Eliza B. Littleton

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.

Intelligent cooperation: A framework of pedagogic practice in the operating room

BACKGROUND Surgeons who work with trainees must address their learning needs without compromising patient safety. METHODS We used a constructivist grounded theory approach to examine videos of five teaching surgeries. Attending surgeons were interviewed afterward while watching cued videos of their cases. Codes were iteratively refined into major themes, and then constructed into a larger framework. RESULTS We present a novel framework, Intelligent Cooperation, which accounts for the highly adaptive, iterative features of surgical teaching in the operating room. Specifically, we define Intelligent Cooperation as a sequence of coordinated exchanges between attending and trainee that accomplishes small surgical steps while simultaneously uncovering the trainees learning needs. CONCLUSIONS Intelligent Cooperation requires the attending to accurately determine learning needs, perform real-time needs assessment, provide critical scaffolding, and work with the learner to accomplish the next step in the surgery. This is achieved through intense, coordinated verbal and physical cooperation.

Teaching, Learning, and Performance in the Surgical Workplace: Insights From the Examination of Intraoperative Interactions

abstract This Conversations Starter article presents a selected research abstract from the 2017 Association of American Medical Colleges Central Region Group on Educational Affairs annual spring meeting. The abstract is paired with the integrative commentary of three experts who shared their thoughts stimulated by the study. These thoughts explore the value of examining intraoperative interactions among attending surgeons and residents for enhancing instructional scaffolding; entrustment decision making; and distinguishing teaching, learning, and performance in the workplace.

Teaching the Retropubic Midurethral Sling Using a Novel Cadaver and Model-Based Approach

Objective To measure the impact of a model-based teaching program on resident comfort and skill with retropubic midurethral sling (MUS). Study design Residents were assessed before and after a retropubic MUS teaching session, which included a brief lecture and three interactive teaching stations (cadaver pelvis, retropubic MUS pelvic model, cystoscopy model). Self-assessment measures included MUS-related visual analog scale (VAS), Likert, and open-ended questions. Objective assessment measures were used to score blinded videos of trocar passage on a pelvic model, including a modified objective structured assessment of technical skills (mOSAT) and a retropubic MUS-specific checklist of surgical steps. Emerging themes from the open-ended questions were identified using grounded theory; analysis ceased once theme saturation was achieved. Results Twenty-five of 37 total residents participated in the training session and 24 participated in this study. Following training, VAS scores, Likert scores, and qualitative analysis indicated greater resident comfort with performing retropubic MUS, with relevant anatomy, and with trocar passage. Residents demonstrated improvement in model trocar passage post-training, with a rise in mOSAT score (47% to 65%; p = .01) and a rise in checklist score (61% to 75%; p = .11). Residents expressed discomfort due to inexperience with MUS, concern regarding trocar passage, and worry over potential complications. Residents reported feeling more prepared to perform MUS after the session. They stressed the importance of repetition and a comfortable learning environment for surgical training, and praised the “hands-on” training session. Conclusion We demonstrate success using a short, single-session, hands-on group training session to improve comfort and skill with retropubic MUS.

How can surgeons facilitate resident intraoperative decision-making?

BACKGROUND Cognitive skills such as decision-making are critical to developing operative autonomy. We explored resident decision-making using a recollection of specific examples, from the attending surgeon and resident, after laparoscopic cholecystectomy. METHODS In a separate semi-structured interview, the attending and resident both answered five questions, regarding the residents operative roles and decisions, ways the attending helped, times when the attending operated, and the effect of the relationship between attending and resident. Themes were extracted using inductive methods. RESULTS Thirty interviews were completed after 15 cases. Facilitators of decision-making included dialogue, safe struggle, and appreciation for retraction. Aberrant case characteristics, anatomic uncertainties, and time pressures provided barriers. Attending-resident mismatches included descriptions of transitioning control to the attending. CONCLUSIONS Reciprocal dialogue, including concept-driven feedback, is helpful during intraoperative teaching. Unanticipated findings impede resident decision-making, and we describe differences in understanding transfers of operative control. Given these factors, we suggest that pre-operative discussions may be beneficial.

The Learner-Teacher Relationship

The relationship between learner and teacher is fundamental to medical education, yet there has been limited research on the subject. We explore how analogies to theories from two other fields—evolutionary biology and social theory—may help us understand some of the tensions in this relationship and may offer guidance on how to solve problems between learners and teachers.