Identification of teaching excellence in operating room and clinic settings

Teaching Before, During, and After a Surgical Resuscitation

Teaching during a surgical resuscitation can be difficult due to the infrequency of these events. Furthermore, when these events do occur, the trainee can experience cognitive overload and an overwhelming amount of stress, thereby impairing the learning process. The emergent nature of these scenarios can make it difficult for the surgical educator to adequately teach. Repeated exposure through simulation, role play, and "war games" are great adjuncts to teaching and preparation before crisis. However, surgical educators can further enhance the knowledge of their trainees during these scenarios by using tactics such as talking out loud, targeted teaching, and debriefing.

Medical students' perception and attitudes on operating theatre learning experience in Sri Lanka

Objective

The operating room is a unique learning experience that has visual, aural, kinesthetic learning stimuli and provides benefits to the medical students such as development of sound clinical knowledge and skills, and gaining personal insight into ones' career choice. However, this can be a challenging place due to the unfamiliar learning environment. We aimed to study the Sri Lankan Medical students' perception and attitudes on operating theatre learning experience.

Design and setting

A descriptive cross-sectional survey was carried out among medical students undergoing surgical clinical training on the perspectives of the teaching and learning experience in the operating theatre in Sri Lanka.

Participants

Our study group consisted of 390 medical students from four different medical faculties in Sri Lanka representing all levels of surgical clinical rotations.

Results

A majority of the students had actively participated in the operating theater. Despite this, the students' clarity of the learning outcomes and expectations in a theatre varied greatly. Majority of the students felt that the surgeons were willingly to teach but also noted that there was no standardization in teaching. This study clearly shows a significant correlation between positive emotions and surgical teams welcoming attitude towards the medical students. Long standing hours were considered a negative emotion by a majority of students. We also observed that theatre environment can be physically and mentally exhausting.

Conclusions

Thus, empathy, feeling welcome and giving breaks to refresh can go a long way in making the learning experience better. Regular feedback to trainers on students' perception of the theatre experience is important to value the students' opinion and improve the quality of the surgical theatre. We strongly recommend initiation of clear induction sessions with introduction of well-structured teaching learning activities in the operating theatre.

Medical Students' Communication Preferences for the Ideal Surgical Educator

OBJECTIVE

Medical students have expectations and preferences for how they are taught by clinical surgical educators. The goal of this study was to (a) determine medical students' prioritizations of ideal teaching behaviors and characteristics for surgical educators, and (b) delineate which teaching behaviors and characteristics were considered to be less important for surgical education.

DESIGN

Using a necessity (low) and luxury (high) budget allocation methodology to build their ideal surgical educator, MSIII and MSIV students (N = 82) completed a survey to prioritize and invest in 10 effective teaching behaviors and characteristics identified in the instructional communication literature (assertiveness, responsiveness, clarity, relevance, competence, character, caring, immediacy, humor, and disclosure).

RESULTS

Repeated-measures ANOVAs indicated MSIII and MSIV students invested significantly more of their teaching budget allocations for their ideal surgical educator into instructor clarity, competence, relevance, responsiveness, and caring, both within a (low) necessity budget (F[5.83, 472.17] = 24.09, p < 0.001, η2p = 0.23) and (high) luxury budget (F(7.65, 619.76) = 67.56, p < 0.001, η2p = 0.46). Using paired t-tests, comparisons of repeated investments in low and high budget allocations revealed that students invested slightly more of a percentage of funds in instructor immediacy (+2.62%; t(81) = 2.90, p = 0.005; d = 0.32) and disclosure (+1.44%; t(81) = 3.26, p = 0.002; d = 0.36), indicating they viewed these teaching behaviors more as luxury components of surgical education rather than necessities, but these behaviors were significantly less important than their ideal prioritizations of instructor clarity, competence, relevance, responsiveness, and caring.

CONCLUSIONS

Results indicated that medical students want a surgical educator who is largely a rhetorical educator; that is, a surgical specialist who clearly communicates expertise and relevant content that students can apply to their careers as future surgeons. However, a relational component was viewed as ideal by students as students also preferred surgical educators to be sensitive and sympathetic to their academic needs.

Surgical Resident Perspectives on the Preferred Qualities of Effective Intraoperative Teachers: A Qualitative Analysis

PURPOSE

Intraoperative teaching is a critical component of surgery residents' education. Although prior studies have investigated best practices from the viewpoint of the expert educator, the perspective of the learner has been less explored. This study examined the ideal faculty teaching behaviors that optimize intraoperative teaching from the surgical residents' perspective.

METHOD

Using a grounded theory method, this study explored perspectives on intraoperative faculty teaching qualities of 5 focus groups of categorical clinical general surgical residents of the same postgraduate year from June to August 2021. Focus group discussions were recorded, transcribed, and coded. Emerging themes were identified, along with their corresponding subthemes.

RESULTS

Thirty-nine general surgery residents participated in the focus groups. Overall, 6 themes emerged regarding resident priorities of intraoperative teaching, with 10 subthemes. Themes included the following: (1) character, with subthemes of caring, respect for resident, and self-control; (2) intraoperative skill, with subthemes of clinical and operative skill and modeling leadership in the operating room; (3) instructional approach; (4) feedback, with subthemes of content of feedback and debriefing; (5) discernment of resident needs, with subthemes of managing expectations, individualizing instruction, and autonomy; and (6) variety of teachers.

CONCLUSIONS

Certain tangible strategies, such as demonstrating genuine care for the learner, using clear directional words, and giving actionable feedback, were considered vital by residents. In the development of great surgical educators, the emphasis should not be on conformity to a single idealized teaching style but should celebrate and encourage diversity of personas and teaching styles within a department or program.

Supplementing Intraoperative Mastoidectomy Teaching With Video-Based Coaching

OBJECTIVES

Video-based coaching might complement general surgery education, but little is known of its applicability for otologic microsurgical teaching. Our purpose was thus to evaluate the content and resident-perceived benefit of video-based coaching for mastoidectomy education.

METHODS

In this mixed-methods pilot design, mastoidectomies were recorded from operative microscopes and reviewed during 30-minute video-based coaching sessions at 2 tertiary care centers. Eight residents and 3 attendings participated. Ten-point Likert-type questionnaires on the extent to which attendings taught 12 topics through 8 techniques were completed by residents after surgical and coaching sessions. Coaching sessions and structured interviews with residents were audio-recorded, transcribed and iteratively coded.

RESULTS

Seven audio-recordings were available for coaching sessions, during which a mean of 2.22 ± 0.5 topics per minute were discussed. Of the 12 teaching topics, technique was discussed most frequently (32%, 0.71 ± 0.2 topics/min), followed by anatomy (16%, 0.31 ± 0.16 topics/min). Of all 8 ratings between coaching and operative sessions, residents indicated a greater extent of discussion of anatomy (median difference, [95% confidence interval (CI)] of 3 [1-4]), progress (2.25 [95% CI, 0.5-4]), technique (3.5 [95% CI, 1.5-5.5]), pitfalls (2.5 [95% CI, 1-3.5]), and summarizing (3 [95% CI, 1-5]). In structured interviews, residents reported improved self-confidence and global perspective.

CONCLUSIONS

Video-based coaching is educationally dense and characterized by perceived richer teaching and promotion of a deeper surgical understanding. It requires no additional resources, can be completed in a short period of time and can be implemented programmatically for any otolaryngologic subspecialty utilizing video-recording capable equipment.

"Influential" Intraoperative Educators and Variability of Teaching Styles

OBJECTIVES

Academic surgeons manage their role as intraoperative educators in a variety of ways. Such variability is neither idiosyncratic nor is there a single best approach. This study sought to explore the practices of surgeons deemed influential by their residents, allowing insight into a variety of potentially effective practices.

PARTICIPANTS

Constructivist grounded theory guided data collection and analysis. Data sources included surveys from senior surgical residents (PGY3-6) and recent graduates from an academic hospital in Canada (36% response rate), intraoperative observations of teaching interactions, and semi-structured interviews with observed surgeons. Rigour was supported by data triangulation, constant comparison, and collection to theoretical sufficiency.

DESIGN

We developed a framework grouping effective teaching into three overlapping approaches: exacting, empowering, and fostering. The approaches differ based on the level of independence granted and the degree of expectation placed on individual residents. Each demonstrates different strategies for balancing the multiple supervisory roles and patient care obligations faced by academic surgeons. We also identified strategies that could be used across approaches to enhance learning.

CONCLUSIONS

For surgical educators seeking to improve upon the quality of the intraoperative supervision they provide, frameworks such as this may serve as models of effective supervision. Enhancing surgeons' knowledge of proven strategies, combined with reflecting on how they teach and how they balance responsibilities to patients and trainees, may allow them to broaden their educational practice.

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.

Preoperative Briefings and Postoperative Debriefings to Increase Resident Operative Autonomy and Performance

OBJECTIVE

To implement the use of standardized preoperative briefings and postoperative debriefings for surgical cases involving residents in an effort to improve resident autonomy and skill acquisition.

DESIGN

Prospective longitudinal study.

SETTING

Johns Hopkins Department of Otolaryngology-Head and Neck Surgery.

PARTICIPANTS

Resident and attending physicians.

RESULTS

Joint Huddles for Improving Resident Education (JHFIRE) tool was created and successfully implemented by 19 residents and 17 faculty members. Over the course of three data collection periods spanning an academic year, overall scores improved though not statistically significantly in the metrics of Zwisch autonomy, Resident Performance, and Objective Structured Assessment of Technical Skills (OSATS) scores. Female residents were scored significantly higher by attendings than their male counterparts in the assessment of baseline Resident Performance.

CONCLUSIONS

(1) JHFIRE tool implemented a standardized preoperative briefing and postoperative debriefing to improve communication and resident skill acquisition; (2) The tool was accepted and utilized throughout an academic year; (3) Zwisch, Resident Performance, and OSATS scores improved though not significantly.

Intraoperative Teaching and Evaluation in General Surgery

The operating room continues to be the location where surgical residents develop both technical and nontechnical skills, ultimately culminating with them being capable of safe and independent practice. The process of intraoperative instruction is, by necessity, moving from an apprentice-based model where skills are acquired somewhat randomly through repeated exposure and evaluation is done in a global gestalt fashion. Modern surgical education demands that intraoperative instruction be intentional and that evaluation provides formative and summative feedback. This chapter describes some best practice approaches to intraoperative teaching and evaluation.

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.

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.

Development of a peer review of operative teaching process and assessment tool

BACKGROUND

While teaching evaluation systems are common in academia, very little information is available regarding formal coaching and peer review of teaching performance in surgery. This article is a report on the development and implementation of a peer review of operative teaching program.

METHODS

Our process was designed using a multistep sequential model which included developing a peer review of teaching instrument that was piloted to study the efficacy and utility of the tool.

RESULTS

Thirty-nine peer reviews of teaching were conducted. Among the most frequent challenges that faculty identified were allowing residents to struggle/give autonomy, judging when to take over the case, communicating effectively, being patient, balancing education and patient safety, and giving feedback.

CONCLUSIONS

Our peer review of teaching program is systematic, feasible, and can be adopted by other surgery departments. Faculty's identified strengths and challenges have been incorporated into our faculty development curricula.

Development and Evaluation of a Surgical Direct Assessment Tool for Resident Training

In podiatric residency training, minimum activity volume numbers are used to assess surgical competency. The purpose of this study was to develop a standardized direct assessment form as a complement to minimum activity volume numbers. Sixteen attending physicians completed 121 direct assessment forms, evaluating six podiatric medicine and surgery residents. Evaluation scores were highly correlated with residency year. Resident feedback was positive, with the open-response portion identified as especially useful. Although further efforts may help refine this approach, the use of standardized, competency-based direct assessment has the potential to improve the training of podiatric medicine and surgery residents.

Quantifying the Opportunity Cost of Resident Involvement in Academic Orthopaedic Sports Medicine: A Matched-Pair Analysis

PURPOSE

To quantify the cost of resident involvement in academic sports medicine by examining differences in operative time, relative value units (RVUs) per case, and RVUs per hour between attending-only cases and cases with resident involvement.

METHODS

A retrospective analysis of common sports medicine procedures identified by Current Procedural Terminology code was performed using data from the American College of Surgeons National Surgical Quality Improvement Program database from 2006 to 2015. Matched cohorts were generated based on demographic variables, comorbidities, preoperative laboratory values, and surgical procedures. Bivariate analysis examined mean differences in operative time, RVUs per case, and RVUs per hour between attending-only cases and cases with resident involvement. A cost analysis was performed to quantify differences in RVUs generated per hour in terms of dollars per case.

RESULTS

A total of 14,840 attending-only cases and 2,230 resident-involved cases were used to generate 2 matched cohorts (N = 4,460). Resident cases had greater mean operative times than attending-only cases, with operative time increasing as residents became more senior (P < .01). Residents participated in cases with larger mean RVUs per case (P < .01). Cases with lone attendings showed greater RVUs per hour (P < .01). The cost of resident involvement increased nearly 8-fold from postgraduate year 1 to postgraduate year 6 residents ($25.70 vs $200.07).

CONCLUSIONS

In academic sports medicine, the involvement of resident physicians increases operative time. The associated decrease in attending physician efficiency in RVUs per hour equates to an average cost per case of $159.18, with costs increasing as residents become more senior.

LEVEL OF EVIDENCE

Level III, retrospective comparative trial.

Factors that influence medical student learning in the operating room

Introduction: The operating room (OR) is a dynamic, high-pressure clinical setting that offers a unique workplace-based learning environment for students. We undertook a narrative synthesis of the literature to identify factors that influence medical student learning in the OR, and we recommend educational strategies that maximize "theater-based learning". Methods: Key words were searched across three databases PubMed, EMBASE and ERIC (Education Resource Information Center). Eligible studies included original articles published after 1997 presenting empirical research on factors that influence medical students learning in the OR. Methodological quality was measured using the Newcastle-Ottawa Score for education. Results: We identified 764 studies on the topic of student learning in the OR, of which 16 studies fulfilled inclusion criteria. The quality assessments demonstrated a mean value of 2.1 out of a maximum of 6. Conclusions: We identified five key domains that influence student learning in the OR: emotional factors, socio-environmental factors, organizational factors, factors related to educational relevance and factors related to the educator. Educational strategies to enhance theater-based learning include: an induction and physical orientation, clear learning objectives, educator feedback, and simulation.

Perioperative Teaching and Feedback: How are we doing in Canadian OTL-HNS programs?

Background

Discrepancies between resident and faculty perceptions regarding optimal teaching and feedback during surgery are well known but these differences have not yet been described in Otolaryngology - Head and Neck Surgery (OTL-HNS). The objectives were thus to compare faculty and resident perceptions of perioperative teaching and feedback in OTL-HNS residency programs across Canada with the aim of highlighting potential areas for improvement.

Methods

An anonymous electronic questionnaire was distributed to residents and teaching faculty in OTL-HNS across Canada with additional paper copies distributed at four institutions. Surveys consisted of ratings on a 5-point Likert scale and open-ended questions. Responses among groups were analysed with the Wilcoxon-Mann Whitney test, while thematic analysis was used for the open-ended questions.

Results

A total of 143 teaching faculty and residents responded with statistically significant differences on 11 out of 25 variables. Namely, faculty reported higher rates of pre and intra-operative teaching compared to resident reports. Faculty also felt they gave adequate feedback on residents’ strengths and technical skills contrary to what the residents thought. Both groups did agree however that pre-operative discussion is not consistently done, nor is feedback consistently given or sought.

Conclusion

Faculty and residents in OTL-HNS residency programs disagree on the frequency and optimal timing of peri-operative teaching and feedback. This difference in perception emphasizes the need for a more structured approach to feedback delivery including explicitly stating when feedback is being given, and the overall need for better communication between residents and staff.

Maintaining operative efficiency while allowing sufficient time for residents to learn

BACKGROUND

Surgical residents desire independent operating experience but recognize that attendings have a responsibility to keep cases as short as possible.

METHODS

We analyzed video and interviews of attending surgeons related to more than 400 moments in which the resident was the primary operator. We examined these moments for themes related to timing and pace.

RESULTS

Our surgeons encouraged the residents to speed up when patient safety could be jeopardized by the case moving too slowly. In contrast, they encouraged the residents to slow down when performing a crucial step or granting independence. Attending surgeons encouraged speed through economical language, by substituting physical actions for words, and through the use of Intelligent Cooperation. Conversely, they encouraged slowing down via just-in-time mini-lectures and by questioning the trainee.

CONCLUSIONS

We present recommendations for safe teaching in the operating room while simultaneously maintaining overall surgical flow. Teaching residents to operate quickly can save time and is likely based on an automaticity in teaching. Slowing a resident down is vital for trainee skill development and patient safety.

Integrating Postoperative Feedback Into Workflow: Perceived Practices and Barriers

OBJECTIVE

Previous studies have found that both resident and staff surgeons highly value postoperative feedback; and that such feedback has high educational value. However, little is known about how to consistently deliver this feedback. Our aim was to understand how often surgical residents should receive feedback and what barriers are preventing this from occurring.

DESIGN

Surveys were distributed to resident and attending surgeons. Questions focused on the current frequency of postoperative feedback, desired frequency and methods of feedback, and perceived barriers. Quantitative data were analyzed with descriptive statistics, and text responses were examined using coding.

SETTING

University-based general surgery department at a Midwestern institution.

PARTICIPANTS

General surgery residents (n = 23) and attending surgeons (n = 22) participated in this study.

RESULTS

Residents reported receiving and staff reported giving feedback for procedure-specific performance after 25% versus 34% of cases, general technical feedback after 36% versus 32%, and nontechnical performance after 17% versus 18%. Both perceived procedure-specific and general technical feedback should be given more than 80% of the time, and nontechnical feedback should happen for nearly 60% of cases. Verbal feedback immediately after the operation was rated as best practice. Both parties identified time, conflicting responsibilities, lack of privacy, and discomfort with giving and receiving meaningful feedback as barriers.

CONCLUSIONS

Both resident and staff surgeons agree that postoperative feedback is given far less often than it should. Future work should study intraoperative and postoperative feedback to validate resident and attending surgeons' perceptions such that interventions to improve and facilitate this process can be developed.

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.

What are the attributes of a good health educator?

OBJECTIVE

The purpose of this study was to examine the attributes that students and educators believe are important to being a good health educator in a non-clinical setting.

METHODS

A cross-sectional survey of first-year health science students and educators involved with a Health Science course in Melbourne, Australia was performed. A convenience sampling approach was implemented, with participants were required to rate the importance of teaching attributes on a previously developed 15-item written questionnaire. Descriptive statistics were generated, with Pearson's chi-square statistics used to examine differences between groups. In total 94/147 (63.9%) of students and 15/15 (100%) of educators participated in the study.

RESULTS

Of the 15 attributes, only 'scholarly activity' was not deemed to be not as an important attribute to define a good educator. Knowledge base (50% vs. 13.3%) and feedback skills (22.3% vs. 0%) were rated as important attributes by students in comparison to educators. Professionalism (20% vs. 5.3%), scholarly activity (20% vs. 3.2%) and role modelling (26.7% vs. 3.2%) were rated as the most important attributes by educators in comparison to students.

CONCLUSIONS

No single attribute makes a good health educator; rather health educators are required to have a rounded approach to teaching. Students have greater focus on the educator providing a transfer of knowledge. Educators are additionally focused on professionalism attributes, which may not be valued by students. Students and educators must enter into a clearer understanding of expectations, from both parties, to obtain optimal education outcomes.

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.

[Evaluation of residency training in general and digestive surgery in Tunisia]

Introduction

De nombreux moyens sont mis à disposition des résidents en chirurgie générale et digestive pour assurer leur formation théorique et pratique. Cependant, le niveau d'utilisation de ces différents outils et leur impact sur la formation des résidents n'ont jamais été évalués. L'objectif de notre étude était d’étudier l’état des lieux des moyens de formation utilisés par les résidents pour évaluer leurs degrés de satisfaction et leurs propositions en vue d'améliorer leur formation.

Méthodes

Un questionnaire anonyme a été distribué aux résidents de chirurgie générale et digestive de l'année 2012-2013. Ce questionnaire portait sur les caractéristiques démographiques, les ressources pédagogiques, ainsi que le cursus médical et universitaire. Une évaluation de la formation ainsi qu'un recueil des propositions faites en vue d'améliorer leurs formations étaient réalisées.

Résultats

Cinquante résidents sur 83 ont répondu au questionnaire. L'orientation de carrière la plus fréquente était l'hospitalo-universitaire dans 70% des cas. La pratique quotidienne et l'internet étaient les deux ressources pédagogiques les plus utilisées. La formation chirurgicale était jugée satisfaisante par seulement 10% des répondants. Parmi l'ensemble des propositions faites, l'apprentissage sur simulateur chirurgical, l'existence d'un ouvrage national de référence, et l'institution d'un tutorat par un chirurgien senior recueillaient plus de 80% d'avis favorable.

Conclusion

La majorité des résidents jugent leur formation non satisfaisante. Une meilleure information sur les ressources déjà existantes, un renforcement du compagnonnage et un accès plus large à un apprentissage sur simulateur chirurgical permettraient de diminuer ce sentiment d'insatisfaction.

Opinions of Otorhinolaryngology Residents about Their Education Process

Objective

Our study was planned to get the views of residents about the Otorhinolaryngology (ORL) education process and to enlighten the studies to make this process more effective.

Methods

A questionnaire was sent to the residents who were still in the residency program in all education clinics via "Google Drive". Seventy-four of 354 residents responded and the answers were evaluated electronically.

Results

Fifty residents (67.56%) gave an affirmative answer to the question about the use of "Resident Log Book" and no difference was seen among the clinics. While 9 residents (12.16%) were reporting that they did not read any scientific papers, 43 (58.1%) reported they read less than three per month. Forty-one residents thougt that they were having a good and sufficient education. Seventeen residents (51.51%) who thought they were not having a sufficient education reported that the education period should be longer. When they were wanted to evaluate the education process, while 66 of them (89.18%) said "Exhausting", 52 (70.27%) said "Stressful", it was seen that the ones who said "Instructive" and "Rewarding" were 26 (35.13%) and 17 (22.97%) respectively. Further, 43 of 48 residents (89.58%) who were over the third year of their residency program indicated that they were unable to perform at least one procedure listed in the questionnaire after finishing their education.

Conclusion

This study is important because it is the first study about the opinion of ORL residents and will help determine the current status in Turkey. This study will be useful for the preparation of educational programs and guides in the future.

The Residency Training Experience in Podiatric Medicine and Surgery

The podiatric medicine and surgery residency is currently characterized by 3 years of comprehensive training. Contemporary issues have recently influenced the direction of training in the profession of podiatric medicine. Formal investigation into the residency training experience has, nonetheless, been limited. The purpose of the present study was to conduct a learning needs assessment of podiatric residency training. An electronic survey was developed, with comparable versions for program directors and residents. The specific topics investigated included the use of minimum activity volume numbers, learning resources, duty hours, strengths and weaknesses of residents, motivation of hosting student externship positions, noncognitive residency traits, meetings between residents and directors, resident satisfaction, and director satisfaction. A total of 197 program directors nationwide were sent the survey electronically, and 109 (53%) responded. Of 230 residents receiving the survey, 159 (78%) responded. Several statistically significant differences, and notable similarities, were observed between the 2 groups encompassing many aspects of the survey. A majority opinion, among both directors and residents, was found that the use of procedural assessment tools might improve resident evaluation. The responding directors and residents agreed that the following 3 topics were weaknesses in podiatric training: practice management, biomechanics, and performing podiatric research. Direct feedback immediately after surgery was the most valuable learning resource reported by the residents. The results of our study reflect the current status of the podiatric medicine and surgery residency and could facilitate improvement in the residency training experience.

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.

Do residents receive the same OR guidance as surgeons report? Difference between residents' and surgeons' perceptions of OR guidance

PURPOSE

Operating room (OR) guidance is important for surgical residents' performance and, ultimately, for the development of independence and autonomy. This study explores the differences in surgical residents' and attending surgeons' perceptions of OR guidance in prerecorded surgical cases.

METHODS

A total of 9 attending surgeons and 8 surgical residents observed 8 prerecorded surgical cases and were asked to identify both the presence and the type of attending surgeons' OR guidance. Each recorded case was observed by 2 attending surgeons and 1 resident. A previously developed taxonomy for types of OR guidance was applied to analyze the data to explore the difference. Agreement by both attending surgeons on the presence and the type of OR guidance served as the concordant guidance behaviors to which the responses of the residents were compared.

RESULTS

Overall, 116 OR guidance events were identified. Attending surgeons agreed on the presence of guidance in 80 of 116 (69.8%) events and consistently identified the type of OR guidance in 91.4% (73/80, Cohen κ = 0.874) of them. However, surgical residents only agreed with attending surgeons on the presence of guidance in 61.25% (49/80) of the events. In addition, there was significant disagreement (Cohen κ = 0.319) between surgical residents and attending surgeons in the type of OR guidance; the residents only identified 54.8% (40/73) of concordant guidance behaviors in the same guidance category as both the surgeons. Among the types of OR guidance, residents and attending surgeons were most likely to agree on the teaching guidance (66.67%) and least likely to agree on the assisting guidance (36.84%).

CONCLUSIONS

Surgical residents and attending surgeons have different perceptions of both the presence and the type of OR guidance. This difference in perception of OR guidance has important implications for the efficiency of training surgical residents in the OR, and, ultimately on residents' development of independence and autonomy.

Impact of resident surgeons on procedure length based on common pediatric otolaryngology cases

OBJECTIVES/HYPOTHESIS

Surgical education remains an important mission of academic medical centers. Financial pressures may favor improved operating room (OR) efficiency at the expense of teaching in the OR. We aim to evaluate factors, such as resident participation, associated with duration of total OR, as well as procedural time of common pediatric otolaryngologic cases.

STUDY DESIGN

Retrospective cohort study.

METHODS

We reviewed resident and attending surgeon total OR and procedural times for isolated tonsillectomy, adenoidectomy, tonsillectomy with adenoidectomy (T&A), and bilateral myringotomy with tube insertion between 2009 and 2013. We included cases supervised or performed by one of four teaching surgeons in children with American Society of Anesthesiology classification < 3. Regression analyses were used to identify predictors of procedural time.

RESULTS

We identified 3,922 procedures. Residents had significantly longer procedure times for all procedures compared to an attending surgeon (4.9-12.8 minutes, P < 0.001). Differences were proportional to case complexity. In T&A patients, older patient age and attending surgeon identity were also significant predictors of increased mean procedural time (P < 0.05).

CONCLUSIONS

Resident participation contributes to increased procedure time for common otolaryngology procedures. We found that differences in operative time between resident surgeons and attending surgeons are proportional to the complexity of the case, with additional factors, such as attending surgeon identity and older patient age, also influencing procedure times. Despite the increased procedural time, our investigation shows that resident education does not result in excessive operative times beyond what may be reasonably expected at a teaching institution.

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.

Effect of resident evaluations of obstetrics and gynecology faculty on promotion

BACKGROUND

Promotion for academic faculty depends on a variety of factors, including their research, publications, national leadership, and quality of their teaching.

OBJECTIVE

We sought to determine the importance of resident evaluations of faculty for promotion in obstetrics-gynecology programs.

METHODS

A 28-item questionnaire was developed and distributed to 185 department chairs of US obstetrics-gynecology residency programs.

RESULTS

Fifty percent (93 of 185) responded, with 40% (37 of 93) stating that teaching has become more important for promotion in the past 10 years. When faculty are being considered for promotion, teaching evaluations were deemed "very important" 60% of the time for clinician track faculty but were rated as mainly "not important" or "not applicable" for research faculty. Sixteen respondents (17%) stated a faculty member had failed to achieve promotion in the past 5 years because of poor teaching evaluations. Positive teaching evaluations outweighed low publication numbers for clinical faculty 24% of the time, compared with 5% for research faculty and 8% for tenured faculty being considered for promotion. The most common reason for rejection for promotion in all tracks was the number of publications. Awards for excellence in teaching improved chances of promotion.

CONCLUSIONS

Teaching quality is becoming more important in academic obstetrics-gynecology departments, especially for clinical faculty. Although in most institutions promotion is not achieved without adequate research and publications, the importance of teaching excellence is obvious, with 1 of 6 (17%) departments reporting a promotion had been denied due to poor teaching evaluations.

Quantifying factors influencing operating theater teaching, participation, and learning opportunities for medical students in surgery

AIMS

Operating room experience offers a unique learning resource, potentially exposing medical students to surgical disease and treatments, use of anesthesia, basic science, team working, and communication skills. However, the alien nature of this environment to newcomers poses particular difficulties in harnessing this resource. This study aimed to assess the operating theater-based teaching and learning experiences of new medical graduates during their medical school course.

METHODS

A 41-item, self-administered questionnaire survey was distributed to newly qualified medical school graduates from 1 university consisting of 5 separate teaching hospitals. Results were analyzed using GraphPad Prism 5.0.

RESULTS

Questionnaires were returned by 209 of 312 graduates (67%). Overall, 121 (59%) respondents attended ≤50% of opportunities available to attend operating theater; 47% felt they knew what was expected of them when attending and only 13% had specific learning objectives set. An interest in pursuing a surgical career was stated by 24 (12%) respondents; this group was more likely to have attended ≥50% of operating theater opportunities (p = 0.0064). Those not intending to pursue a surgical career were more likely to have been discouraged by their experiences (p = 0.0001). Active participation while scrubbed, knowing what was expected, being made to feel welcome, and being set learning objectives were all significantly positively correlated with attendance. Although female respondents felt equally welcome, in comparison with their male colleagues, they were more likely to receive negative comments (p = 0.0106). The majority of respondents (80%) stated that attendance at operating theater sessions should be a mandatory component of the curriculum.

CONCLUSIONS

Although operating theater attendance is recognized as an important component of the medical school curriculum, overall attendance at sessions was low. Attendance could be increased by ensuring students knowing what is expected of them, making them feel welcome, setting learning objectives, and allowed them to actively participate. These results highlight the need to ensure that the time spent by medical students in the operating room is positive and maximized to its full potential through structured learning involving all members of the theater team.

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.

Educational feedback in the operating room: a gap between resident and faculty perceptions

BACKGROUND

Immediate feedback regarding performance in the operating room remains a key component of resident education. The aim of this study was to assess resident and faculty perceptions regarding postoperative feedback.

METHODS

Anonymous surveys were distributed to residents and faculty members. Questions addressed the timing, amount, and specificity of feedback; satisfaction; and the definition and importance of feedback. Additional questions regarded the importance and frequency of feedback in 7 specific areas of surgical competency.

RESULTS

Resident satisfaction with timing, amount, and specificity of feedback was significantly lower than faculty satisfaction. Perceptions of the importance of feedback for each of the 7 specific areas did not differ. Faculty members' perceptions on the frequency of feedback were higher than residents' perception in all competencies of feedback (5-point scale, all P values = .001).

CONCLUSIONS

There are significant differences between resident and faculty perceptions regarding postoperative feedback. Although faculty members believed they delivered appropriate amounts of timely, quality feedback, this perception was not shared by residents.

Teaching techniques in the operating room: the importance of perceptual motor teaching

PURPOSE

To identify sucessful teaching techniques in the operating room environment through examining the teaching of the midurethral sling (MUS) surgery.

METHOD

The authors distributed questionnaires with open-ended questions about teaching and learning MUS to 5 urogynecology attendings and 16 obstetrics-gynecology residents in spring 2010. In an effort to identify qualities of an effective sling teacher, the authors used grounded theory to determine common themes and to code participant responses for examples.

RESULTS

Of 21 potential respondents, 14 (67%) returned questionnaires. The authors analyzed these and identified seven commonalities among effective sling teachers: they (1) emphasize anatomical landmarks (as determined by 64 total comments); (2) use perceptual-motor teaching (PMT; 38 comments); (3) encourage repetition (28); (4) promote early independence (34); (5) demonstrate confident competence (23); (6) maintain a calm demeanor in the operating room (20); and (7) exhibit a willingness to accept responsibility for mistakes and consequences (9). The second-most common attribute, using PMT, requires the teaching attending to emphasize the motor and tactile aspects of operating and involves incorporating not only what learners see but also what they feel.

CONCLUSIONS

The authors report seven qualities or techniques fundamental to good teaching practice in a high-stress, high-technology surgical environment, and they have identified the use of PMT, which to their knowledge has not been previously described. Teachers and learners in this study characterized PMT, which is likely generalizable to surgical procedures other than the MUS, as important. Future research should focus on exploring this technique in other surgeries.

War stories: a qualitative analysis of narrative teaching strategies in the operating room

BACKGROUND

"War stories" are commonplace in surgical education, yet little is known about their purpose, construct, or use in the education of trainees.

METHODS

Ten complex operations were videotaped and audiotaped. Narrative stories were analyzed using grounded theory to identify emergent themes in both the types of stories being told and the teaching objectives they illustrated.

RESULTS

Twenty-four stories were identified in 9 of the 10 cases (mean, 2.4/case). They were brief (mean, 58 seconds), illustrative of multiple teaching points (mean, 1.5/story), and appeared throughout the operations. Anchored in personal experience, these stories taught both clinical (eg, operative technique, decision making, error identification) and programmatic (eg, resource management, professionalism) topics.

CONCLUSIONS

Narrative stories are used frequently and intuitively by physicians to emphasize a variety of intraoperative teaching points. They socialize trainees in the culture of surgery and may represent an underrecognized approach to teaching the core competencies. More understanding is needed to maximize their potential.

Disparity between resident and faculty surgeons' perceptions of preoperative preparation, intraoperative teaching, and postoperative feedback

PURPOSE

The education occurring within the operating room is fundamental to the development of a surgical resident. The purpose of this study was to investigate differing perceptions of surgical residents and faculty in regard to preoperative preparation, intraoperative teaching, and postoperative feedback.

METHODS

A validated survey tool was slightly adapted, piloted, and then administered to the surgical residents and faculty of a university-based general surgery residency program. The wording of the survey was specific to either residents or faculty and consisted of similar questions with responses on a 5-point Likert scale (1: strongly disagree to 5: strongly agree). The responses of the 2 groups for each question were averaged and compared using Wilcoxon-Mann-Whitney test to determine significant differences.

RESULTS

In all, 27 residents and 30 faculty members completed the survey for a response rate of 100%. With respect to preoperative preparation, significant differences were found in perceptions about reading (4.22 vs 2.59; p < 0.001) and anatomy review (4.11 vs 2.31; p < 0.001) before the procedure. Considering intraoperative perceptions, significant differences were found with respect to teaching the operative steps (3.59 vs 4.06 p = 0.048), surgical skills (2.85 vs 3.78; p = 0.001), instrument handling (3.19 vs 4.00; p = 0.002), and surgical technique (3.44 vs 4.28; p < 0.001). Significant disagreement was found in the perceived effort of the faculty to act as a teacher in the operating room (3.56 vs 4.09; p < 0.007). Postoperatively, significant differences were found in perceptions of positive feedback (2.63 vs 3.34; p = 0.01) and feedback on areas to improve (2.78 vs 3.50; p = 0.009).

CONCLUSIONS

Although there is agreement on the need to improve intraoperative education, there is significant disparity in perceptions of preoperative preparation as well as intraoperative and postoperative feedback between residents and surgical faculty.

Perspectives on intraoperative teaching: divergence and convergence between learner and teacher

OBJECTIVE

While current emphases on operative teaching focus on "virtual" education, residents and faculty engage most intimately in the operating room. The utilization of intraoperative teaching techniques, drawn from adult education principles, is understudied.

DESIGN

A survey with both quantitative and qualitative elements was administered to surgical residents and their faculty. Thirty-eight analogous questions regarding teaching techniques, populating four general domains, were rated for frequency of application. Respondents were asked to rank best teaching practices and identify other effective educational approaches using open-ended questions.

SETTING

University-based general surgical residency (5 institutions).

PARTICIPANTS

General surgical residents and their faculty.

RESULTS

46 residents (77%) and 37 faculty (63%; mean 17 yrs experience) completed the survey. There was significant disagreement between residents and faculty in how frequently 32 of the 38 teaching techniques were applied (all p < 0.032). Faculty rated the technique "I set and communicate high standards" as the most frequently applied strategy, while residents rated "The faculty demonstrate technical consistency" the highest. The least employed approach, acknowledged by both groups, was "The faculty ask how they might improve their teaching." There were few differences between perceptions and preferences of junior vs. senior learners, and junior vs. senior faculty. Resident and faculty appreciation of most-effective teaching approaches was similar. Qualitative analysis of the open-ended questions yielded themes which resonate with both learners and teachers: communication processes, time pressures, optimization of the work/teaching environment, teacher engagement, patience/tolerance, autonomy, feedback, learner preparedness, and patient advocacy.

CONCLUSIONS

The perceptions of residents and faculty regarding the frequency of using effective approaches for operative teaching are disparate. While faculty appear to value adult learning principles and perceive that they are employed regularly, residents have a discrepant viewpoint. However, themes that were identified by both residents and faculty through qualitative analysis provide the foundation for educational process improvements.

Perceptions of operating room learning experiences during the obstetrics and gynecology clerkship

BACKGROUND

There is little published describing curriculum development for the medical student in the operating room (OR).

PURPOSE

Explore student and faculty perceptions of learning experiences in the OR during the Obstetrics and Gynecology (Ob/Gyn) clerkship as a prelude to defining OR-specific learning objectives and curriculum.

METHODS

Fourth year students and Obstetrics and Gynecology faculty participated in structured, audiotaped focus groups aimed at defining OR educational objectives and curriculum content. Review of audiotapes identified emergent themes used to categorize perceived learning experiences.

RESULTS

Two focus groups including 13 students and 1 focus group including 5 faculty were conducted. Four dominant categories of OR learning were identified: (1) development of a foundation of clinical knowledge; (2) surgical technique and skill acquisition; (3) personal insight into career choice; and (4) surgical culture and OR functioning.

CONCLUSIONS

Students and faculty were aligned regarding general categories of key OR learning experiences, building an experiential framework for developing OR-specific learning objectives and curricular components.

Mixing it but not mixed-up: mixed methods research in medical education (a critical narrative review)

BACKGROUND

Some important research questions in medical education and health services research need 'mixed methods research' (particularly synthesizing quantitative and qualitative findings). The approach is not new, but should be more explicitly reported.

AIM

The broad search question here, of a disjointed literature, was thus: What is mixed methods research - how should it relate to medical education research?, focused on explicit acknowledgement of 'mixing'.

METHODS

Literature searching focused on Web of Knowledge supplemented by other databases across disciplines.

FINDINGS

Five main messages emerged: - Thinking quantitative and qualitative, not quantitative versus qualitative - Appreciating that mixed methods research blends different knowledge claims, enquiry strategies, and methods - Using a 'horses for courses' [whatever works] approach to the question, and clarifying the mix - Appreciating how medical education research competes with the 'evidence-based' movement, health services research, and the 'RCT' - Being more explicit about the role of mixed methods in medical education research, and the required expertise

CONCLUSION

Mixed methods research is valuable, yet the literature relevant to medical education is fragmented and poorly indexed. The required time, effort, expertise, and techniques deserve better recognition. More write-ups should explicitly discuss the 'mixing' (particularly of findings), rather than report separate components.

Assessing the quality of clinical teachers: a systematic review of content and quality of questionnaires for assessing clinical teachers

BACKGROUND

Learning in a clinical environment differs from formal educational settings and provides specific challenges for clinicians who are teachers. Instruments that reflect these challenges are needed to identify the strengths and weaknesses of clinical teachers.

OBJECTIVE

To systematically review the content, validity, and aims of questionnaires used to assess clinical teachers.

DATA SOURCES

MEDLINE, EMBASE, PsycINFO and ERIC from 1976 up to March 2010.

REVIEW METHODS

The searches revealed 54 papers on 32 instruments. Data from these papers were documented by independent researchers, using a structured format that included content of the instrument, validation methods, aims of the instrument, and its setting.

RESULTS

Aspects covered by the instruments predominantly concerned the use of teaching strategies (included in 30 instruments), supporter role (29), role modeling (27), and feedback (26). Providing opportunities for clinical learning activities was included in 13 instruments. Most studies referred to literature on good clinical teaching, although they failed to provide a clear description of what constitutes a good clinical teacher. Instrument length varied from 1 to 58 items. Except for two instruments, all had to be completed by clerks/residents. Instruments served to provide formative feedback ( instruments) but were also used for resource allocation, promotion, and annual performance review (14 instruments). All but two studies reported on internal consistency and/or reliability; other aspects of validity were examined less frequently.

CONCLUSIONS

No instrument covered all relevant aspects of clinical teaching comprehensively. Validation of the instruments was often limited to assessment of internal consistency and reliability. Available instruments for assessing clinical teachers should be used carefully, especially for consequential decisions. There is a need for more valid comprehensive instruments.

The complex role of veterinary clinical teachers: how is their role perceived and what is expected of them?

The purpose of this study was to identify personal attributes in veterinary clinical teachers that are valued most by members of their work environment (fellow faculty, clinical training scholars [CTS; residents], undergraduate students, and referring veterinary surgeons) and to determine whether the opinions of these subgroups differed. Faculty (n=50), CTS (n=35), students (n=200), and referring veterinary surgeons (n=25) were presented with a list of 15 potentially desirable attributes. Respondents were asked to rank the three most important and the three least important attributes of effective clinical teachers. Respondents were also asked to select in which of the three main activities (clinical service, teaching, or research) in which clinical teachers currently invest the most and the least effort and in which they should invest the most and the least effort. All respondent groups agreed that "competence-knowledge" was among the most desirable attributes. Faculty, undergraduate students, and referring veterinary surgeons additionally included "enthusiasm" in the top three, whereas CTS regarded "respects independence" as more important. All respondent groups consistently chose "scholarly activity" as one of the three least important characteristics. A similar number of faculty members (38%) expressed that the greatest effort should be invested in clinical service or teaching, and the greatest proportions of CTS (44%) and students (56%) felt that most emphasis should be put on teaching alone. The differences in opinion between respondent groups regarding importance of attributes and emphasis of activity indicate that what is perceived as effective performance of clinical teachers differs depending on the role of those who engage with them.

The power of one: looking beyond the teacher in clinical instruction

BACKGROUND

Research on clinical teaching in medicine tends to focus on preceptors and senior attending physicians as the primary source of learning for medical students. As a result, there is an artificial separation of 'teacher' from context in much of the research on clinical teaching in medicine.

AIMS

The central aim of this study was to challenge the taken-for-granted assumption that student learning can be attributed primarily to a preceptor or attending physician on a rotation.

METHODOLOGY

Twenty-two medical students and forty-one clinical faculty members generated explanations for a study that showed a positive effect on NMBE results for 3rd year clerkship students who had at least one highly effective clinical teacher during their clinical rotation in medicine.

RESULTS

Student and faculty explanations resulted in fourteen factors and six propositions describing the nature of highly effective clinical teaching. Students believed contextual factors influenced their own learning, but did not comment on that possibility in the study (Griffith CH, Georgesen JC, Wilson JF. 2000. Six-year documentation of the association between excellent clinical teaching and improved student examination performance. Acad Med 75(10): October Supplement). Most clinical faculty did question the assumption that one teacher could have that effect.

CONCLUSIONS

We recommend refocusing research on clinical instruction toward engagement within a community of professionals, rather than attributing 'power' to a single clinical teacher.