESULTS Seven audio-recordings were available for coaching sessions, during which a mean of 2.22 ± 0.5 topics per minute were discussed. Of the 12 teaching topics, technique was discussed most frequently (32%, 0.71 ± 0.2 topics/min), followed by anatomy (16%, 0.31 ± 0.16 topics/min). Of all 8 ratings between coaching and operative sessions, residents indicated a greater extent of discussion of anatomy (median difference, [95% confidence interval (CI)] of 3 [1-4]), progress (2.25 [95% CI, 0.5-4]), technique (3.5 [95% CI, 1.5-5.5]), pitfalls (2.5 [95% CI, 1-3.5]), and summarizing (3 [95% CI, 1-5]). In structured interviews, residents reported improved self-confidence and global perspective. CONCLUSIONS Video-based coaching is educationally dense and characterized by perceived richer teaching and promotion of a deeper surgical understanding. It requires no additional resources, can be completed in a short period of time and can be implemented programmatically for any otolaryngologic subspecialty utilizing video-recording capable equipment.
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Affiliation(s)
- Mallory Raymond
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Matthew Studer
- Department of Otolaryngology - Head and Neck Surgery, Oregon Health and Science University, Portland, OR, USA
| | - Kareem Al-Mulki
- Department of Otorhinolaryngology - Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
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Rupani N, Evans A, Iqbal M. A quantitative cross-sectional study assessing the surgical trainee perception of the operating room educational environment. BMC MEDICAL EDUCATION 2022; 22:764. [PMID: 36344964 PMCID: PMC9640905 DOI: 10.1186/s12909-022-03825-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 10/04/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Limited hours and service provision are diminishing training opportunities, whilst increasing standards of surgical proficiency is being sought. It is imperative to maximise the value of each educational event. An objective measure of higher surgical trainee perception of the operating room environment in England has not been performed before and this can steer future change in optimising educational events in theatre. The Operating Room Educational Environment Measure (OREEM) evaluates each component of the learning environment to enable optimisation of these educational events. However, the OREEM has not yet been assessed for reliability in higher surgical trainees in England. The aim of the current study was to explore areas of strength and weakness in the educational environment in the operating room as perceived by surgical trainees' in one English region. The secondary aim was to assess the reliability of the OREEM. METHODS Using a quantitative approach, data was collected over one month from surgical trainees in England using the OREEM. RESULTS Fifty-four surgical trainees completed the questionnaire. The OREEM had good internal consistency (α = 0.906, variables = 40). The mean OREEM score was 79.16%. Areas for improvement included better learning opportunities (average subscale score = 72.9%) and conducting pre- and post-operative teaching (average score = 70.4%). Trainees were most satisfied with the level of supervision and workload (average subscale score = 82.87%). The learning environment favoured senior trainees (p = 0.017). There was a strong correlation between OREEM and the global satisfaction score (p < 0.001). CONCLUSIONS The OREEM was shown to be a reliable measure of the educational environment. It can be used to identify areas of improvement and as an audit tool. The current perception of the education environment is satisfactory, however, areas of improvement include reducing service provision, empowering trainees to plan lists, improving teamwork and using tools to optimise the educational value of each operation. There is a favourable attitude regarding the use of improvement tools, especially for dissatisfied trainees.
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Affiliation(s)
- Neal Rupani
- Nuffield Orthopaedic Centre, University of Oxford, Windmill Road, Oxford, OX3 7LD, UK.
| | - Ashish Evans
- Nuffield Orthopaedic Centre, University of Oxford, Windmill Road, Oxford, OX3 7LD, UK
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Sutkin G, Littleton EB, Arnold L, Kanter SL. Optimizing surgical teaching through the lens of sociocultural learning theory. Am J Surg 2022; 224:379-383. [DOI: 10.1016/j.amjsurg.2022.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 02/01/2022] [Accepted: 03/01/2022] [Indexed: 11/01/2022]
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Nieboer P, Huiskes M, Cnossen F, Stevens M, Bulstra SK, Jaarsma DADC. Explicit teaching in the operating room: Adding the why to the what. MEDICAL EDUCATION 2022; 56:202-210. [PMID: 34612530 PMCID: PMC9297931 DOI: 10.1111/medu.14675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 09/14/2021] [Accepted: 09/29/2021] [Indexed: 06/13/2023]
Abstract
CONTEXT Residents need their supervisors in the operating room to inform them on how to use expertise in present and future occasions. A few studies hint at such explicit teaching behaviour, however without explaining its underlying mechanisms. Understanding and improving explicit teaching becomes more salient nowadays, as access of residents to relevant procedures is decreasing, while end-terms of training programs remain unchanged: high quality patient care. OBJECTIVES A structured analysis of (1) the practices supervisors use for explicit teaching and (2) how supervisors introduce explicit teaching in real time during surgical procedures. METHODS An observational qualitative collection study in which all actions of nine supervisor-resident dyads during a total hip replacement procedure were videotaped. Interactions in which supervisors explicitly or implicitly inform residents how to use their expertise now and in future occasions were included for further analysis, using the iterative inductive process of conversation analysis. RESULTS 1. Supervisors used a basic template of if/then rules for explicit teaching, which they regularly customised by adding metaphors, motivations, and information about preference, prevalence and consequence. 2. If/then rules are introduced by supervisors to solve a (potential) problem in outcome for the present patient in reaction to local circumstances, for example, what residents said, did or were about to do. CONCLUSIONS If/then rules add the why to the what. Supervisors upgrade residents' insights in surgical procedures (professional vision) and teach the degree of individual freedom and variation of their expert standards for future occasions. These insights can be beneficial in improving supervisors' teaching skills.
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Affiliation(s)
- Patrick Nieboer
- Department of Orthopedic SurgeryUniversity Medical Center GroningenGroningenThe Netherlands
| | - Mike Huiskes
- Center for Language and CognitionUniversity of GroningenGroningenThe Netherlands
| | - Fokie Cnossen
- Department of Artificial Intelligence, Bernouilli Institute of Mathematics, Computer Science and Artificial IntelligenceUniversity of GroningenGroningenThe Netherlands
| | - Martin Stevens
- Department of Orthopedic SurgeryUniversity Medical Center GroningenGroningenThe Netherlands
| | - Sjoerd K. Bulstra
- Department of Orthopedic SurgeryUniversity Medical Center GroningenGroningenThe Netherlands
| | - Debbie A. D. C. Jaarsma
- Center for Research and Innovation in Medical EducationUniversity Medical Center GroningenGroningenThe Netherlands
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Nieboer P, Huiskes M, Cnossen F, Stevens M, Bulstra SK, Jaarsma DADC. The Supervisor's Toolkit: Strategies of Supervisors to Entrust and Regulate Autonomy of Residents in the Operating Room. Ann Surg 2022; 275:e264-e270. [PMID: 32224741 DOI: 10.1097/sla.0000000000003887] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To identify what strategies supervisors use to entrust autonomy during surgical procedures and to clarify the consequences of each strategy for a resident's level of autonomy. BACKGROUND Entrusting autonomy is at the core of teaching and learning surgical procedures. The better the level of autonomy matches the learning needs of residents, the steeper their learning curves. However, entrusting too much autonomy endangers patient outcome, while entrusting too little autonomy results in expertise gaps at the end of training. Understanding how supervisors regulate autonomy during surgical procedures is essential to improve intraoperative learning without compromising patient outcome. METHODS In an observational study, all the verbal and nonverbal interactions of 6 different supervisors and residents were captured by cameras. Using the iterative inductive process of conversational analysis, each supervisor initiative to guide the resident was identified, categorized, and analyzed to determine how supervisors affect autonomy of residents. RESULTS In the end, all the 475 behaviors of supervisors to regulate autonomy in this study could be classified into 4 categories and nine strategies: I) Evaluate the progress of the procedure: inspection (1), request for information (2), and expressing their expert opinion (3); II) Influence decision-making: explore (4), suggest (5), or declare the next decision (6); III) Influence the manual ongoing action: adjust (7), or stop the resident's manual activity (8); IV) take over (9). CONCLUSIONS This study provides new insights into how supervisors regulate autonomy in the operating room. This insight is useful toward analyzing whether supervisors meet learning needs of residents as effectively as possible.
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Affiliation(s)
- Patrick Nieboer
- Department of Orthopedic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Mike Huiskes
- Center for Language and Cognition, University of Groningen, Groningen, The Netherlands
| | - Fokie Cnossen
- Department of Artificial Intelligence, Bernouilli Institute of Mathematics, Computer Science and Artificial Intelligence, University of Groningen, Groningen, The Netherlands
| | - Martin Stevens
- Department of Orthopedic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Sjoerd K Bulstra
- Department of Orthopedic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Debbie A D C Jaarsma
- Center for Research and Innovation in Medical Education, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Instructional methods of attendings as exhibited during intraoperative takeovers: A pilot study. Surgery 2021; 170:446-453. [PMID: 33781584 DOI: 10.1016/j.surg.2021.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 02/04/2021] [Accepted: 02/09/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND This pilot study examined intraoperative instructional techniques during "takeovers," defined as the act of an attending taking control of a case from a resident. This work describes what happens during takeovers and identifies possible reasons for takeovers. METHODS Intraoperative audio-video recordings during 25 laparoscopic inguinal hernia repair procedures were collected. Participants included 2 postgraduate year-5 residents and 5 attendings. Postoperative evaluation forms were completed by attendings. Coding schemes for takeovers during hernia reduction and mesh placement steps were developed using conventional and directed content analysis in an iterative process by study team members, including individuals with expertise in education, surgery, and surgical education. RESULTS Takeovers occurred in 72% of cases. Frequency of takeovers was not related to case difficulty or differences in resident technical skill levels, nor did they decrease over the duration of the 2-month rotation. Takeovers most commonly occurred when a resident struggled to progress the case. They also occurred when anatomy was unclear or when the attending wanted to teach a specific skill. Differences were identified among attendings regarding frequency of takeovers. The majority of takeover behaviors were directed at instructing residents; however, attendings' teaching techniques did not vary by resident. CONCLUSION Attending teaching habits appear to be independent of resident skills and depend on the attending's teaching style rather than residents' learning needs. Findings highlight the need for faculty development to help surgical educators learn how to tailor instruction to individual trainees. Additionally, future research is needed to establish the effectiveness of instruction through takeovers in the operating room.
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Foster MJ, O'Hara NN, Weir TB, Aneizi A, Henn RF, Packer JD, Hasan SA, Slobogean GP, Gilotra MN. Difference in Resident Versus Attending Perspective of Competency and Autonomy During Arthroscopic Rotator Cuff Repairs. JB JS Open Access 2021; 6:JBJSOA-D-20-00014. [PMID: 33748637 PMCID: PMC7963494 DOI: 10.2106/jbjs.oa.20.00014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
A noted deficiency in orthopaedic resident education is a lack of intraoperative autonomy; however, no studies exist evaluating this issue. The purpose of this study was to determine whether there is a difference between resident and attending perception of resident competency and autonomy during arthroscopic rotator cuff repairs and whether increased perceived competency leads to more autonomy.
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Affiliation(s)
- Michael J Foster
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Nathan N O'Hara
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Tristan B Weir
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Ali Aneizi
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - R Frank Henn
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jonathan D Packer
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - S Ashfaq Hasan
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Gerard P Slobogean
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Mohit N Gilotra
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
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Isreb S, Attwood S, Hesselgreaves H, McLachlan J, Illing J. Synchronized Video-Review as a Tool to Enhance Reflection and Feedback: A Design-Based Feasibility Study. JOURNAL OF SURGICAL EDUCATION 2021; 78:1-8. [PMID: 32768384 DOI: 10.1016/j.jsurg.2020.07.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 06/24/2020] [Accepted: 07/13/2020] [Indexed: 06/11/2023]
Abstract
INTRODUCTION UK surgical training currently faces the challenge of expanding surgical skills in a context of reduced training opportunities. Video-review in theatre offers the potential to gain more from each learning opportunity and to enhance feedback. AIM This was a designed-based study to test the feasibility of using synchronized video-review as a reflective tool to enhance surgical training and to gain a deeper understanding of intraoperative feedback. METHOD Ten supervised laparoscopic cholecystectomy operations were video-recorded using a synchronized split screen, to show trainees' actions, instrument manipulation, and interactions with other theatre staff. This was followed up by joint review of the operation-recording by both the trainee and supervisor. Video-review sessions were audio-recorded along with the consultant and Specialist Registrar interviews after the review session. Audio recordings were thematically analyzed. Supervisors completed the Procedure-Based Assessment forms, twice: post operation and post video-review to check potential trainers' enhanced insight. Forms were analyzed to note any changes and to triangulate the findings. RESULTS Overall trainee and supervisor feedback was positive. Trainees and supervisors reported the video-review added value in terms of reflection-on-action. It removed the stress of conducting/supervising the operation in real time and focused the attention on feedback. Satisfaction was reported across trainee levels with both scrubbed and unscrubbed supervisors. Audio-visual review allowed trainees to understand the feedback better and to identify new targets beyond those gained from the verbal feedback during the procedure. It also facilitated appraisal of the trainer's teaching. DISCUSSION This study established the feasibility of using synchronized video-review as a reflection-on-action tool to potentially enhance surgical training by improving feedback. It identified trainees' difficulty in processing intraoperative feedback due to mental overload from the operation. It showed the limitations of current verbal feedback practice, using Procedure-Based Assessment forms, with regard to enhancing technical and nontechnical skills due to denial and memory fading.
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Affiliation(s)
- Siddek Isreb
- Department of Health Services Research, Durham University, Stockton on Tees, Durham, United Kingdom.
| | - Stephen Attwood
- Department of Health Services Research, Durham University, Stockton on Tees, Durham, United Kingdom
| | - Hannah Hesselgreaves
- Northumbria University, The Business School, Newcastle upon Tyne, United Kingdom
| | - John McLachlan
- University of Central Lancashire, Preston, United Kingdom
| | - Jan Illing
- Newcastle University, Newcastle upon Tyne, United Kingdom
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Teaching in the robotic environment: Use of alternative approaches to guide operative instruction. Am J Surg 2020; 219:191-196. [DOI: 10.1016/j.amjsurg.2019.06.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 06/03/2019] [Accepted: 06/05/2019] [Indexed: 01/18/2023]
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Miranda SP, Schaefer KG, Vates GE, Gormley WB, Buss MK. Palliative Care and Communication Training in Neurosurgery Residency: Results of a Trainee Survey. JOURNAL OF SURGICAL EDUCATION 2019; 76:1691-1702. [PMID: 31239231 DOI: 10.1016/j.jsurg.2019.06.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 06/10/2019] [Accepted: 06/10/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE Neurosurgeons care for critically ill patients near the end of life, yet little is known about how well their training prepares them for this role. We surveyed a random sample of neurosurgery residents to describe the quantity and quality of teaching activities related to serious illness communication and palliative care, and resident attitudes and perceived preparedness to care for seriously ill patients. METHODS A previously validated survey instrument was adapted to reflect required communication and palliative care competencies in the 2015 the Accreditation Council for Graduate Medical Education (ACGME) Milestones for Neurological Surgery. The survey was reviewed for content validity by independent faculty neurosurgeons, piloted with graduating neurosurgical residents, and distributed online in August 2016 to neurosurgery residents in the United States using the American Association of Neurological Surgeons (AANS)/Congress of Neurological Surgeons (CNS) Joint Section on Neurotrauma and Critical Care email listserv. Multiple choice and Likert scale responses were analyzed using descriptive statistics. RESULTS Sixty-two responses were recorded between August 2016 and October 2016. Most respondents reported no explicit teaching on: explaining risks and benefits of intubation and ventilation (69%), formulating prognoses in neurocritical care (60%), or leading family meetings (69%). Compared to performing craniotomies, respondents had less frequent practice leading discussions about withdrawing life-sustaining treatment (61% vs. 90%, p < 0.01, "weekly or more frequently"), and were less often observed (18% vs. 87%, p < 0.01) and given feedback on their performance (11% vs. 58%, p < 0.01). Nearly all respondents (95%) felt "prepared to discuss withdrawing life-sustaining treatments," however half (48%) reported they "would benefit from more communication training during residency." Most (87%) reported moral distress, agreeing that they "participated in operations and worried whether surgery aligned with patient goals." CONCLUSIONS Residents in our sample reported limited formal training, and relatively less observation and feedback, on required ACGME competencies in palliative care and communication. Most reported preparedness in this domain, but many were receptive to more training. Better quality and more consistent palliative care education in neurosurgery residency could improve competency and help ensure that neurosurgical care aligns with patient goals.
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Affiliation(s)
- Stephen P Miranda
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Kristen G Schaefer
- Division of Palliative Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - G Edward Vates
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York
| | - William B Gormley
- Harvard Medical School, Boston, Massachusetts; Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Mary K Buss
- Harvard Medical School, Boston, Massachusetts; Section of Palliative Care, Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Raîche I, Hamstra S, Gofton W, Balaa F, Dionne É. Cognitive challenges of junior residents attempting to learn surgical skills by observing procedures. Am J Surg 2019; 218:430-435. [DOI: 10.1016/j.amjsurg.2018.11.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Revised: 11/12/2018] [Accepted: 11/14/2018] [Indexed: 10/27/2022]
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Abstract
Surgical training has focused on the development of technical competency. Interpersonal and cognitive skills are essential to working as an interdisciplinary team, which translates into safety for the patient and well-being for the surgeon and colleagues. This article offers an "alternative" surgical curriculum topic list to augment the technical skill sets traditionally taught to trainees.
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Chen XP, Sullivan AM, Smink DS, Alseidi A, Bengtson JM, Kwakye G, Dalrymple JL. Resident Autonomy in the Operating Room: How Faculty Assess Real-time Entrustability. Ann Surg 2019; 269:1080-1086. [PMID: 31082905 DOI: 10.1097/sla.0000000000002717] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study aimed to identify the empirical processes and evidence that expert surgical teachers use to determine whether to take over certain steps or entrust the resident with autonomy to proceed during an operation. BACKGROUND Assessing real-time entrustability is inherent in attending surgeons' determinations of residents' intraoperative autonomy in the operating room. To promote residents' autonomy, it is necessary to understand how attending surgeons evaluate residents' performance and support opportunities for independent practice based on the assessment of their entrustability. METHODS We conducted qualitative semi-structured interviews with 43 expert surgical teachers from 21 institutions across 4 regions of the United States, using purposeful and snowball sampling. Participants represented a range of program types, program size, and clinical expertise. We applied the Framework Method of content analysis to iteratively analyze interview transcripts and identify emergent themes. RESULTS We identified a 3-phase process used by most expert surgical teachers in determining whether to take over intraoperatively or entrust the resident to proceed, including 1) monitoring performance and "red flags," 2) assessing entrustability, and 3) granting autonomy. Factors associated with individual surgeons (eg, level of comfort, experience, leadership role) and the context (eg, patient safety, case, and time) influenced expert surgical teachers' determinations of entrustability and residents' final autonomy. CONCLUSION Expert surgical teachers' 3-phase process of decisions on take-over provides a potential framework that may help surgeons identify appropriate opportunities to develop residents' progressive autonomy by engaging the resident in the determination of entrustability before deciding to take over.
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Affiliation(s)
- Xiaodong Phoenix Chen
- Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- The Ohio State University, Columbus, OH
| | - Amy M Sullivan
- Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - Douglas S Smink
- Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | | | - Joan M Bengtson
- Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | | | - John L Dalrymple
- Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
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Nieboer P, Huiskes M, Cnossen F, Stevens M, Bulstra SK, Jaarsma DADC. Recruiting expertise: how surgical trainees engage supervisors for learning in the operating room. MEDICAL EDUCATION 2019; 53:616-627. [PMID: 30900304 DOI: 10.1111/medu.13822] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 09/10/2018] [Accepted: 01/10/2019] [Indexed: 06/09/2023]
Abstract
CONTEXT For centuries now, the operating room (OR) has been the environment in which surgical trainees come to master procedures. Restricted working hours and insufficient levels of autonomy at the end of their training necessitate a shift towards alternative effective learning strategies. Self-regulated learning is a promising strategy by which surgical trainees can learn more with fewer exposures. However, the challenge is to understand how surgical trainees regulate their learning in the clinical context of the OR. OBJECTIVES The purpose of this study is to identify and understand the strategies of surgical trainees in engaging their supervisors for learning purposes and how these strategies contribute to effective learning. METHODS Total hip replacement procedures performed by four surgical trainees and their supervisors were videotaped. Using the iterative inductive process of conversation analysis, each verbal initiative to engage the supervisor was identified, analysed ('why that now') and categorised. RESULTS Surgical trainees used a range of practices to engage supervisors and recruit expertise, ranging from explicit recruitment to implicit hints. We identified four major categories. Surgical trainees: (i) invite the supervisor to provide an evaluation of the ongoing task; (ii) express an evaluation of the ongoing task and then explicitly invite the supervisor to provide an evaluation; (iii) express an evaluation of the ongoing task and then invite the supervisor to provide confirmation, and (iv) express an evaluation of the ongoing task without engaging the supervisor. CONCLUSIONS Surgical trainees recruit expertise from supervisors using practices of four different categories. Trainees' actions are provoked by the moment at which they experience insufficient expertise and are focused on the task at hand in the immediate present. Supervisors can and do elaborate on these requests to provide explicit teaching. Insight into these practices provides tools for reflection on OR learning, proficiency assessment and deliberation to adapt guidance in the real time of the procedure.
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Affiliation(s)
- Patrick Nieboer
- Department of Orthopaedic Surgery, University Medical Centre Groningen, Groningen, the Netherlands
| | - Mike Huiskes
- Centre for Language and Cognition, University of Groningen, Groningen, the Netherlands
| | - Fokie Cnossen
- Department of Artificial Intelligence, Bernouilli Institute of Mathematics, Computer Science and Artificial Intelligence, University of Groningen, Groningen, the Netherlands
| | - Martin Stevens
- Department of Orthopaedic Surgery, University Medical Centre Groningen, Groningen, the Netherlands
| | - Sjoerd K Bulstra
- Department of Orthopaedic Surgery, University Medical Centre Groningen, Groningen, the Netherlands
| | - Debbie A D C Jaarsma
- Centre for Research and Innovation in Medical Education, University Medical Centre Groningen, Groningen, the Netherlands
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17
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Preventing Error in the Operating Room: Five Teaching Strategies for High-Stakes Learning. J Surg Res 2019; 236:12-21. [DOI: 10.1016/j.jss.2018.10.050] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 10/14/2018] [Accepted: 10/26/2018] [Indexed: 01/27/2023]
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18
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Chen X(P, Cochran A, Dalrymple JL. Framework for Faculty Development in Resident Autonomy and Entrustment in the Operating Room. JAMA Surg 2019; 154:5-6. [DOI: 10.1001/jamasurg.2018.3529] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
| | - Amalia Cochran
- The Ohio State University, Columbus
- Web and Social Media Editor, JAMA Surgery
| | - John L. Dalrymple
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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19
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Chen XP, Sullivan AM, Alseidi A, Kwakye G, Smink DS. Assessing Residents' Readiness for OR Autonomy: A Qualitative Descriptive Study of Expert Surgical Teachers' Best Practices. JOURNAL OF SURGICAL EDUCATION 2017; 74:e15-e21. [PMID: 28712687 DOI: 10.1016/j.jsurg.2017.06.034] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 05/26/2017] [Accepted: 06/27/2017] [Indexed: 06/07/2023]
Abstract
PURPOSE Providing resident autonomy in the operating room (OR) is one of the major challenges for surgical educators today. The purpose of this study was to explore what approaches expert surgical teachers use to assess residents' readiness for autonomy in the OR. We particularly focused on the assessments that experts make prior to conducting the surgical time-out. METHODS We conducted semistructured in-depth interviews with expert surgical teachers from March 2016 to September 2016. Purposeful sampling and snowball sampling were applied to identify and recruit expert surgical teachers from general surgery residency programs across the United States to represent a range of clinical subspecialties. All interviews were audio-recorded, deidentified, and transcribed. We applied the Framework Method of content analysis, discussed and reached final consensus on the themes. RESULTS We interviewed 15 expert teachers from 9 institutions. The majority (13/15) were Program or Associate Program Directors; 47% (7/15) primarily performed complex surgical operations (e.g., endocrine surgery). Five themes regarding how expert surgical teachers determine residents' readiness for OR autonomy before the surgical time-out emerged. These included 3 domains of evidence elicited about the resident (resident characteristics, medical knowledge, and beyond the current OR case), 1 variable relating to attending characteristics, and 1 variable composed of contextual factors. Experts obtained one or more examples of evidence, and adjusted residents' initial autonomy using factors from the attending variable and the context variable. CONCLUSIONS Expert surgical teachers' assessments of residents' readiness for OR autonomy included 5 key components. Better understanding these inputs can contribute to both faculty and resident development, enabling increased resident autonomy and preparation for independent practice.
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Affiliation(s)
- Xiaodong Phoenix Chen
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
| | - Amy M Sullivan
- Harvard Medical School, Boston, Massachusetts; Shapiro Institute for Education and Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Adnan Alseidi
- Department of General Surgery, Virginia Mason Medical Center, Seattle, Washington
| | - Gifty Kwakye
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Douglas S Smink
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
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20
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Sutkin G, Littleton EB, Kanter SL, Cianciolo AT, Chen XP, Cope A, Koschmann T. Teaching, Learning, and Performance in the Surgical Workplace: Insights From the Examination of Intraoperative Interactions. TEACHING AND LEARNING IN MEDICINE 2017; 29:378-382. [PMID: 29020522 DOI: 10.1080/10401334.2017.1384732] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
This Conversations Starter article presents a selected research abstract from the 2017 Association of American Medical Colleges Central Region Group on Educational Affairs annual spring meeting. The abstract is paired with the integrative commentary of three experts who shared their thoughts stimulated by the study. These thoughts explore the value of examining intraoperative interactions among attending surgeons and residents for enhancing instructional scaffolding; entrustment decision making; and distinguishing teaching, learning, and performance in the workplace.
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Affiliation(s)
- Gary Sutkin
- a Departments of Biomedical and Health Informatics and Obstetrics and Gynecology , University of Missouri-Kansas City School of Medicine , Kansas City , Missouri , USA
| | - Eliza Beth Littleton
- b Department of Medicine , University of Pittsburgh School of Medicine , Pittsburgh , Pennsylvania , USA
| | - Steven L Kanter
- c Office of the Dean , University of Missouri-Kansas City School of Medicine , Kansas City , Missouri , USA
| | - Anna T Cianciolo
- d Department of Medical Education , Southern Illinois University School of Medicine , Springfield , Illinois , USA
| | - Xiaodong Phoenix Chen
- e Obstetrics Gynecology and Reproductive Biology , Brigham and Women's Hospital , Boston , Massachusetts , USA
| | - Alexandra Cope
- f Leeds Institution of Medical Education , University of Leeds , Leeds , England
| | - Timothy Koschmann
- d Department of Medical Education , Southern Illinois University School of Medicine , Springfield , Illinois , USA
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Stone JL, Aveling EL, Frean M, Shields MC, Wright C, Gino F, Sundt TM, Singer SJ. Effective Leadership of Surgical Teams: A Mixed Methods Study of Surgeon Behaviors and Functions. Ann Thorac Surg 2017; 104:530-537. [PMID: 28395873 PMCID: PMC5527126 DOI: 10.1016/j.athoracsur.2017.01.021] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 12/30/2016] [Accepted: 01/04/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND The importance of effective team leadership for achieving surgical excellence is widely accepted, but we understand less about the behaviors that achieve this goal. We studied cardiac surgical teams to identify leadership behaviors that best support surgical teamwork. METHODS We observed, surveyed, and interviewed cardiac surgical teams, including 7 surgeons and 116 team members, from September 2013 to April 2015. We documented 1,926 surgeon/team member interactions during 22 cases, coded them by behavior type and valence (ie, positive/negative/neutral), and characterized them by leadership function (conductor, elucidator, delegator, engagement facilitator, tone setter, being human, and safe space maker) to create a novel framework of surgical leadership derived from direct observation. We surveyed nonsurgeon team members about their perceptions of individual surgeon's leadership effectiveness on a 7-point Likert scale and correlated survey measures with individual surgeon profiles created by calculating percentage of behavior types, leader functions, and valence. RESULTS Surgeon leadership was rated by nonsurgeons from 4.2 to 6.2 (mean, 5.4). Among the 33 types of behaviors observed, most interactions constituted elucidating (24%) and tone setting (20%). Overall, 66% of interactions (range, 43%-84%) were positive and 11% (range, 1%-45%) were negative. The percentage of positive and negative behaviors correlated strongly (r = 0.85 for positive and r = 0.75 for negative, p < 0.05) with nonsurgeon evaluations of leadership. Facilitating engagement related most positively (r = 0.80; p = 0.03), and negative forms of elucidating, ie, criticism, related most negatively (r = -0.81; p = 0.03). CONCLUSIONS We identified 7 surgeon leadership functions and related behaviors that impact perceptions of leadership. These observations suggest actionable opportunities to improve team leadership behavior.
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Affiliation(s)
- Juliana L Stone
- Department of Health Research and Policy, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Emma-Louise Aveling
- Department of Health Research and Policy, Harvard T. H. Chan School of Public Health, Boston, Massachusetts; Cambridge Centre for Health Services Research, University of Cambridge, Cambridge, United Kingdom
| | - Molly Frean
- Department of Health Research and Policy, Harvard T. H. Chan School of Public Health, Boston, Massachusetts; Health Care Management Department, The Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Morgan C Shields
- Department of Health Research and Policy, Harvard T. H. Chan School of Public Health, Boston, Massachusetts; Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts
| | - Cameron Wright
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Francesca Gino
- Negotiation, Organizations & Markets, Harvard Business School, Boston, Massachusetts
| | - Thoralf M Sundt
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Sara J Singer
- Department of Health Research and Policy, Harvard T. H. Chan School of Public Health, Boston, Massachusetts; Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts.
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Timberlake MD, Mayo HG, Scott L, Weis J, Gardner AK. What Do We Know About Intraoperative Teaching? Ann Surg 2017; 266:251-259. [DOI: 10.1097/sla.0000000000002131] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Phitayakorn R, Kelz RR, Petrusa E, Sippel RS, Sturgeon C, Patel KN, Perrier ND. Expert consensus of general surgery residents’ proficiency with common endocrine operations. Surgery 2017; 161:280-288. [DOI: 10.1016/j.surg.2016.06.067] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 06/05/2016] [Accepted: 06/14/2016] [Indexed: 11/25/2022]
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Ambani SN, Lypson ML, Englesbe MJ, Santen S, Kasten S, Mullan P, Lee CT. The Surgery Fellow's Education Workshop: A Pilot Study to Determine the Feasibility of Training Senior Learners to Teach in the Operating Room. JOURNAL OF SURGICAL EDUCATION 2016; 73:741-748. [PMID: 26966080 DOI: 10.1016/j.jsurg.2016.02.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Revised: 01/05/2016] [Accepted: 02/01/2016] [Indexed: 06/05/2023]
Abstract
BACKGROUND In 2013, we developed an education workshop to enhance the teaching skills of surgical fellows. We sought to investigate the feasibility of the monthly educational workshop format and its effect on participant teaching skills. STUDY DESIGN Surgical and medical education faculty created a broadly applicable curriculum developed from evidence-based teaching principles, delivered across 8 monthly 90-minute weekday sessions. Workshop feasibility and effect were assessed using evaluations, attendance records, and a variety of self-reported surveys. Each session was associated with a specified education action plan to be completed between sessions. RESULTS A total of 13 fellows intended to participate. More than 60% attendance was achieved in 7 of 8 sessions. In all, 11 of 13 fellows were engaged (actual attendance or excused absence) across 75% or more of the sessions. Mean participant satisfaction scores ranged from 4.0 to 4.9 on a 5 point Likert scale across 87.5% of sessions. Postworkshop surveys showed increased understanding of the following: (1) knowledge gaps related to education; (2) the role of education for academic surgeons; (3) educational tools to improve teaching performance; and (4) perceived knowledge and attitudes about teaching in the operating room. An action plan was performed in 43% of cases; the most common reason for nonparticipation was lack of time (38%). CONCLUSIONS Our pilot supports the feasibility of an educational workshop series to enhance fellow's educational skills in the area of intraoperative teaching. Participant engagement and satisfaction were high in this self-selected group of initial trainees. Sessions were effective, resulting in a thoughtful self-assessment of teaching skills.
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Affiliation(s)
- Sapan N Ambani
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Monica L Lypson
- VA Ann Arbor Healthcare System, Ann Arbor, Michigan; Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan; Department of Learning Health Sciences, University of Michigan, Ann Arbor, Michigan
| | | | - Sally Santen
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, Michigan; Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan
| | - Steven Kasten
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Patricia Mullan
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, Michigan
| | - Cheryl T Lee
- Department of Urology, University of Michigan, Ann Arbor, Michigan.
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Chen XP, Williams RG, Smink DS. Dissecting Attending Surgeons' Operating Room Guidance: Factors That Affect Guidance Decision Making. JOURNAL OF SURGICAL EDUCATION 2015; 72:e137-e144. [PMID: 26153113 DOI: 10.1016/j.jsurg.2015.06.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 05/29/2015] [Accepted: 06/04/2015] [Indexed: 06/04/2023]
Abstract
PURPOSE The amount of guidance provided by the attending surgeon in the operating room (OR) is a key element in developing residents' autonomy. The purpose of this study is to explore factors that affect attending surgeons' decision making regarding OR guidance provided to the resident. METHODS We used video-stimulated recall interviews (VSRI) throughout this 2-phase study. In Phase 1, 3 attending surgeons were invited to review separately 30 to 45 minute video segments of their prerecorded surgical operations to explore factors that influenced their OR guidance decision making. In Phase 2, 3 attending surgeons were observed and documented in the OR (4 operations, 341min). Each operating surgeon reviewed their videotaped surgical performance within 5 days of the operation to reflect on factors that affected their decision making during the targeted guidance events. All VSRI were recorded. Thematic analysis and manual coding were used to synthesize and analyze data from VSRI transcripts, OR observation documents, and field notes. RESULTS A total of 255 minutes of VSRI involving 6 surgeons and 7 surgical operations from 5 different procedures were conducted. A total of 13 guidance decision-making influence factors from 4 categories were identified (Cohen's κ = 0.674): Setting (case schedule and patient morbidity), content (procedure attributes and case progress), resident (current competency level, trustworthiness, self-confidence, and personal traits), and attending surgeon (level of experience, level of comfort, preferred surgical technique, OR training philosophy, and responsibility as surgeon). A total of 5 factors (case schedule, patient morbidity, procedure attributes, resident current competency level, and trustworthiness) influenced attending surgeons' pre-OR guidance plans. "OR training philosophy" and "responsibility as surgeon" were anchor factors that affected attending surgeons' OR guidance decision-making patterns. CONCLUSIONS Surgeons' OR guidance decision making is a dynamic process that is influenced by 13 situational factors. These factors can be used by residency programs to tailor strategies designed to increase resident autonomy in the OR.
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Affiliation(s)
| | - Reed G Williams
- Department of Surgery, Indiana University, Indianapolis, Indiana
| | - Douglas S Smink
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
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