Teaching in the Operating Room
Brian George
THE COMPLEXITY OF TEACHING IN THE OR
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.
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.
THE BID MODEL
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.
ESTABLISHING AND MAINTAINING CLIMATE
Importance for Learning
The most tangible aspects of an educational program are its curricula. Yet trainees are also influenced by the educational environment or “climate” of the training program.6 For example, some programs are very authoritarian, while others may be more egalitarian. Trainees perceive these unwritten components to the curriculum differently. For some, one type of climate may be motivating while for another it may be demotivating. In general, however, a supportive climate is essential for trainees to optimize their learning (and performance).
The impact of climate on learning has been demonstrated across a range of learning domains and learning outcomes.7 In residency programs, it has been linked to the quality of resident education,8 performance,9 and well-being.10 But how does climate have these effects? One plausible mechanism may be through the stress engendered by hostile or intimidating environments.
There is a well-established relationship between psychological stress and performance, first described by Yerkes and Dodson in 1908.11 As summarized more recently by Dobson, “A little anxiety from time to time can be beneficial to task performance… This is illustrated by the Yerkes Dodson law which states that performance is improved until an optimum level of arousal is reached.”12 Yet clearly too much stress diminishes performance, in part by increasing the amount of mental energy spent dealing with the emotional reaction engendered by those stimuli. This is especially true as task difficulty increases (Figure 19.1). As a result, managing the learning climate has a direct impact on trainees’ stress and therefore their performance and learning.
Before discussing how to optimize the learning climate, one must first acknowledge that it is shaped at multiple levels. For example, a training program is situated within a hospital, a larger educational system, and a professional culture, all of which interact to create what might be usefully simplified to be the “program-level”
climate. But there is also a smaller level of climate, one that can be influenced by instructors. In the wider educational literature this is referred to as the “classroom-level” climate.7 In surgery, the operating room is a classroom, which is where trainees learn how to operate.
climate. But there is also a smaller level of climate, one that can be influenced by instructors. In the wider educational literature this is referred to as the “classroom-level” climate.7 In surgery, the operating room is a classroom, which is where trainees learn how to operate.
 Figure 19.1 Relationship between the amount of stress and performance. Easy tasks are performed better with relatively more stress (panel A) than more difficult tasks (panel B) (Adapted from Yerkes and Dodson and Weiss KB, Bagian JP, Nasca TJ. The clinical learning environment: the foundation of graduate medical education. J Am Med Assoc. 2013;309(16):1687-1688. doi:10.1001/jama.2013.1931.) |
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.”
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
