Teaching in the Operating Room

Teaching in the Operating Room

Brian George



Teaching in the operating room is one of the most difficult activities undertaken by human beings. It requires the teaching surgeon to perform at the highest level in multiple complex roles simultaneously. While performing (or supervising the performance of) the technical steps of an operation, attending surgeons must also lead the team to execute the broader operative plan and maintain the situational awareness needed to identify when the original plan must change.1 As if that weren’t enough, teaching faculty are expected to identify, in real time, knowledge gaps to which they can teach in order to achieve the learning goals of individual trainees. This latter goal is made even more difficult when there are multiple learners and therefore multiple learning goals.

Remarkably, teaching faculty are expected to perform these instructional activities on a routine basis with little formal training.2 Instead, most surgeons learn how to balance the competing demands of the patient, the team, and the learners
through observing others and self-directed trial-and-error. Some faculty also have access to more formal didactic resources. Unfortunately, these strategies are not always successful. In those cases where faculty are not confident in their teaching skills, it can be tempting for them to minimize the time they spend teaching. This temptation is further reinforced by the fact that teaching is rarely necessary to meet the immediate needs of the current patient.

Further complicating the task, teaching in the operating room today must be different than it has been in the past. The next generation of surgeons is much more diverse than the last.3 This diversity is clearly a strength, yet it also introduces additional challenges when teaching in the operating room. A “one size fits all” approach is now even less effective than it already has been, and more advanced techniques are needed to better individualize teaching. Unfortunately, as with other teaching skills, most faculty have not had formal training in these techniques.

In addition, bias risks compromising the education of some trainees who have not historically been well represented in surgery. For example, women are provided less autonomy by both male and female teaching faculty.4 These effects almost certainly exist for other demographic groups. To avoid unconsciously discriminating against some learners, it is important to consciously develop a teaching framework that can be equitably applied to all learners according to their individual needs.

This chapter provides information about teaching in general while also highlighting the need to individualize the support of learners with different goals, backgrounds, and perspectives. While it is challenging to holistically integrate multiple responsibilities, doing so will bring benefits to both current and future patients.


This chapter leverages a few existing conceptual frameworks to organize and motivate the information. The most widely known framework for teaching in the OR is the Briefing, Intraoperative teaching, and Debriefing, or BID, model.5

  • The Briefing phase classically occurs while the team is at the scrub sink, where the faculty and resident can explicitly identify learning goals for the upcoming case. This is also an opportunity for faculty to define the limits of the trainee’s knowledge so that intraoperative teaching can be targeted to the zone of learning that is neither too easy nor too difficult for the specific learner.

  • The Intraoperative phase encapsulates behaviors that are typically associated with teaching in the OR, although in this model faculty teaching efforts are targeted to the goals identified during the Briefing Phase. Again, the goal is to individualize teaching to address the unique needs of learners with diverse needs and prior knowledge.

  • The Debriefing phase occurs at the end of the case and is when faculty can provide feedback to trainees about their performance during the case, again aligned to the Briefing goals. One way for faculty to structure the Debriefing conversation is to (1) invite trainees to self-assess their performance on the identified learning goals, (2) help trainees to formulate new learning as a general principle or rule to guide future practice, (3) reinforce what was done right, and (4) correct mistakes, especially cognitive errors.

Each of these phases presents opportunities to equitably support and include diverse learners, as described below.


Approach to Establishing a Supportive Climate

Fortunately, faculty have a great deal of influence in the operating room. As such, they also have an important role to play in cultivating the operating room climate. This can be seen in the results of a student where medical students reported that attending physicians’ attitudes and interactions in the OR were strongly correlated with the environment being conducive to learning.13 Attributes such as “Attending was a positive role model” and “Attending surgeon tone” were most strongly correlated with the conduciveness of the OR environment for learning.

The climate can be established even before the team enters the operating room. The original description of the Briefing phase recommended a discussion about learning goals. This behavior also supports establishing a supportive learning climate because it is a clear signal that the trainee’s needs are valued and supported. If the teaching surgeon hasn’t often operated with the resident, it is also useful to set expectations not only for participation and autonomy but, importantly, for the amount of time being deliberately set aside for teaching. For medical students, an effective behavior is to learn their name—an easy but also easily overlooked intervention. Publicly introducing medical students to the OR team as one enters the theater can help put them at ease and also communicate to other team members that the student has a legitimate role and “belongs.”

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May 5, 2022 | Posted by in GENERAL SURGERY | Comments Off on Teaching in the Operating Room

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