Contemporary Delivery of Surgical Education
Gurjit Sandhu
Gifty Kwakye
Rebecca Minter
HOW DO FACULTY ENTRUST A TRAINEE?
It is 7:40 am on a Friday and the OR is already running 10 minutes late with the first patient not in the room yet. This is the first of four complex cases Dr. Smith has scheduled that day, with the last one tentatively slated to be done by 4 pm so she can make it to a meeting at 5. It’s almost 8 when the “room ready” page goes out and the Anesthesia team roles the patient into the room. Also walks in the PGY 2 on the service who apologizes for not being there earlier and explains that due to an emergency, the chief resident initially assigned had been pulled for coverage elsewhere. When asked if she’d ever assisted with an abdominoperineal resection for rectal cancer before, her answer is no.
However, she is eager to learn and assist however necessary. Dr. Smith appreciates her enthusiasm but realizes this could impact her intended pace for the day. Prior to scrubbing in, she calls her administrative assistant to cancel the 5 PM meeting.
However, she is eager to learn and assist however necessary. Dr. Smith appreciates her enthusiasm but realizes this could impact her intended pace for the day. Prior to scrubbing in, she calls her administrative assistant to cancel the 5 PM meeting.
THE PARAGON TRIPLE-THREAT SURGEON
Most enter academia drawn by the opportunity to practice clinically, conduct research, and be involved in teaching learners across all stages—the heroic “Triple-Threat” surgeon.1,2 In an attempt to provide a more in-depth definition of what this entails, Rosengart and his team studied the curriculum-vitae and self-descriptive vignettes of seven surgeons considered giants in the field.3 Seven key attributes discovered were
1. identifies complex clinical problems ignored or thought unsolvable by others,
2. becomes an expert,
3. innovates to advance treatment,
4. observes outcomes to further improve and innovate,
5. disseminates knowledge and expertise,
6. asks important questions to further improve care, and
7. trains the next generation of surgeons and scientists.
Of all these, Sir William Osler, who is credited for the Triple Threat concept, considered the training of students “by far the most useful and important work I have been called upon to do.”1,2
Unfortunately, due to increased productivity pressures, demands to improve efficiency, and shifting expectations regarding supervision and the participation of learners, most faculty are faced with a myriad of daunting challenges. An unintended consequence is that the teaching mission has been relegated to the background or completely discarded. It is no surprise then that residents are graduating without the necessary skills to succeed in independent practice and that more are seeking additional fellowship training.4,5 The degree of unpreparedness reported in several studies is alarming.5,6,7 For instance, Mattar et al.7 surveyed fellowship program directors regarding performance of new fellows. They found that 66% were unable to operate unsupervised for 30 minutes of a complex case and 26% could not recognize anatomical planes. This is not a judgment of the quality of contemporary trainees, but rather a system of training which has failed them.
The detrimental impact of this failed system on the ability to provide quality patient care and to educate future generations of surgeons has created a sense of urgency among governing bodies and training programs, leading to calls to revive the teaching mission.5,8 More funding has also been allocated to research to help understand how to teach and motivate both learners and faculty more effectively. As a result, concepts such as “Autonomy” and “Entrustability” have surfaced and assessment tools, such as the System for Improving and Measuring Procedural Learning (SIMPL) smartphone application, have been adopted by many programs.9,10,11
The Conflict With Intraoperative Teaching
Despite these efforts, teaching effectively and attaining the desired outcome continue to be quite challenging especially in the operating room. Faculty have to take into account a wide range of trainee ability, even among individuals at the same level, and be quick to adapt depending on a multitude of factors.12,13,14 These include the complexity of the case, number and experience of support staff, and even the surgeon’s own level of experience. In addition, the faculty surgeon often has had limited contact with the trainee and does not know the level of skill and experience the resident has with the planned operation.
Before an incision is made, most faculty have an operative plan in place, in addition to alternatives depending on the operative findings. They have also predetermined, to an extent, the degree of autonomy they are willing to allow the resident.14,15 Chen et al.14 found that this decision was influenced by five main factors (Figure 18.1):
1. case schedule/start time,
2. patient morbidity,
3. procedure attributes,
4. resident current competency level, and
5. trustworthiness.
The resident’s current competency—consisting of their PGY level, knowledge, experience, and/or skills—was the most important factor.14 In follow-up studies,15,16 the investigators took a closer look at how attending surgeons determine these resident factors preoperatively as a means of gauging readiness for autonomy. Strategies used included
1. directly asking the resident about previous experience doing the same or similar case;
2. judging preparedness for a case based on knowledge, attitude, or confidence exhibited; and
3. using evidence acquired before the case from prior interactions, assessments, or the resident’s reputation among peers or other faculty.
 Figure 18.1 Factors determining resident intraoperative autonomy. |
Of course, most if not all of these strategies lend themselves to subjective influences, which can result in mismatched intraoperative expectations. For instance, attending surgeons and residents have been found to have different learning goals and interpretations of what counts as adequate preoperative preparation for the same case.17,18 Understandably it is also difficult to utilize these strategies when resident case assignments are changed at the very last minute, as in the scenario described above, or when faculty are less familiar with a resident.
Once the surgery begins, the amount of autonomy actually provided is strongly dependent on the attributes of the attending surgeon themselves rather than the resident.14,19 These, as alluded to earlier, include their level of experience or comfort with a case, their preferred surgical technique, or their own beliefs regarding teaching residents in the operating room. These inherent attending attributes also influence the degree of faculty entrustment exhibited. Faculty entrustment is defined as “actions that impart trust and responsibility for patient care to the resident while providing appropriate supervision.”19 Interestingly, neither case difficulty nor faculty years of experience is associated with faculty entrustment in direct observational studies performed.19
Providing “teaching” in the operating room is not sufficient to ensure independent practice if it is not combined with an intentional process of assessment and feedback to residents actually participating in performing the operation. Traditionally, resident assessment has been conducted at various time intervals over the year relying on the attending surgeon’s remote memory. Studies have shown, however, that evaluations completed more than 3 days after the interaction often lack granular details, especially regarding performance.10,20 Instead, what has been found to be effective is real-time and video-based assessment with feedback pertaining to both resident technical and nontechnical skills (NOTSS—situational awareness, decision making, leadership, communication, and teamwork).10,21,22
HOW DO RESIDENTS DEMONSTRATE THAT THEY ARE ENTRUSTABLE?
Faculty responsibility with respect to patient care, supervisory regulations, and conditions of employment have significant bearing on surgeon actions and carry real consequences for lack of adherence.23,24,25 It is thus understandable that these forces would have a constraining effect on how surgeons teach. As the surgical environment continues to change at an extraordinary pace (e.g., costs of care, operative efficiencies, patient acuity and comorbidities, virtual resources, milestones, and competencies), faculty alone cannot be responsible for the education mission.7,26 Balancing multiple and competing responsibilities in the operating room—the dynamic high-stakes education environment unique to surgical residencies—requires an equally dynamic reimagining of teaching and learning in the operating room. Enhancing faculty-trainee intraoperative interactions to optimize learner growth is a responsibility that must also be incurred by residents. Learner responsibility is explored through resident agency in education, culture as a driver of performance, and the recognition of the important role of mentees.
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