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Karmarkar T, Mahadev A, Bachar A, McKenzie A, Sutkin G. "Right Into the Center": A Semantic Analysis of Direction in Operating Room Instruction. JOURNAL OF SURGICAL EDUCATION 2024; 81:688-695. [PMID: 38548558 DOI: 10.1016/j.jsurg.2024.02.010] [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: 11/02/2023] [Revised: 02/11/2024] [Accepted: 02/19/2024] [Indexed: 04/26/2024]
Abstract
OBJECTIVE In our previous work, teaching surgeons used potentially ambiguous language in the OR 12.3 times per minute. Our objectives were to examine ambiguous examples featuring Directional Frame of Reference (DFoR), which involves instructions containing directional terms like "up" or "left," and to uncover what contributes to understanding or misunderstanding of such instruction. DESIGN We videorecorded the critical moments of 6 surgeries, as chosen by the surgeons. With a semanticist, we applied constructs from formal semantics to choose potentially ambiguous DFoR terms commonly flagged in our previous work. We separately interviewed attending and resident surgeons, asking each to describe the meaning of those DFoR terms while they viewed case recordings alongside transcripts. We compared their responses, analyzing them for agreement in direction. We performed thematic analysis on case and interview transcripts for themes related to DFoR. SETTING Midwestern academic university teaching hospital. PARTICIPANTS Six attending and 6 resident surgeons. RESULTS Attending and resident surgeons disagreed on direction in 9 of the 26 (34.6%) DFoR examples. Misunderstanding arose from using linear direction to describe three-dimensional space, e.g., "up" for anterior/cephalad/right. It also arose when combining degree modifiers with DfoR, e.g., "we're far enough back" combines the ambiguities of "back" (DfoR) and "far enough" (degree modifier). Use of axial parts (noun-like directional terms), e.g., "bottom," and confusing "left" for "right" also provoked misunderstanding. Misunderstanding was associated with lack of experience and mitigated by pointing with a finger or instrument, concurrent with speech. CONCLUSIONS Use of ambiguous language with DFoR incurs a high potential for misunderstanding, especially with novice surgeons. We recommend avoiding linear directions and axial parts, and instead physically pointing to represent complex 3D directions. Degree modifiers can be replaced with exact distances e.g., replace "little more anterior" with "1 centimeter anterior," and semaphores can be used to clarify direction.
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Affiliation(s)
- Tanvi Karmarkar
- Female Pelvic Medicine and Reconstructive Surgery, University of Missouri Kansas City School of Medicine, 2411 Holmes Street, Kansas City, MO 64108
| | - Ashna Mahadev
- Female Pelvic Medicine and Reconstructive Surgery, University of Missouri Kansas City School of Medicine, 2411 Holmes Street, Kansas City, MO 64108
| | - Austin Bachar
- Female Pelvic Medicine and Reconstructive Surgery, University of Missouri Kansas City School of Medicine, 2411 Holmes Street, Kansas City, MO 64108
| | - Andrew McKenzie
- Department of Linguistics, University of Kansas, 1541 Lilac Lane, Lawrence, KS 66045
| | - Gary Sutkin
- Female Pelvic Medicine and Reconstructive Surgery, University of Missouri Kansas City School of Medicine, 2411 Holmes Street, Kansas City, MO 64108.
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A Novel Framework for Routine Versus Critical Communication in Surgical Education-Don't Take It Personally. J Am Acad Orthop Surg 2023; 31:115-121. [PMID: 36656272 DOI: 10.5435/jaaos-d-22-00912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 11/11/2022] [Indexed: 01/20/2023] Open
Abstract
Despite their impressive academic track records and mastery of controlled classroom-based didactic learning, many orthopaedic surgery residents struggle to adjust from learning in the classroom environment in medical school to learning in the operating room as surgical residents. Instead of learning in lectures, surgical residents take on a more apprenticeship-based role with the goal of mastering technical skills in an experiential learning environment. Yet, no framework has been explicitly described in the literature to help learners make this transition. Consequently, we feel there is a need to clearly define the different learning environments and modes of communication, such that the residents can better understand how information is acquired and retained as well as how feedback is delivered in the operating room compared with more traditional spaces (eg, medical school classroom). The objectives of this summary are to (1) identify the major differences between learning in the classroom environment and the operating room and (2) introduce the concept of routine versus critical communication. We hope that by better defining the new learning environment with an emphasis on communication styles that may be encountered in this setting, learners can more easily make the transition from high-performing academicians to high-performing surgeons.
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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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Liu C, McKenzie A, Sutkin G. Semantically Ambiguous Language in the Teaching Operating Room. JOURNAL OF SURGICAL EDUCATION 2021; 78:1938-1947. [PMID: 33903062 DOI: 10.1016/j.jsurg.2021.03.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 03/23/2021] [Accepted: 03/28/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE Teaching and training surgeons work hard in the OR to understand each other, yet miscommunication is an important cause of preventable adverse events in surgery. Our objective was to perform a formal semantic analysis of language in authentic teaching surgical cases, identify the prevalence and typology of ambiguous or potentially ambiguous language, and describe their potential for miscommunication. DESIGN In this secondary analysis of qualitative data, we collaborated with a semanticist, categorizing linguistic phenomena often associated with miscommunication. We defined an ambiguous phenomenon as a string of language that could be reasonably interpreted in more than one way. We analyzed transcripts of 319 minutes of surgery, coding for 14 linguistic categories. Cohen's kappa was calculated. We determined the prevalence and rate of each linguistic category and chose illustrative examples. PARTICIPANTS AND SETTING Six surgical attendings, four fellows, and six residents, ranging from PGY1 to PGY4, at the University of Pittsburgh Medical Center, a tertiary medical center in Pittsburgh, Pennsylvania. RESULTS We found 3912 examples of potentially ambiguous language, 12.3 per minute. Percentage agreement between two expert raters was 76.3%. The most common phenomena were deixis (3.1 per minute), directional (2.6), anaphora (1.3), implicit instruction (1.3), and degree modifiers (0.7). Restatements/reframing occurred 1.4 times per minute. We identified 131 near misses associated with potentially ambiguous language. Cohen's kappa was 0.70 among expert semanticists. CONCLUSIONS Potentially ambiguous language is common and has the potential to jeopardize safe teaching surgery. We postulate that the high amount of potentially ambiguous language use in the operating room places a burden on the training surgeon to comprehend surgical instruction.
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Affiliation(s)
- Cynthia Liu
- Department of Obstetrics and Gynecology, Female Pelvic Medicine and Reconstructive Surgery, University Missouri Kansas City School of Medicine, Kansas City, Missouri
| | - Andrew McKenzie
- Department of Linguistics, University of Kansas, Kansas City, Missouri
| | - Gary Sutkin
- Department of Obstetrics and Gynecology, Female Pelvic Medicine and Reconstructive Surgery, University Missouri Kansas City School of Medicine, Kansas City, Missouri.
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Levin M, McKechnie T, Kruse CC, Aldrich K, Grantcharov TP, Langerman A. Surgical data recording in the operating room: a systematic review of modalities and metrics. Br J Surg 2021; 108:613-621. [PMID: 34157080 DOI: 10.1093/bjs/znab016] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 10/09/2020] [Accepted: 12/28/2020] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Operating room recording, via video, audio and sensor-based recordings, is increasingly common. Yet, surgical data science is a new field without clear guidelines. The purpose of this study is to examine existing published studies of surgical recording modalities to determine which are available for use in the operating room, as a first step towards developing unified standards for this field. METHODS Medline, EMBASE, CENTRAL and PubMed databases were systematically searched for articles describing modalities of data collection in the operating room. Search terms included 'video-audio media', 'bio-sensing techniques', 'sound', 'movement', 'operating rooms' and others. Title, abstract and full-text screening were completed to identify relevant articles. Descriptive statistical analysis was performed for included studies. RESULTS From 3756 citations, 91 studies met inclusion criteria. These studies described 10 unique data-collection modalities for 17 different purposes in the operating room. Data modalities included video, audio, kinematic and eye-tracking among others. Data-collection purposes described included surgical trainee assessment, surgical error, surgical team communication and operating room efficiency. CONCLUSION Effective data collection and utilization in the operating room are imperative for the provision of superior surgical care. The future operating room landscape undoubtedly includes multiple modalities of data collection for a plethora of purposes. This review acts as a foundation for employing operating room data in a way that leads to meaningful benefit for patient care.
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Affiliation(s)
- M Levin
- Department of Otolaryngology, Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - T McKechnie
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - C C Kruse
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - K Aldrich
- Center for Medical Interoperability, Nashville, Tennessee, USA
| | - T P Grantcharov
- International Center for Surgical Safety, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Ontario, Canada
| | - A Langerman
- Center for Medical Interoperability, Nashville, Tennessee, USA.,International Center for Surgical Safety, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Ontario, Canada.,Department of Otolaryngology - Head and Neck Surgery, Department of Radiology and Radiological Sciences, Surgical Analytics Lab, Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Sutkin G, Littleton EB, Arnold L, Kanter SL. Micro-relational interdependencies are the essence of teaching and learning in the OR. MEDICAL EDUCATION 2020; 54:1137-1147. [PMID: 32794212 DOI: 10.1111/medu.14353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 07/23/2020] [Accepted: 08/07/2020] [Indexed: 06/11/2023]
Abstract
CONTEXT In the high-stakes, time-critical environment of the operating room (OR), attendings and residents strive to complete safe, effective surgeries and ensure that learning occurs. Yet meaningful resident participation often receives less attention, and that impedes residents' ability to learn and achieve autonomous operative practice. We need a new conceptual framework for understanding progression to autonomous practice that can guide both faculty and residents. Thus, we sought a new conceptualisation of intraoperative teaching and learning (IOT&L) through the lens of Eraut's notion of informal workplace learning and Billett's theory of relational interdependence between social and individual agency. METHODS We viewed authentic examples of IOT&L in video and transcripts of live OR cases and interviews with participating attendings and residents. By systematically applying Eraut and Billet's theories to the transcripts and interviews, we developed concrete descriptions about how IOT&L occurs, categorised them into theory-based principles and derived a conceptualisation and related research ideas about IOT&L. RESULTS Established workplace learning theories frame IOT&L as socially negotiated processes transpiring in distinct interdependent interactions between residents' individual cognitive experiences and their OR social experiences that direct their learning. As the surgery unfolds, spontaneous events and the rules of surgery create opportunities for unplanned and informal learning. These authentic interrelated cognitive and social experiences are stimulated when residents reveal a learning need or attendings recognise a learning gap, and efforts ensue to bridge that gap. Through these minute distinct exchanges, labelled here as 'atomic' IOT&L, residents gain crucial knowledge and skill. CONCLUSION Framing authentic OR interactions between attendings and residents in terms of micro-relational interdependencies shows how granular teaching/learning exchanges yield high-value informal learning. To improve IOT&L, we must examine and change it at this fundamental level by using and testing this new theoretical conceptualisation. These insights produced ideas about IOT&L to test and research.
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Affiliation(s)
- Gary Sutkin
- University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | | | - Louise Arnold
- University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
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Systematic Review of Intraoperative Assessment Tools in Minimally Invasive Gynecologic Surgery. J Minim Invasive Gynecol 2020; 28:692-697. [PMID: 33086146 PMCID: PMC7568765 DOI: 10.1016/j.jmig.2020.10.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 10/07/2020] [Accepted: 10/15/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To collect, summarize, and evaluate the currently available intraoperative rating tools used in abdominal minimally invasive gynecologic surgery (MIGS). DATA SOURCES Medline, Embase, and Scopus databases from January 1, 2000, to May 12, 2020. METHODS OF STUDY SELECTION A systematic search strategy was designed and executed. Published studies evaluating an assessment tool in abdominal MIGS cases were included. Studies focused on simulation, reviews, and abstracts without a published manuscript were excluded. Risk of bias and methodological quality were assessed for each study. TABULATION, INTEGRATION, AND RESULTS Disparate study methods prevented quantitative synthesis of the data. Ten studies were included in the analysis. The tools were grouped into global (n = 4) and procedure-specific assessments (n = 6). Most studies evaluated small numbers of surgeons and lacked a comparison group to evaluate the effectiveness of the tool. All studies demonstrated content validity and at least 1 dimension of reliability, and 2 have external validity. The intraoperative procedure-specific tools have been more thoroughly evaluated than the global scales. CONCLUSION Procedure-specific intraoperative assessment tools for MIGS cases are more thoroughly evaluated than global tools; however, poor-quality studies and borderline reliability limit their use. Well-designed, controlled studies evaluating the effectiveness of intraoperative assessment tools in MIGS are needed.
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Brennan P, De Martino M, Ponnusamy M, White S, De Martino R, Oeppen R. Review: Avoid, trap, and mitigate – an overview of threat and error management. Br J Oral Maxillofac Surg 2020; 58:146-150. [DOI: 10.1016/j.bjoms.2020.01.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 01/02/2020] [Indexed: 11/27/2022]
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Surgical education research: How to move beyond the survey. Surgery 2019; 167:269-272. [PMID: 31253415 DOI: 10.1016/j.surg.2019.05.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 05/15/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Surgical education serves as the foundation for high-quality, efficient patient care. Because clinical knowledge is gained and newer surgical techniques developed, this material is incorporated into the curricula of surgical trainees. Methods for studying this integration vary widely, however, providing data that, at times, is challenging to interpret in the context of patient care and outcomes. METHODS A review of the literature was conducted to evaluate current practices in surgical education research, as well as topics areas of focus. RESULTS Several techniques in surgical education research currently exist, including surveys, knowledge assessments, tests of skill, and single-arm educational interventions, which may or may not include a prepost design with assessments administered both before and immediately following the intervention. The applicability of these measures to patient outcomes is variable. CONCLUSION Research in surgical education represents a field of great interest, with opportunity for novel investigations among a broad collection of topic areas. Educational research should be approached in a methodologically rigorous fashion with high investigational standards in order to advance the education of surgical trainees and the care of surgical patients.
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