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

Development of a Competency Framework Defining Effective Surgical Educators

OBJECTIVE

The objective of this study is to develop a practical framework of competencies and behaviors which define an effective surgical educator.

DESIGN

A modified Delphi approach was used. A literature review and series of discussions with surgical education experts led to creation of a survey instrument which was sent to surgical faculty and trainees from a single academic institution. The results from this initial survey informed the creation of the subsequent survey instrument which was also sent to surgical faculty and trainees. Focus groups with surgical faculty and residents were conducted separately, transcribed, deidentified, and then evaluated for recurring themes. A competency framework was developed.

SETTING

The surveys were administered and focus groups were conducted at the University Hospitals Cleveland Medical Center, a tertiary care academic institution.

PARTICIPANTS

Residents, fellows, and faculty surgeons from the fields of general surgery, plastic surgery, vascular surgery, orthopedic surgery, otolaryngology, neurosurgery, and urology.

RESULTS

There were 115 responses (31.3%) from 367 faculty surgeons, residents, and fellows invited to complete the initial survey examining 50 competencies. Eighteen competencies received a mean Likert score of at least 4 by both faculty and residents and were included in the subsequent survey instrument which was completed by 72 participants (19.6%). Focus groups were held separately with 6 faculty surgeons and 6 residents. Analysis of the survey results and focus group discussions identified several themes which informed the development of a competency framework consisting of 5 overarching competencies as well as 16 specific behaviors.

CONCLUSIONS

A practical framework was developed consisting of 5 competencies and 16 behaviors which define an effective surgical educator. The 5 competencies are: 1) fosters psychological safety, 2) displays exemplary medical knowledge and patient care, 3) diagnoses the learner and adjusts teaching, 4) communicates thought process to trainee, and 5) displays learner-centeredness. Based on the competency framework, residency leadership may specifically tailor faculty development initiatives to improve surgical education programming.

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.

Evolution of Cleft Lip and Palate Surgical Training in the UK: A Qualitative Study

BACKGROUND

Although the United Kingdom (UK) cleft surgeons follow a similar training pathway, and cleft centers adhere to similar protocols regarding the timing of palate surgery and surgical technique, speech outcomes still vary between centers.

OBJECTIVE

To explore the training experiences of consultant cleft lip and palate (CL/P) surgeons, performing a Sommerlad radical intravelar veloplasty (IVVP) and their approach to teaching others.

DESIGN

An exploratory, qualitative approach was adopted to understand the views of UK cleft surgeons performing a Sommerlad radical IVVP and discuss what was important during training and upon qualifying as a consultant.

METHOD

A semi-structured interview schedule was designed, interviews were conducted in-person or via videoconferencing, depending on preference and availability, with interested surgeons. The interviews were recorded, transcribed, and checked for accuracy. Analysis involved inductive thematic analysis.

RESULTS

Fourteen cleft consultants from the UK participated (3F:11M). Seven of the consultants were trained in plastic surgery and four in maxillofacial surgery. Seven themes were identified from the thematic analysis. Three themes, namely Learning to perform palate repair, Teaching others to perform palate repair, and Ongoing learning as a consultant are discussed.

CONCLUSIONS

Cleft palate repair is clearly a technically challenging procedure to learn and teach with the potential to cause harm if performed incorrectly. Positive changes have been made to improve exposure to palate surgery, encourage practice away from the patient, and increase supervised practical experience. The role of colleagues in providing mentorship and support appears invaluable. We provide some simple recommendations that may improve the training experience and ensure parity for all trainees.

Microsurgery for intracranial aneurysms: A qualitative survey on technical challenges and technological solutions

Introduction

Microsurgery for the clipping of intracranial aneurysms remains a technically challenging and high-risk area of neurosurgery. We aimed to describe the technical challenges of aneurysm surgery, and the scope for technological innovations to overcome these barriers from the perspective of practising neurovascular surgeons.

Materials and Methods

Consultant neurovascular surgeons and members of the British Neurovascular Group (BNVG) were electronically invited to participate in an online survey regarding surgery for both ruptured and unruptured aneurysms. The free text survey asked three questions: what do they consider to be the principal technical barriers to aneurysm clipping? What technological advances have previously contributed to improving the safety and efficacy of aneurysm clipping? What technological advances do they anticipate improving the safety and efficacy of aneurysm clipping in the future? A qualitative synthesis of responses was performed using multi-rater emergent thematic analysis.

Results

The most significant reported historical advances in aneurysm surgery fell into five themes: (1) optimising clip placement, (2) minimising brain retraction, (3) tissue handling, (4) visualisation and orientation, and (5) management of intraoperative rupture. The most frequently reported innovation by far was indocyanine green angiography (84% of respondents). The three most commonly cited future advances were hybrid surgical and endovascular techniques, advances in intraoperative imaging, and patient-specific simulation and planning.

Conclusions

While some surgeons perceive that the rate of innovation in aneurysm clipping has been dwarfed in recent years by endovascular techniques, surgeons surveyed highlighted a broad range of future technologies that have the potential to continue to improve the safety of aneurysm surgery in the future.

Keep it SIMPL: Improved Feedback After Implementation of an App-Based Feedback Tool

BACKGROUND

Data defining the utility of the system for improving and measuring procedural learning (SIMPL) in surgical education is limited. The aim of this pilot study is to describe the impact of SIMPL on resident and faculty perspectives regarding operative feedback.

METHODS

Residents and faculty were surveyed prior to and 6 months after SIMPL implementation. Associations were analyzed using χ2 for categorical and Student's t-test for continuous variables. Statistical significance was defined as P-value < .05.

RESULTS

The proportion of residents receiving intraoperative feedback at least once/day increased significantly (35% to 73%, P = .025); there was a trend toward increased postoperative feedback (15% to 33%, P = .201). Faculty reported an increase in intraoperative (55% to 91%, P = .041) and postoperative feedback (21% to 64%, P = .020). Satisfaction with intraoperative feedback improved from a score of 3.50 ± 1.05 to 3.93 ± .62, although not statistically significant (P = .181). Satisfaction with postoperative feedback improved significantly from 2.85 ± .93 to 3.50 ± .65 (P = .032). The proportion of faculty who felt they were providing effective feedback increased (53% to 91%, P = .032). The proportion of residents who perceived that feedback enhanced their surgical skill increased as well (65% to 93%, P = .048).

DISCUSSION

Despite a modest increase in frequency of postoperative feedback, perceived quality of feedback improved substantially after implementation of SIMPL. Introduction of SIMPL also increased the amount of feedback provided by faculty intraoperatively. SIMPL, via direct and indirect effects, has a positive impact on the resident operative learning environment. Further work is necessary to examine the influence this may have on resident operative skill and patient outcomes.

The Quality of Operative Performance Narrative Feedback: A Retrospective Data Comparison Between End of Rotation Evaluations and Workplace-based Assessments

OBJECTIVE

To describe the quality of operative performance feedback using evaluation tools commonly used by general surgery residency training programs.

SUMMARY OF BACKGROUND DATA

The majority of surgical training programs administer an evaluation through which faculty members may rate and comment on trainee operative performance at the end of the rotation (EOR). Many programs have also implemented the system for improving and measuring procedural learning (SIMPL), a workplace-based assessment tool with which faculty can rate and comment on a trainee's operative performance immediately after a case. It is unknown how the quality of narrative operative performance feedback delivered with these tools compares.

METHODS

The authors collected EOR evaluations and SIMPL narrative comments on trainees' operative performance from 3 university-based surgery training programs during the 2016-2017 academic year. Two surgeon raters categorized comments relating to operative skills as being specific or general and as encouraging and/or corrective. Comments were then classified as effective, mediocre, ineffective, or irrelevant. The frequencies with which comments were rated as effective were compared using Chi-square analysis.

RESULTS

The authors analyzed a total of 600 comments. 10.7% of EOR and 58.3% of SIMPL operative performance evaluation comments were deemed effective (P < 0.0001).

CONCLUSIONS

Evaluators give significantly higher quality operative performance feedback when using workplace-based assessment tools rather than EOR evaluations.

Efficacy of a resident-as-teacher program (RATP) for general surgery residents: An evaluation of 3 Years of implementation

BACKGROUND

Teaching is a responsibility of general surgery residents and formal teaching instruction is mandated. This study examines the efficacy of a formal RATP incorporated into our general surgery residency curriculum.

METHODS

The RATP was developed locally and delivered longitudinally over the course of the academic year, starting in 2017. Self-assessment surveys were distributed to residents before and after completion of the program each academic year. Medical students were surveyed regarding their impression of teaching on the surgical clerkship.

RESULTS

RATP data was collected annually. All sessions were highly rated. Residents reported improved teaching self-efficacy after participation. Medical student agreement with the statement 'Residents provided effective teaching during the [surgery] clerkship' increased from 68.6% prior to RATP implementation to 79.7% in the following years (p < 0.05).

CONCLUSIONS

Incorporation of a locally developed RATP improved residents' self-perceptions and medical student perception of residents as teachers. RATPs should be adopted widely.

Bronchoscopy Teaching Without a Gold Standard: Attending Pulmonologists' Assessment of Learners, Supervisory Styles, and Variation in Practice

BACKGROUND

Despite the growing role of simulation in procedural teaching, bronchoscopy training largely is experiential and occurs during patient care. The Accreditation Council for Graduate Medical Education sets a target of 100 bronchoscopies to be performed during pulmonary fellowship. Attending physicians must balance fellow autonomy with patient safety during these clinical teaching experiences. Few data on best practices for bronchoscopy teaching exist, and a better understanding of how bronchoscopy currently is supervised could allow for improvement in bronchoscopy teaching.

RESEARCH QUESTION

How do attending bronchoscopists supervise bronchoscopy, and in particular, how do attendings balance fellow autonomy with patient safety?

STUDY DESIGN AND METHODS

This was a focused ethnography conducted at a single center using audio recording of dialog between attendings and fellows during bronchoscopies, supplemented by observation of nonverbal teaching. Interviews with attending bronchoscopists and limited interviews of fellows also were recorded. Interviews were transcribed verbatim before analysis. We used constant comparative analysis to analyze data and qualitative research software to support data organization and thematic analysis. Education researchers from outside of pulmonary critical care joined the team to minimize bias.

RESULTS

We observed seven attending bronchoscopists supervising eight bronchoscopies. We noted distinct teaching behaviors, classified into themes, which then were grouped into four supervisory styles of modelling, coaching, scaffolding, and fading. Observation and interviews illuminated that assessing fellow skill was one tool used to choose a style, and attendings moved between styles. Attendings accepted some, but not all, variation in both performing and supervising bronchoscopy.

INTERPRETATION

Attending pulmonologists used a range of teaching microskills as they moved between different supervisory styles and selectively accepted variation in practice. These distinct approaches may create well-rounded bronchoscopists by the end of fellowship training and should be studied further.

Qualities and Methods of Highly Effective Surgical Educators: A Grounded Theory Model

OBJECTIVE

To identify personal qualities and teaching methods of highly effective surgical educators using a novel research design.

DESIGN

In this qualitative study, surgical residents were sent an electronic survey soliciting nominations for faculty perceived as highly effective surgical educators. In-depth, semistructured interviews were conducted with surgeons receiving the most nominations. Grounded theory methodology identified themes for analysis.

SETTING

General, vascular, and plastic surgery residents and faculty at the University of Pennsylvania Health System.

PARTICIPANTS

A total of 77 surgical residents were surveyed. Data saturation occurred after 12 semistructured interviews with attending surgeons, corresponding to the top 15% of faculty.

RESULTS

Interviewees described both personal characteristics and specific teaching approaches that facilitated successful learning. These included providing exceptional surgical education as a mission, a strong influence from past mentors and role models, a love for the profession, and a low rate of self-professed burnout. Desirable teaching methods included promoting a culture of psychological safety (the perceived ability to take interpersonal risks within one's environment), progressive autonomy, accountability of trainees, and individualized teaching for the learner. Interviewees saw education as inseparable from clinical duties, and all surgeons believed providing exceptional patient care was the foundation of effective surgical teaching. The derived themes suggested that educators prefer "cognitive-based" approaches, focusing on learning processes rather than specific outcomes.

CONCLUSIONS

This study identified characteristics and educational styles of highly effective educators in a cohort of academic surgeons. This framework may inform the development of educational programs for residents and faculty in effective teaching methods.

Quality of Operative Performance Feedback Given to Thoracic Surgery Residents Using an App-Based System

OBJECTIVE

Residents frequently report inadequate feedback both in quantity and quality. The study evaluates the quality of faculty feedback about operative performance given using an app-based system.

DESIGN

Residents requested operative performance evaluation from faculty on a real-time basis using the "Zwisch Me!!" mobile application which allows faculty to provide brief written feedback. Qualitative analysis of feedback was performed using grounded theory.

SETTING

The 7 academic medical centers with thoracic surgery training programs.

PARTICIPANTS

Volunteer thoracic surgery residents in both integrated and traditional training pathways and their affiliated cardiothoracic faculty.

RESULTS

Residents (n = 33) at 7 institutions submitted a total of 596 evaluations to faculty (n = 48). Faculty acknowledged the evaluation request in 476 cases (80%) and in 350 cases (74%) provided written feedback. Initial open coding generated 12 categories of feedback type. We identified 3 overarching themes. The first theme was the tone of the feedback. Encouraging elements were identified in 162 comments (46%) and corrective elements in 230 (65%). The second theme was the topic of the feedback. Surgical technique was the most common category at 148 comments (42.2%) followed by preparation for case (n = 69, 19.7%). The final theme was the specificity of the feedback. Just over half of comments (n = 190, 54.3%) contained specific feedback, which could be applied to future cases. However, 51 comments (14.6%) contained no useful information for the learners.

CONCLUSIONS

An app-based system resulted in thoracic surgery residents receiving identifiable feedback in a high proportion of cases. In over half of comments the feedback was specific enough to allow improvement. Feedback was better quality when addressing error prevention and surgical technique but was less useful when addressing communication, flow of the case, and assisting. Faculty development around feedback should focus on making feedback specific and actionable, avoiding case descriptions, or simple platitudes.

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.

Improving the Teaching Skills of Residents in a Surgical Training Program: Results of the Pilot Year of a Curricular Initiative in an Ophthalmology Residency Program

OBJECTIVE

To design and implement a teaching skills curriculum that addressed the needs of an ophthalmology residency training program, to assess the effect of the curriculum, and to present important lessons learned.

DESIGN

A teaching skills curriculum was designed for the Harvard Medical School (HMS) Residency Training Program in Ophthalmology. Results of a needs assessment survey were used to guide curriculum objectives. Overall, 3 teaching workshops were conducted between October 2012 and March 2013 that addressed areas of need, including procedural teaching. A postcurriculum survey was used to assess the effect of the curriculum.

SETTING

Massachusetts Eye and Ear Infirmary, a tertiary care institution in Boston, MA.

PARTICIPANTS

Overall, 24 residents in the HMS Residency Training Program in Ophthalmology were included.

RESULTS

The needs assessment survey demonstrated that although most residents anticipated that teaching would be important in their future career, only one-third had prior formal training in teaching. All residents reported they found the teaching workshops to be either very or extremely useful. All residents reported they would like further training in teaching, with most residents requesting additional training in best procedural teaching practices for future sessions.

CONCLUSIONS

The pilot year of the resident-as-teacher curriculum for the HMS Residency Training Program in Ophthalmology demonstrated a need for this curriculum and was perceived as beneficial by the residents, who reported increased comfort in their teaching skills after attending the workshops.

Endoscopic and keyhole endoscope-assisted neurosurgical approaches: a qualitative survey on technical challenges and technological solutions

INTRODUCTION

The literature reflects a resurgence of interest in endoscopic and keyhole endoscope-assisted neurosurgical approaches as alternatives to conventional microsurgical approaches in carefully selected cases. The aim of this study was to assess the technical challenges of neuroendoscopy, and the scope for technological innovations to overcome these barriers.

MATERIALS AND METHODS

All full members of the Society of British Neurosurgeons (SBNS) were electronically invited to participate in an online survey. The open-ended structured survey asked three questions; firstly, whether the surgeon presently utilises or has experience with endoscopic or endoscope-assisted approaches; secondly, what they consider to be the major technical barriers to adopting such approaches; and thirdly, what technological advances they foresee improving safety and efficacy in the field. Responses were subjected to a qualitative research method of multi-rater emergent theme analysis.

RESULTS

Three clear themes emerged: 1) surgical approach and better integration with image-guidance systems (20%), 2) intra-operative visualisation and improvements in neuroendoscopy (49%), and 3) surgical manipulation and improvements in instruments (74%).

DISCUSSION

The analysis of responses to our open-ended survey revealed that although opinion was varied three major themes could be identified. Emerging technological advances such as augmented reality, high-definition stereo-endoscopy, and robotic joint-wristed instruments may help overcome the technical difficulties associated with neuroendoscopic approaches.

CONCLUSIONS

Results of this qualitative survey provide consensus amongst the technology end-user community such that unambiguous goals and priorities may be defined. Systems integrating these advances could improve the safety and efficacy of endoscopic and endoscope-assisted neurosurgical approaches.