Christopher P. Magas

Progressive Entrustment to Achieve Resident Autonomy in the Operating Room: A National Qualitative Study With General Surgery Faculty and Residents.

Objective: The purpose of this study was to identify behaviors that faculty and residents exhibit during intraoperative interactions, which support or inhibit progressive entrustment leading to operative autonomy. Background: In the operating room, a critical balance is sought between direct faculty supervision and appropriate increase in resident autonomy with indirect faculty supervision. Little is known regarding perspectives of faculty and residents about how attendings increasingly step back and safely delegate autonomy to trainees. Understanding the context in which these decisions are made is critical to achieving a safe strategy for imparting progressive responsibility. Methods: A qualitative study was undertaken from January 2014 to February 2015. Semistructured interviews were conducted with 37 faculty and 59 residents from 14 and 41 institutions, respectively. Participants were selected using stratified random sampling from general surgery residency programs across the United States to represent a range of university, university-affiliated, and community programs, and geographic regions. Audio recordings of interviews were transcribed, iteratively analyzed, and emergent themes identified. Results: Six themes were identified as influencing progressive entrustment in the operating room: optimizing faculty intraoperative feedback; policies and regulations affecting role of resident in the operating room; flexible faculty teaching strategies; context-specific variables; leadership opportunities for resident in the case; and safe struggle for resident when appropriate. Conclusions: Perspectives of faculty and residents while overlapping were different in emphasis. Better understanding faculty–resident interactions, individual behaviors, contextual influences, and national regulations that influence intraoperative education have the potential to significantly affect progressive entrustment in training paradigms.

OpTrust: Validity of a Tool Assessing Intraoperative Entrustment Behaviors

Objective: The aim of this study is to establish evidence to support the validity of a novel faculty-resident intraoperative assessment tool for entrustment known as OpTrust. Background: Recently, the landscape of surgical training has been altered, in part, because of resident work-hour changes and increased supervision requirements. To address these concerns, a new model for assessment of teaching and learning in surgical residencies must be anchored on progression through milestones and entrustment. Methods: OpTrust was designed to assess the faculty-resident dyad in the operating room and measure the entrustment exhibited during intraoperative interactions across 5 domains: (i) types of questions asked, (ii) operative plan, (iii) instruction, (iv) problem solving, and (v) leadership by the surgical resident. After initial pilot testing and refinement of OpTrust, 5 individual raters underwent rater training sessions; 49 individual operating room observations were completed based on 28 cases. Results: OpTrust, as a tool for assessing intraoperative entrustment, is supported by strong validity evidence. In part, it demonstrates strong interrater reliability across all faculty domains as measured by intraclass correlation 1 (ICC1) (0.81–0.93). For resident domains the results were similar with ICC1 (0.84–0.94). Cronbach alpha was 0.89 and 0.87 for faculty and resident entrustment respectively, signifying the 5 domains could be combined into a single construct of entrustment. A high correlation existed between faculty and resident scores (Pearson r = 0.94, P < 0.001) indicating a strong positive linear relationship between faculty and resident mean entrustment scores across all scale domains. Conclusions: OpTrust successfully assesses behaviors associated with entrustment during intraoperative faculty-resident interactions, and has the potential to be adopted across other procedural-based specialties to promote autonomous training progression.

Strategic questioning in surgical education

In the complex and nuanced world of surgical education, oneway teaching – often in the form of directives from the attending physician to the resident (i.e. from specialist to trainee) – is insuffi cient for understanding the needs of trainees and developing safe opportunities for learner advancement. We propose a novel learnercentred approach to intraoperative teaching using questioning that integrates: (1) Socratic questioning and (2) Bloom ’ s Taxonomy, which respectively incorporates wait time and progressively complex questioning to stimulate higherorder thinking. 1–4 As surgical faculty members, surgical residents and medical educators, we collaborate on this actionoriented initiative to enhance trainee education. The need for this multidimensional team approach has become particularly important in the context of educational time constraints, as a side effect of trainee workhour restrictions and the exponential growth in surgical innovations, interventions and technologies.

Intraoperative questioning to advance higher-order thinking

BACKGROUND The type of question asked elicits a particular response. The purpose of this study was to determine what types and levels of questions were asked in the operating room. These insights are important for understanding how questions are used to advance learners. METHODS 12 laparoscopic cholecystectomy operations were observed and recorded at a single institution. Intraoperative questions asked by faculty were transcribed for all cases. Using revised Blooms taxonomy, questions were classified into one of 5 levels: (1) remembering, (2) understanding, (3) applying, (4) analyzing, (5) evaluating. RESULTS 141 questions were asked by faculty and ranged from 0 to 34 questions per case. Classification of questions showed there were 43 remembering, 29 understanding, 47 applying, 13 analyzing, and 8 evaluating questions asked. CONCLUSIONS Questioning was predominately classified at lower-order and mid-level thinking skills (120/141). Integrating intraoperative questions at higher-order levels has the potential to guide trainees into progressively complex thinking and decision making.

It's worth the wait: optimizing questioning methods for effective intraoperative teaching

The use of questioning to engage learners is critical to furthering resident education intraoperatively. Previous studies have demonstrated that higher level questioning and optimal wait times (>3 s) result in learner responses reflective of higher cognition and retention. Given the importance of intraoperative learning, we investigated question delivery in the operating room.