Efforts to enhance operating room teaching

Intraoperative teaching methods, models, and frameworks: A scoping review for surgical resident education

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.

Perceptions and Guiding Strategies to Regulate Entrusted Autonomy of Residents in the Operating Room: A Systematic Literature Review

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.

Matching intraoperative teaching and learning for medical undergraduates via modified briefing-intraoperative teaching-debriefing (BID) model

Intraoperative teaching is a challenging task. The briefing-intraoperative teaching-debriefing (BID) model, which is based on guided discovery learning at limited time intervals, has rarely been investigated. This study validated the benefits of the modified BID model on medical clerks. This study involved 37 first-year medical clerks enrolled from September 2019 to May 2020. Every learner scrubbed in one the totally implantable venous access device placement surgery and completed a pre-/posttest survey on surgical procedures and associated anatomy conducted through an intraoperative teaching questionnaire. Of these participants, 15 merely observed throughout the entire procedure (observation group), whereas the remaining 22 performed simple suturing under supervision (suturing group). All participants underwent an objective structured assessment of simple interrupted suturing skills at the end of the observership. Correlations were tested using a two-tailed paired t-test, with a p-value < 0.05 indicating statistical significance. The response rate was 100% and participants could reconfirm the precise venous access, catheter tip location, and suture materials for portal fixation after totally implantable venous access device placement (p < 0.05). Although a relatively higher satisfaction of the intraoperative teaching environment and educator attitude was reported in the suturing group than in the observation group, the difference in scores on the objective structured assessment was not statistically significant (8.7 ± 1.8 vs. 7.2 ± 3.7; p = 0.104). Our findings indicate that the modified BID model with hands-on experience is a practicable module for matching intraoperative teaching and learning via learning perception enhancement for medical undergraduates during totally implantable venous access device placement.

Intervention for Intraoperative Teaching in Anesthesiology Using Weekly Keyword Program: Development and Usability Study

BACKGROUND

Learning in the operating room (OR) for residents in anesthesiology is difficult but essential for successful resident education. Numerous approaches have been attempted in the past to varying degrees of success, with efficacy often judged afterward using surveys distributed to participants. The OR presents a particularly complex set of challenges for academic faculty due to the pressures required by concurrent patient care, production pressures, and a noisy environment. Often, educational reviews in ORs are personnel specific, and instruction may or may not take place in this setting, as it is left to the discretion of the parties without regular direction.

OBJECTIVE

This study aims to determine if a structured intraoperative keyword training program could be used to implement a curriculum to improve teaching in the OR and to facilitate impactful discussion between residents and faculty. A structured curriculum was chosen to allow for the standardization of the educational material to be studied and reviewed by faculty and trainees. Given the reality that educational reviews in the OR tend to be personnel specific and are often focused on the clinical cases of the day, this initiative sought to increase both the time and efficiency of learning interactions between learners and teachers in the stressful environment of the OR.

METHODS

The American Board of Anesthesiology keywords from the Open Anesthesia website were used to construct a weekly intraoperative didactic curriculum, which was distributed by email to all residents and faculty. A weekly worksheet from this curriculum included 5 keywords with associated questions for discussion. The residents and faculty were instructed to complete these questions on a weekly basis. After 2 years, an electronic survey was distributed to the residents to evaluate the efficacy of the keyword program.

RESULTS

A total of 19 teaching descriptors were polled for participants prior to and following the use of the intraoperative keyword program to assess the efficacy of the structured curriculum. The survey results showed no improvement in intraoperative teaching based on respondent perception, despite a slight improvement in teaching time, though this was statistically insignificant. The respondents reported some favorable aspects of the program, including the use of a set curriculum, suggesting that greater structure may be beneficial to facilitate more effective intraoperative teaching in anesthesiology.

CONCLUSIONS

Although learning is difficult in the OR for residents, the use of a formalized didactic curriculum, centered on daily keywords, does not appear to be a useful solution for residents and faculty. Further efforts are required to improve intraoperative teaching, which is well known to be a difficult endeavor for both teachers and trainees. A structured curriculum may be used to augment other educational modalities to improve the overall intraoperative teaching for anesthesia residents.

Attributes of excellent clinician teachers and barriers to recognizing and rewarding clinician teachers' performances and achievements: a narrative review

BACKGROUND

Over the last 31 years, there have been several institutional efforts to better recognize and reward clinician teachers. However, the perception of inadequate recognition and rewards by clinician teachers for their clinical teaching performance and achievements remains. The objective of this narrative review is two-fold: deepen understanding of the attributes of excellent clinician teachers considered for recognition and reward decisions and identify the barriers clinician teachers face in receiving recognition and rewards.

METHODS

We searched OVID Medline, Embase, Education Source and Web of Science to identify relevant papers published between 1990 and 2020. After screening for eligibility, we conducted a content analysis of the findings from 43 relevant papers to identify key trends and issues in the literature.

RESULTS

We found the majority of relevant papers from the US context, a paucity of relevant papers from the Canadian context, and a declining international focus on the attributes of excellent clinician teachers and barriers to the recognition and rewarding of clinician teachers since 2010. 'Provides feedback', 'excellent communication skills', 'good supervision', and 'organizational skills' were common cognitive attributes considered for recognition and rewards. 'Stimulates', 'passionate and enthusiastic', and 'creates supportive environment', were common non-cognitive attributes considered for recognition and rewards. The devaluation of teaching, unclear criteria, and unreliable metrics were the main barriers to the recognition and rewarding of clinician teachers.

CONCLUSIONS

The findings of our narrative review highlight a need for local empirical research on recognition and reward issues to better inform local, context-specific reforms to policies and practices.

Learning outcomes of structured perioperative teaching based on adult learning

BACKGROUND

Self-directed learning is the cornerstone of adult learning. The aim of the study was to investigate the improvement of core competency and increase interest to be a surgeon among medical students after a perioperative training through a structured learning with written record model. The mediating role of adult learning pattern on core competency was also examined.

METHODS

A 2-week training protocol was based on a structural learning model which included a structured written record by the learner for postoperative immediate feedback. An adult learning questionnaire (ALQ) was developed to assess learners' adult learning pattern and a clinical core competency questionnaire (CCCQ) was developed to assess learning outcomes. A two-way repeated measured of ANCOVA would be used to analyze the interaction effect of adult learning pattern and learning effect on learning outcomes.

RESULTS

From Jan 2017 to Dec 2019, 412 medical students were enrolled in the study. The increase scores of CCCQ and a significant numbers of increase interest to be a surgeon were shown after the perioperative training. Two-way repeated measure ANOVA revealed that there were significant differences in change between pre- and post-CCCQ across four levels of ALQ (interaction effect F = 13.0, p <0.001). The more adult learning patterns medical students own, the more they will benefit from the training.

CONCLUSIONS

The structural learning with written record model provides an effective perioperative training represented with clinical core competency and increase the interest to be a surgeon in the future. Medical students with tendency of adult learning pattern would learn better.

Trigger videos: a novel application of a tool for surgical faculty development

BACKGROUND

Trigger videos have occasionally been used in medical education; however, their application to surgical faculty development is novel. We assessed participants' attitudes towards workshops on intraoperative teaching (IOT) that were anchored by trigger videos, and studied whether they could generate discussion-for-learning among surgeons in this workshop setting.

METHODS

Surgeons from multiple specialties attended one of six faculty development workshops where IOT trigger videos were shown and discussed during break-out sessions. Participants completed questionnaires to (1) evaluate videos via survey and feedback, and (2) identify adoptable and discardable IOT techniques. Teaching techniques were collated to identify planned IOT changes and survey data and feedback were analyzed.

RESULTS

A total of 135 surgeons identified 292 adoptable and 202 discardable IOT techniques based on trigger videos and discussions, and 94% of participants reported that the trigger videos were useful and encouraged them to discuss and consider new IOT techniques in their own practice.

CONCLUSIONS

Participants reported that the trigger videos were useful and motivating. Surgeons critically reflected on IOT during the sessions, identifying numerous adoptable and discardable techniques relevant to their own teaching styles. Trigger videos can be a valuable tool for surgical faculty development and can be tailored to other medical specialties.

Learning in the Operating Theatre: A Thematic Analysis of Opportunities Lost and Found

OBJECTIVE

The operating theatre (OT) is an important learning environment. Trainees face barriers to learning in the OT that may reduce meaningful educational interactions. The impact of these barriers on the intraoperative learning experience of trainees and the strategies that they employ to overcome them are not known. This qualitative study aimed to describe the intraoperative learning experiences of senior general surgery trainees in Australia and their strategies to optimize learning in the OT.

DESIGN, SETTING, PARTICIPANTS

The authors developed a semi-structured interview guide based on published literature. Purposive sampling was used to identify a representative group of general surgery trainees in Australia, who were interviewed in a private setting with audio recordings deidentified for verbatim transcription and analysis. Thematic analysis was conducted using an interpretivist approach to produce a coding framework.

RESULTS

Ten trainees participated in the study. Themes were divided into external and internal barriers to learning, promoters of effective learning and actions to facilitate learning. External barriers included cultural neglect of an important issue, with inadequate prioritization of teaching and a lack of structure for intraoperative learning. From this, we identified the theme of missed opportunities. Internal barriers included difficulties in developing assertiveness required to address these issues and a failure to adequately plan for learning, with reliance on the mentor to initiate. Actions to facilitate learning were rarely employed by trainees, as most were unaware of strategies to maximize intraoperative learning.

CONCLUSIONS

Trainees find the barriers to learning in the OT difficult to address and are not well acquainted with strategies that may allow them to maximize their learning.

Operating Room Educational Environment in Canada: Perceptions of Surgical Residents

OBJECTIVE

The educational experience in operating rooms (OR) plays a central role in the transformation of a trainee into a surgeon. As Canadian residency programs transition to competency-based medical education, and since most surgical competencies are attained in the OR, we investigated the perceptions of Canadian surgical residents about their OR learning environment.

DESIGN

Cross-sectional, national survey.

SETTING

An online questionnaire, including the validated 40-item operating room educational environment measure (OREEM) inventory, was sent to residency programs of all surgical specialties in Canada. The OREEM assesses the trainees' perceptions of the "trainer and training," "learning opportunities," "atmosphere in the operating room," "supervision, workload, and support," Each individual item was rated using a 5-point Likert scale ranging from "strongly disagree" (scores 1) to "strongly agree" (scores 5). The mean score of each individual item was measured, and the mean scores of each subscale and an overall score of the questions were also measured.

PARTICIPANTS

Surgical residents in Canada.

RESULTS

Four hundred thirty residents were included for final analysis. The overall mean OREEM score was 3.72 ± 0.4. "Atmosphere in the OR" was the subscale with the highest mean score (3.87 ± 0.5), while "supervision, workload, and support" had the lowest subscale mean score (3.49 ± 0.5). The overall OREEM mean score for junior and senior residents was 3.67 ± 0.4 and 3.80 ± 0.4, respectively (p = 0.001). No significant differences were seen in the mean OREEM score between males and females or different surgical programs. Nevertheless, general surgery had the lowest "supervision, workload, and support" subscale score (3.27 ± 0.5; p < 0.001).

CONCLUSIONS

The overall educational environment in OR may be considered satisfactory as perceived by Canadian surgical residents; however, several areas for potential improvement are identified and suggestions for optimizing the learning environment are described.

Disparity of perspectives between teachers and learners on perioperative teaching and learning

BACKGROUND

To build a consensus about learning objectives in the operating room, the aim of the study was to evaluate both surgical teacher and learner perspectives on perioperative teaching and learning in Taiwan.

METHODS

Twelve main technical and non-technical learning objectives in the operating room were evaluated by learners and surgical teachers in Kaohsiung Medical University Hospital. The learners included postgraduate year (PGY) 1-3 residents (junior learner, JL) and PGY 4-7 residents (senior learner, SL). The definition of learning preferences were recommended learning objectives, and learning load was defined as demands of learning preferences. During the survey, surgical teachers evaluated the learning preferences for the learner, and learners evaluated their learning preferences. The learners also evaluated the learning preferences that the surgical teachers should teach.

RESULTS

Response rate of the questionnaire was 65.4%. A total of 31 learners and 39 surgical teachers completed the survey. The consensus was that the need to increase the learning loads and ethical issues were the learning preferences for SL, and indications, details of procedure, and teamwork were important to both JL and SL. The teachers intended to set specific learning objectives for different learner levels, including (i) indications, details of procedure, teamwork, and postoperative care for both JL and SL; (ii) preoperative preparation, surgical anatomy, and instrument handling for JL (P = 0.022, 0.021 and 0.006); and (iii) surgical technique, independent practice, clinical reasoning, complications, and ethical issues for SL (P = 0.010, < 0.001, < 0.001, 0.001, 0.011). Resident perspective on learning objectives differed between JL and SL, and there was discrepancy between resident's learning as perceived by teachers, particularly in the JL.

CONCLUSIONS

Our study revealed significant disparity of perspectives between teachers and learners on perioperative teaching and learning. Surgical teachers should set specific learning objectives for different learner levels, since junior and senior residents have different learning preferences even though both scrub in the same case. Effective communication between teachers and learners has the potential to improve learning experience and create a positive environment in the operating room.

General Surgery Residents' Perception of Feedback: We Can Do Better

BACKGROUND

Feedback (FB) regarding perioperative care is essential in general surgery residents' (GSRs) training. We hypothesized that FB would be distributed unevenly across preoperative (PrO), intraoperative (IO), and postoperative (PO) continuum of the perioperative period. We aimed to compare results between university- and community-hospital settings planning to institute structured, formalized FB in a large health care system operating multiple surgery residency programs in departments that are linked strategically.

METHODS

Quantitative, cross-sectional, Likert scale anonymous surveys were distributed to all GSRs (categorical and preliminary; university: community 1:2). Twenty-five questions considered frequency and perceived quality of FB in PrO, IO, and PO settings. Data were tabulated using REDCap and analyzed in Microsoft Excel using the Mann-Whitney U test, with α = 0.05. Comparisons were made between university- and community-hospital settings, between junior (Post-Graduate Year (PGY) 1-3) and senior (PGY 4-5) GSRs, and by gender.

RESULTS

Among 115 GSRs surveyed, 83 (72%) responded. Whereas 93% reported receiving some FB within the past year, 46% reported receiving FB ≤ 20% of the time. A majority (58%) found FB to be helpful ≥ 80% of the time. Among GSRs, 77%, 24%, and 64% reported receiving PrO, IO, or PO FB ≤ 20% of the time, respectively, but 52% also believed that FB was lacking in all 3 areas. Most GSRs wanted designated time for PrO planning FB (82%) and PO FB (87%), respectively. Thirty-six percent of GSRs reported that senior/chief (i.e., PGY-4/PGY-5 GSRs) took them through cases ≥40% of the time; notably,78% reported that FB from senior/chief GSRs was equally or more valuable than FB from attending surgeons. A majority (78%) reported that attending surgeons stated explicitly when they were providing FB only ≤20% of the time. GSRs at the community hospital campuses reported receiving a higher likelihood of "any" FB, IO FB, and PO FB (p < 0.05). Most GSRs surveyed preferred a structured format and designated times for debriefing and evaluation of performance. Subanalyses of gender and GSR level of training showed no differences.

CONCLUSIONS

FB during GSR training varies across the perioperative continuum of care. Community programs seem to do better than University Programs. More work need to be done to elucidate why differences exist between the frequency of FB at University and Community programs. Further, data show particularly low FB outside of the operating room. Ideally, according to respondents, FB would be provided in a structured format and at designated times for debriefing and evaluation of performance, which poses a challenge considering the temporal dynamism of general surgery services.

Correlation between students' and trainers' evaluations while learning delegated surgical procedures: A prospective cohort study

BACKGROUND

The delegation of procedures within the medical competence to the nurses can increase the effectiveness of the healthcare provided. The objectives of the study are (1) to assess the quality of training courses for delegated surgical procedures through implementation for graduate scrub nursing ("students") (2) and to evaluate the correlation between the evaluation of this training carried out by students and the self-assessment conducted by the faculty ("trainers").

MATERIALS AND METHODS

We set up a 49-h training for five groups of 10 students from July 2016 to July 2017 in our tertiary academic hospital. The course consisted mostly in simulations based on the "Zwisch" model and focused on acquiring the control of the gesture as well as on the development of critical reasoning. An evaluation of the training by the students but also a self-assessment of trainers were prospectively collected using the SFDP26 questionnaire.

RESULTS

52 active scrub nursing students and 21 trainers were included. 96% of students and 86% of trainers evaluated the training from "good" to "very good". Progress was observed for 41 (79%) of the students and 18 (86%) of the trainers, and 98% of students felt able to put their new skills into clinical practice after training. There was no difference between the total scores of students and teachers (p = 0.153). A statistically significant difference between the evaluations produced by the students and the self-evaluations produced by the trainers was observed for 8 of the 26 items of assessment. In case of inadequacy, the trainers' scores were always lower than those of the students.

CONCLUSIONS

Training in performing delegated surgical procedures by mixed cognitive and motor gestures learning, based on the development of critical thinking and simulations seems to be effective, with a significant improvement in students' knowledge and skills. Expectations of students and trainers are well correlated.

How postgraduate trainees from different health professions experience the learning climate within an operating theater: a mixed-methods study

BACKGROUND

The learning climate within a learning environment is a key factor to determine the potential quality of learning. There are different groups of postgraduate trainees who study primarily in the operating theater (OT), which is a complex, high-stake environment. This study created and validated an interprofessional measure of the OT educational climate and explored how postgraduate trainees from different health professions experienced the learning climate within the operating theater.

METHODS

An explanatory, sequential mixed-method design was used. The quantitative phase used and validated a newly developed questionnaire, the Operating Theater Educational Climate Test (OTECT), to evaluate the perceptions of anesthesia residents, surgical residents and student registered nurse anesthetists. In the qualitative phase, three mono-professional focus groups participants' opinions on the factors influencing their learning climate were explored.

RESULTS

The OTECT questionnaire was found to be valid. The questionnaire response rate was 78.9% (142 respondents from 180). Questionnaire results indicated similar perceptions of the OT learning climate by learners from all disciplines. Focus groups revealed three major influencing factors on the experienced learning climate: 1) nature of work in the OT, 2) the role of the supervisor, and 3) the interprofessional dimension of work in the OT.

CONCLUSIONS

The OT learning climate was perceived similarly by trainees from three health profession. The high stakes nature of the OT inhibited learning most as it impacted both trainees and supervisors. The results can be applied to improve the overall learning environment in the OT for all groups of learners.

Questions Posed by Residents in the Operating Room: A Thematic Analysis

OBJECTIVE

Questioning behavior is a type of intraoperative communication for which little information exists on the types of questions that residents ask. The purpose of this study is to describe and identify themes of questions asked by residents in the operating room.

DESIGN

Trained observers documented questions asked by residents during operations. Thematic analysis was applied.

SETTING

University of Utah Hospital (Salt Lake City, Utah) operating rooms; institutional.

PARTICIPANTS

A total of 10 general surgical residents (postgraduate year 1 to 5) were observed along with 10 attending general surgeons. Cases were purposefully selected to be broadly representative of general surgery cases.

RESULTS

Thematic saturation occurred following examination of 16 operative cases, which included 178 questions asked by residents. Two broad categories of questions emerged: case-related (71%) and noncase-related (29%), with multiple subcategories within the 2 groups. Case-related subcategories included operative techniques, logistics, patient care, and other. Questions unrelated to the case included subcategories of social, work-related but unrelated to case, other. Less than 1% of questions asked by residents during operations were reflective.

CONCLUSIONS

Most questions related to the case were technical and most of those unrelated to the case were social; almost all questions were transactional in nature. Our identification of questioning themes by residents expands understanding of resident questioning behaviors, and therefore may enable residents and faculty to be more effective in establishing entrustment.

Identifying Priorities for Faculty Development in General Surgery Using the Delphi Consensus Method

OBJECTIVE

Faculty teaching skills are critical for effective surgical education, however, which skills are most important to be taught in a faculty development program have not been well defined. The objective of this study was to identify priorities for faculty development as perceived by surgical educators.

DESIGN

We used a modified Delphi methodology to assess faculty perceptions of the value of faculty development activities, best learning modalities, as well as barriers and priorities for faculty development. An expert panel developed the initial survey and distributed it to the membership of the Association of Program Directors in Surgery. Responses were reviewed by the expert panel and condensed to 3 key questions that were redistributed to the survey participants for final ranking.

PARTICIPANTS

Seven experts reviewed responses to 8 questions by 110 participants. 35 participants determined the final ranking responses to 3 key questions.

RESULTS

The top three priorities for faculty development were: 1) Resident assessment/evaluation and feedback 2) Coaching for faculty teaching, and 3) Improving intraoperative teaching skills. The top 3 learning modalities were: 1) Coaching 2) Interactive small group sessions, and 3) Video-based education. Barriers to implementing faculty development included time limitations, clinical workload, faculty interest, and financial support.

CONCLUSIONS

Faculty development programs should focus on resident assessment methods, intraoperative and general faculty teaching skills using a combination of coaching, small group didactic and video-based education. Concerted efforts to recognize and financially reward the value of teaching and faculty development is required to support these endeavors and improve the learning environment for both residents and faculty.

Mixed-Method Evaluation of a Cadaver Dissection Course for General Surgery Interns: An Innovative Approach for Filling the Gap Between Gross Anatomy and the Operating Room

OBJECTIVE

To evaluate an innovative whole cadaver dissection curriculum designed to focus on teaching procedure-relevant anatomy and surgical skills to surgery interns.

DESIGN

A mixed methods explanatory sequential design incorporating both quantitative and qualitative evaluations was used to evaluate the cadaver dissection course. Quantitative data were prospectively collected and retrospectively reviewed in order to compare anatomy knowledge and operative skills before and after the course. In the qualitative phase, open-ended telephone interviews were conducted in order to explore the major strengths and weaknesses of the course and gain a more in-depth understanding of resident perceptions and attitudes toward the course.

SETTING

All UCLA categorical surgery interns who have undergone the cadaver dissection curriculum between the years 2010 to 2016 were recruited for evaluation and interview.

PARTICIPANTS

From 2010 to 2016, 6 to 7 categorical surgery interns were enrolled in the cadaver dissection course each year.

RESULTS

Anatomy practical examination scores increased following implementation of the course from 50.5% to 83.5% (p < 0.01). Faculty ratings of operative skills improved as well (average Likert scale rating for technical skills improved from 4.1 ± 0.4 to 4.4 ± 0.3, p = 0.06). Almost all interviewees (96%) reported that the course improved their knowledge of anatomy, and 78% of respondents believed the course was conducive to improving technical skills.

CONCLUSIONS

We believe that cadaver dissection courses offer a superior educational model for teaching clinically relevant anatomy as well as surgical skills. We found improvements in anatomy knowledge and technical skills, and trainees expressed strongly favorable views of the program.

Perioperative feedback in surgical training: A systematic review

BACKGROUND

Changes in surgical training have raised concerns about residents' operative exposure and preparedness for independent practice. One way of addressing this concern is by optimizing teaching and feedback in the operating room (OR). The objective of this study was to perform a systematic review on perioperative teaching and feedback.

METHODS

A systematic literature search identified articles from 1994 to 2014 that addressed teaching, feedback, guidance, or debriefing in the perioperative period. Data was extracted according to ENTREQ guidelines, and a qualitative analysis was performed.

RESULTS

Thematic analysis of the 26 included studies identified four major topics. Observation of teaching behaviors in the OR described current teaching practices. Identification of effective teaching strategies analyzed teaching behaviors, differentiating positive and negative teaching strategies. Perceptions of teaching behaviors described resident and attending satisfaction with teaching in the OR. Finally models for delivering structured feedback cited examples of feedback strategies and measured their effectiveness.

CONCLUSIONS

This study provides an overview of perioperative teaching and feedback for surgical trainees and identifies a need for improved quality and quantity of structured feedback.

The Surgery Fellow's Education Workshop: A Pilot Study to Determine the Feasibility of Training Senior Learners to Teach in the Operating Room

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.

Resident training in a teaching hospital: How do attendings teach in the real operative environment?

BACKGROUND

The study aim was to explore the nature of intraoperative education and its interaction with the environment where surgical education occurs.

METHODS

Video and audio recording captured teaching interactions between colorectal surgeons and general surgery residents during laparoscopic segmental colectomies. Cases and collected data were analyzed for teaching behaviors and workflow disruptions. Flow disruptions (FDs) are considered deviations from natural case progression.

RESULTS

Across 10 cases (20.4 operative hours), attendings spent 11.2 hours (54.7%) teaching, using directing (M = 250.1), and confirming (M = 236.1) most. FDs occurred 410 times, accounting for 4.4 hours of case time (21.57%). Teaching occurred with FD events for 2.4 hours (22.2%), whereas 77.8% of teaching happened outside FD occurrence. Teaching methods shifted from active to passive during FD events to compensate for patient safety.

CONCLUSIONS

Understanding how FDs impact operative learning will inform faculty development in managing interruptions and improve its integration into resident education.

Exploring the Content of Intraoperative Teaching

INTRODUCTION

Much teaching to surgical residents takes place in the operating room (OR). The explicit content of what is taught in the OR, however, has not previously been described. This study investigated the content of what is taught in the OR, specifically during laparoscopic cholecystectomies (LCs), for which a cognitive task analysis (CTA), explicitly delineating individual steps, was available in the literature.

METHODS

A checklist of necessary technical and decision-making steps to be executed during performance of LCs, anchored in the previously published CTA, was developed. A convenience sample of LCs was identified over a 12-month period from February 2011 to February 2012. Using the checklist, a trained observer recorded explicit teaching that occurred regarding these steps during each observed case. All observations were tallied and analyzed.

RESULTS

In all, 51 LCs were observed; 14 surgery attendings and 33 residents participated in the observed cases. Of 1042 observable teaching points, only 560 (53.7%) were observed during the study period. As a proportion of all observable steps, technical steps were observed more frequently, 377 (67.3%), than decision-making steps, 183 (32.7%). Also when focusing on technical and decision-making steps alone, technical steps were taught more frequently (60.9% vs 43.3%).

CONCLUSIONS

Only approximately half of all possible observable teaching steps were explicitly taught during LCs in this study. Technical steps were more frequently taught than decision-making steps. These findings may have important implications: a better understanding of the content of intraoperative teaching would allow educators to steer residents' preoperative preparation, modulate intraoperative instruction by members of the surgical faculty, and guide residents to the most appropriate teaching venues.

Factors associated with adverse clinical outcomes among obstetrics trainees

OBJECTIVES

This study was conducted to determine whether UK obstetrics trainees transitioning from directly to indirectly supervised practice have a higher likelihood of recording adverse patient outcomes in operative deliveries compared with other indirectly supervised trainees, and to examine whether performing more procedures under direct supervision is associated with fewer adverse outcomes in initial practice under indirect supervision.

METHODS

We examined all deliveries (13 856) conducted by obstetricians at a single centre over 6 years (2008-2013). Mixed-effects logistic regression models were used to compare estimated blood loss (EBL), maternal trauma, umbilical arterial pH, delayed neonatal respiration, failed instrumental delivery, and critical incidents for trainees in their first indirectly supervised year with those for trainees in all other years of indirect supervision. Outcomes for trainees in their first indirectly supervised 3 months were compared with their outcomes for the remainder of the year. Linear regression was used to examine the relationship between number of procedures performed under direct supervision and initial outcomes under indirect supervision.

RESULTS

Trainees in their first indirectly supervised year had a higher likelihood of recording EBL of > 2 L at any delivery (odds ratio [OR] 1.32, 95% confidence interval [CI] 1.01-1.64; p < 0.05) and of failed instrumental delivery (OR 2.33, 95% CI 1.37-3.29; p < 0.05) compared with other indirectly supervised trainees. Other measured outcomes showed no significant differences. In the first 3 months of indirect supervision, the likelihood of operative vaginal deliveries with EBL of > 1 L (OR 2.54, 95% CI 1.88-3.20; p < 0.05) was higher than in the remainder of the first year. Performing more deliveries under direct supervision prior to beginning indirectly supervised training was associated with decreased risk for recording EBL of > 1 L (p < 0.05).

CONCLUSIONS

Obstetrics trainees in their first year of indirectly supervised practice have a higher likelihood of recording immediate adverse delivery outcomes, which are primarily maternal rather than neonatal. Undertaking more directly supervised procedures prior to transitioning to indirectly supervised practice may reduce adverse outcomes, which suggests that experience is a key consideration in obstetrics training programme design.

How surgical mentors teach: a classification of in vivo teaching behaviors part 1: verbal teaching guidance

OBJECTIVES

To illuminate surgical teaching at a fine level of detail by filming intraoperative communication between surgical attending physicians and trainees and provide a naturalistic categorization and analysis of verbal teaching behaviors.

DESIGN

Live, intraoperative verbal exchanges between surgical attending physicians and their trainees (residents and fellows) were filmed, and key verbal teaching moments were transcribed. In follow-up interviews, attending physicians and trainees watched video clips of their teaching case and answered open-ended questions about their surgical teaching methods. Using a grounded theory approach, we examined the videos and interviews for what might be construed as a teaching behavior and refined verbal teaching categories through constant comparison.

SETTING

We filmed 5 cases in the operating suite of a university teaching hospital that provides gynecologic surgical care.

PARTICIPANTS

We included 5 attending gynecologic surgeons, 3 fellows, and 5 residents for this study.

RESULTS

More than 6 hours of film, 3 hours of interviews, and more than 400 verbal teaching utterances from our participating attending surgeons were transcribed. We found that attending surgeons used unique types of verbal guidance to describe relevant anatomy, explain the rationale behind a specific surgical action, command the trainee to perform the next step, reference a specific aspect of the surgery, and provide an indirect verbal construct. Attending physicians prefixed speech with polite terms and used terse language, colorful verbal analogies, and sometimes humor. Our participants denied a significant Hawthorne effect. Interrater reliability was high using Cohen κ with 0.77 for the verbal categories.

CONCLUSIONS

Our categorization of live intraoperative verbal teaching can provide a measurable, replicable basis for studying how spoken guidance can lead to the best intraoperative learning. Because surgical teaching occurs on a microscopic level, film review is important when analyzing intraoperative teaching behaviors.

Teaching the surgical craft: surgery residents perception of the operating theater educational environment in a tertiary institution in Nigeria

Background:

The transformation of a surgical trainee into a surgeon is strongly influenced by the quality of teaching in the operating theater. This study investigates the perceptions of residents about the educational environment of the operating theater and identifies variables that may improve the operating theater education of our trainees.

Materials and Methods:

Residents in the department of surgery anonymously evaluated teaching in the operating room using the operating theater education environment measure. The residents evaluated 33 variables that might have an impact on their surgical skills within the operating theater. The variables were grouped into four subscales; teaching and training, learning opportunities, operating theater atmosphere and workload/supervision/support. Differences between male and female residents and junior and senior registrars were assessed using Mann-Whitney test. Statistical analysis was completed with the statistics package for the social sciences version 17.

Results:

A total of 33 residents were participated in this study. Twenty nine (88%) males and 4 (12%) females. 30 (90%) were junior registrars. The mean total score was 67.5%. Operating theater atmosphere subscale had the highest score of 79.2% while workload/supervision/support subscale had the least score of 48.3%. There were significant differences between male and female resident's perception of workload/supervision/support P < 0.05; however, there was no significant differences in junior registrar versus senior registrar's perception of the education environment in all the subscales P > 0.05.

Conclusion:

This study has shown a satisfactory teaching environment based on the existing local realities of means, resources and tools and highlighted the need for improvement in workload/supervision/support in our institution. An acceptable learning environment in the operating theatre will produce surgeons that are technically competent to bridge the gap in the enormous unmet need for surgical care in Nigeria.

The introduction and the validation of a surgical encounter template to facilitate surgical coaching of gynaecologists at a metropolitan tertiary obstetrics and gynaecology hospital

INTRODUCTION

At a metropolitan tertiary obstetrics and gynaecology hospital some gynaecologists identified a need for surgical coaching. Full-time specialists in a teaching hospital are expected to teach surgery whilst having limited access to improving their own surgical skills. Over time, this resulted in some degree of technical deskilling. This in turn led to a loss of confidence in their technical ability to perform complex procedures. The trainee was potentially taught surgery by gynaecologists who were not confident in some aspects of their own surgical skill.

METHODS

A pilot program was introduced to validate a structured surgical encounter template to facilitate surgical coaching in a dedicated regular operating list.

RESULTS

There was a high degree of satisfaction amongst participants in the program. Learning objectives were predominantly related to acquisition of psychomotor skills, but cognitive and affective skills were also identified. Participants felt they gained confidence and improved their surgical skill as a result of the program. The descriptive feedback validated the structured encounter template in facilitating the learning and teaching environment in the operating room. Most participants expressed an intention to adopt a more structured approach in their surgical teaching.

DISCUSSION

A structured surgical coaching template used in a surgical coaching program facilitated short-term self-perceived improvement in surgical skill and confidence. Participants also expressed an intention to introduce a more structured approach in their teaching. The structured programme using the encounter template may have a potential role in remediating a surgeon identified as an outlier by a credentialing body.

A theory-based model for teaching and assessing residents in the operating room

The operating room (OR) remains primarily a master/apprenticeship-based learning environment for surgical residents. Changes in surgical education and health care systems challenge faculty to efficiently and effectively graduate residents truly competent in operations classified by the Surgical Council on Resident Education as "common essential" and "uncommon essential." Program directors are charged with employing resident evaluation systems that yield useful data, yet feasible enough to fit into a busy surgical faculty member's workflow. This paper proposes a simple model for teaching and assessing residents in the operating room to guide faculty and resident interaction in the OR, and designating a resident's earned level of autonomy for a given procedure. The system as proposed is supported by theories associated with motor skill acquisition and learning.

Teaching in the operating room: results of a national survey

BACKGROUND

With the institution of the work-hour restrictions in 2003, less time may be available for surgical residents to learn operative technique and judgment. While numerous studies have evaluated the use of surgical simulation training to enhance operative skills, little is known about the quality of teaching that takes place in the operating room (OR). The purpose of this study was to assess residents' perception of faculty teaching in the OR in order to target ways to improve operative education.

METHODS

A request for resident participation in an online survey was sent to the Program Coordinator at all 255 ACGME-accredited general surgery residency programs.

RESULTS

A total of 148 programs (59%) participated in the survey, and anonymous responses were submitted by 998 of 4926 residents (20%). Most residents reported that attending surgeons verbalize their operative approach (55%), include residents in intraoperative decisions (61%), and offer technical advice (84%). However, few residents reported that faculty help to identify the resident's personal educational operative goals preoperatively (18%) or discuss areas of improvement with residents (37%). Of all cases scrubbed in the past year, most residents feel as though they only actually performed the procedure between 26% and 50% (29%) or between 51% and 75% (32%) of the time. However, more than half of all residents (51%) log these procedures for ACGME as primary surgeon 76%-100% of the time.

CONCLUSIONS

This study demonstrates that from the residents' perspective, a number of opportunities exist to improve teaching in the OR, such as guiding residents with preoperative preparation and providing them with constructive feedback. These findings also suggest that residents may be logging cases without feeling as though they actually perform the operations.

Master surgeons' operative teaching philosophies: a qualitative analysis of parallels to learning theory

OBJECTIVES

Practicing within the Halstedian model of surgical education, academic surgeons serve dual roles as physicians to their patients and educators of their trainees. Despite this significant responsibility, few surgeons receive formal training in educational theory to inform their practice. The goal of this work was to gain an understanding of how master surgeons approach teaching uncommon and highly complex operations and to determine the educational constructs that frame their teaching philosophies and approaches.

DESIGN

Individuals included in the study were queried using electronically distributed open-ended, structured surveys. Responses to the surveys were analyzed and grouped using grounded theory and were examined for parallels to concepts of learning theory.

SETTING

Academic teaching hospital.

PARTICIPANTS

Twenty-two individuals identified as master surgeons.

RESULTS

Twenty-one (95.5%) individuals responded to the survey. Two primary thematic clusters were identified: global approach to teaching (90.5% of respondents) and approach to intraoperative teaching (76.2%). Many of the emergent themes paralleled principles of transfer learning theory outlined in the psychology and education literature. Key elements included: conferring graduated responsibility (57.1%), encouraging development of a mental set (47.6%), fostering or expecting deliberate practice (42.9%), deconstructing complex tasks (38.1%), vertical transfer of information (33.3%), and identifying general principles to structure knowledge (9.5%).

CONCLUSIONS

Master surgeons employ many of the principles of learning theory when teaching uncommon and highly complex operations. The findings may hold significant implications for faculty development in surgical education.