Beginning resident (maximum assistance and supervision)
Mid-residency (moderate assistance and supervision)
Senior resident (minimal assistance and supervision)
Preoperative (preop plan as guide)
Resident to read about procedure preoperatively. Preoperative discussion of 1–2 surgical goals for resident. With X-rays, discussion of indications for surgery, including various options. Discussion of comorbidity. Classification of fracture. Discussion of consent and potential complications
With X-rays, discussion of indications for surgery, including comorbid factors. Include discussion of reduction techniques. Discussion of resident operative goals
Confirm indications for surgery, including comorbidities. Resident to explain reduction technique, implant, and potential difficulties foreseen preoperatively
Attending present and scrubbed for most of the case. Conversation about optimal guide wire placement, basic reduction techniques. Demonstration of basic surgical principals
Attending present and scrubbed for all critical parts. Conversation and participation for critical parts of the case. Resident to perform parts of the case, with intervention by faculty when having difficulty. A smooth flow of differing parts of the case between faculty and resident should be the goal of allowing maximum resident participation but maintaining quality of care
Attending to be present for all critical portions of the case. For uncomplicated to moderately complicated fractures, the faculty member should not need to scrub in. Towards the end of training, the resident is expected to confirm their ability to perform this case
Attending to review with the resident the procedure, with discussion of what went well and what could be improved. Important to set goals for the next procedure of this type
Review with resident of case and the performance by the resident. Include goals for improvement. Discussion of postoperative plan, to include weight-bearing status, DVT prophylaxis, and antibiotics
Confirmation by resident of the postoperative plan to include the use of antibiotics, DVT prophylaxis, and weight-bearing status
For a preoperative discussion, a patient’s history and physical are reviewed, diagnosis discussed, and an operative plan made. A preoperative plan, written by the resident and turned in to the attending prior to the surgery for review, is an excellent learning tool. A formal preoperative plan written out by the resident allows the resident to independently analyze the case, and allows the faculty to assess the resident’s level of understanding prior to starting the case. This communication between faculty and resident is essential to maximizing the learning experience for each surgical case. This is particularly true of junior residents who may not have had exposure to this procedure. Reading about a procedure, followed by formulating a preoperative plan, which includes writing out the sequential steps, is a useful exercise for imprinting a procedure.
The preoperative plan is an educational tool that serves a number of important educational purposes including integrating anatomical knowledge, critical thinking, and importance of presurgical planning. While there are a number of ways to do this, the best way is one which allows robust discussion of the written preoperative plan that occurs between the faculty and resident. For fracture cases, it is best to draw out the anatomy, draw out the implant used, and then write the sequential steps in order of performance. Simple, low-tech drawings are the easiest to do as a learning exercise. This type of exercise can be done anywhere in the world, even under austere circumstances. Prior to the use of computers and preoperative templating of electronic X-rays, the simple drawings were often used. As a faculty member today, I am often presented with electronic X-rays which have an implant superimposed from a templating program. While this is a much easier exercise for resident to perform, there is often little critical thinking involved in formulating such a plan. Encouraging the residents to keep an electronic file of surgical plans is appealing to residents as these written surgical plans are useful for reference in later cases, and for when they embark in independent practice.
Depending on the level of the resident, the preoperative discussion should be done to ensure that the proper procedure is being planned, and a check of the equipment is needed, and the status of the patient with regard to preoperative clearance, consent, and need for blood. A junior resident will require more discussion to ensure that the patient has been properly cleared, the equipment is ready, and the procedure itself has been properly planned. Less double checking needs to be done by faculty once the resident is familiar with the routine for a given case. Preoperative clearance will become more automatic and expected of a resident as they advance through training. Educational goals should be set in the preoperative discussion. These educational goals should be used as guidance for the procedure. By verbal agreement, no more than 2–3 main goals for improvement should be sought for a particular case. Less experienced residents will perform less of the procedure when compared to a senior resident who is near graduation. When utilizing the operating room for teaching, performing simpler tasks of the procedure, followed by observation and seeing firsthand the more complex aspects of the case, is an important aspect of learning how to do a procedure. Building on the simpler experience to become more competent and have more autonomy during the case is the goal of teaching in the operating room. A mid-level resident who has participated in this procedure before will have more advanced goals for the procedure. Finally, the goal for a senior resident is to perform the procedure with minimal or no assistance from faculty.
Intraoperative Teaching (I)
Intraoperatively, the educational goals should follow what was discussed preoperatively. Outlining 1–3 goals prior to the onset of the procedure is a reasonable way to approach teaching in the operating room. Moulton et al. [2, 3] described surgical thought and behaviors as a transition back and forth between “automatic” and “effortful” [1, 2]. The automatic behavior is the accomplishment of the procedure or steps in the procedure in a routine manner. Most elective procedures in orthopaedic surgery are accomplished in this manner. More “effortful” behaviors are characterized by slowing down and concentrating on the unanticipated or more complex tasks. “Slowing down” to focus on the more critical teaching points of the case is extremely important for guidance and teaching. “Slowing down” will occur in areas where more time should be spent either with agreed-upon learning objectives for improvement during the case or in cases when unexpected events occur. Mastery of a surgical procedure will mean that the surgeon will accomplish the procedure automatically without giving the conscious thought to sequential steps. While some aspects of the case should be automatic, depending on the level of the resident, the areas which faculty and learner agree need work will be an effort of extra concentration allowing for possibly extra time to concentrate, receive feedback, and master the skill.
Postoperatively, faculty and the resident should have a short discussion to debrief on what went well and what areas need additional training. Ideally, faculty should inquire as to what the resident felt went well and what areas for improvement still exist. Based on the resident’s response, and faculty input, a future educational plan can be made for improving the resident’s surgical skills. The postoperative discussion, therefore, becomes a mechanism where residents learn to identify gaps, elicit feedback, and develop an educational plan for future learning. Furthermore, the resident learns the case three times: before the case, doing the case, and debriefing the case. This maximizes educational efficiency.
In teaching, an important tenet is that the faculty member meet the resident where they are at and teach to their level. By identifying each resident’s strengths and weaknesses, and skills can be built on throughout the rotation. This idea supports the resident working with a single faculty member for a rotation, allowing for the maximum amount of teaching to occur. With larger teams, and multiple faculty members, care must be taken to employ the BID technique each time, to know how to maximize the resident’s experience and not just make the education too diffuse.
Operating Room Communication
Chen et al. [3–6] reported on interviews of nine attending surgeons and eight residents when observing operative interactions recorded by video between faculty and residents when performing one of eight common general surgery procedures [3, 5]. Both the attending surgeons and residents were then asked to review the videos and answer semistructured questionnaire. The authors found that there were three guiding behaviors demonstrated by faculty in the operating room which they characterized as teaching, directing, and assisting. Teaching was when the faculty demonstrated or described something new for the resident of the procedure. Directing behavior was when the resident was being guided verbally for an operative task. Assisting was when the faculty acts to facilitate the case, without prompting directions from the resident. An example of the latter would be to adjust a retractor as the resident is dissecting.
Roberts et al. attempted to identify verbal interactions that occurred in the operating room and categorize them as to the type of interaction being performed . Four main types of interactions were described in this study. Instrumental interactions were used to move the procedure forward. In other words, this type of interaction was specific direction given by faculty member to move the case along in a timely manner. Pure teaching interactions were identified as those interactions in which the faculty provided enough context to improve the resident’s understanding of the case. This type of interaction added to the resident’s knowledge or was considered to help shape the resident’s judgment.
A mixture of the previous two interactions was also noted. The use of instrumental plus teaching interactions provided guidance and provided a foundation for what was being accomplished at that point in the procedure. The last type of interaction that was noted was described as being “banter.” This was considered by the authors to be conversation that was unrelated to the procedure. The authors went further to described “teachable moments” in which a faculty member noted an area of improvement, and described in real time a means to improve resident performance. On-the-spot, real-time, correction and improvement in resident performance is one of the most important facets of teaching in the operating room. In this study, the authors found that nearly half the interactions were “teaching” or “instrumental plus teaching.”
In moving a case along, and facilitating progress, faculty need to assert themselves during the case to ensure that the procedure goes as is expected and that the teaching/learning experience is maximized.
Moulton et al. evaluated interactions between faculty and residents and how a faculty member controls the case to ensure that an appropriate balance between safety and education was maintained . The authors interviewed 28 surgeons at 4 academic teaching hospitals, with 5 general surgeons being observed in the operating room. The authors were interested in evaluating how dynamics of the case proceeded when more difficult sections of the case were encountered which they referred to as “slowing down.” They described how surgeons take direct control of the case when they perceive that the resident needs help or there is a more difficult section of the case. For more routine steps, they will often guide a resident through parts of the case, allowing for increasing autonomy as the resident gains the faculty confidence. Difficulties arise when the faculty and resident are “out of sync” with each other and do not see eye to eye on how the case should proceed. Additionally, the authors describe how faculty takes direct control of the procedure too late which results in either a less-than-optimal performance or a complication. The authors describe this as “skidding.” Not trusting or having confidence in the residents’ abilities does lead to too much control in which the resident is doing less than they are capable. The authors noted that bargaining was often done between residents and faculty in which doing more of the case was a reward for doing a job well, and less of the case as a punitive measure if the resident was perceived as doing less than expected.