Teaching Prescription Pad: Teaching in the Operating Room
Session Recorded September 9, 2021

Welcome to this session of the teaching prescription pad, where we learn the prescription for effective teaching from the best clinical teachers. This session is on teaching in the operating room. Our expert is Dr. Megan McDonald. Dr. McDonald is an assistant professor of gynecologic oncology at the University of Iowa Hospitals and Clinics and a graduate of the Master in Medical Education Program. She has a particular interest in surgical training, both in and out of the operating room. I am Jeff Pettit, your moderator for the session. Welcome, Dr. MacDonald.

Thank you so much for having me. I just want to clarify, I am by no means an expert in this area, but I do have an interest in it. And that is something that I have looked into. So, I appreciate you being able to share my thoughts today.

My first question is, why is this topic important or of interest to you?

I recently had an experience that I really think illustrates perfectly why we should care about teaching in the operating room. I thought I'd just share it quickly. Imagine this: I am 40 weeks pregnant. It is 11 o'clock at night and my water breaks. I go into the hospital shortly into the labor process. My baby's heart rate drops, and it does not come back up. I am rushed back to the operating room for an emergency C-section under general anesthesia. I am laying there in the operating room table, drifting off to sleep, and I am looking up at the two surgeons who are about to do my surgery. I realize it is a senior resident that I taught how to operate and a recent graduate of our residency program, also who I taught to operate. All I could think to myself was, “Oh, God, please let me have taught these women how to tie a good knot!" before I go to sleep. I think that is a dramatic example. The only reason to care about teaching in the operating room isn't just in case the learners are operating on you at some point, but definitely something to think about.

But long before my delivery experience, I identified a need for improved teaching in the operating room.  I think anyone who teaches in the operating room can recognize that in recent years there has been a tangible shift away from the time and the resources being dedicated or allocated to operative teaching.  Because of the shift, we really must work that much harder to make these interactions in this limited amount of time that much more meaningful.

What are some of the challenges to teaching in the operating room?

There are really a lot, unfortunately. The first thing that I feel quite intensely is from the administration side of things. There is this very myopic view from the administration that time is money. So, again, when there is no tangible financial gain for the hospital, there is really no incentive for teaching. I see that this year, my Arvizu targets have gone up, but my overtime that I have dedicated has gone down. We are trying to squeeze in more cases and more limited amounts of time. And with that, something has got to give. Unfortunately, a lot of times it is the teaching part of it that that gives.

There is also this issue of new technology coming along. When I was a resident, it was the robotic console. That was the new sexy thing that was coming along. With that, some of our surgical staff had to learn the nuances of that machine. In doing so, I think my residency, my experience got a little bit less. Now as a staff, what I see is we are using something called sentinel nodes and endometrial and cervical cancer. As I learned the fluorescence technology, I am teaching less of that to my residents and my fellows as well. There will always be evolution of technology and with that, some compromise to learn our education.

Resident expectations have changed quite a bit even since I have been a resident. There are more conferences that our residents attend. There is significantly more documentation that we are expecting from our residents last time around. All of this is to be completed with increasingly strict guidelines due to our restrictions. Our residents are consistently spending a couple hours a night on documentation outside of the 80-hour work restrictions. That gives them less time to do things like spend time in the same lab or study anatomy or watch surgical videos. There is that working against us as well.

And then I think there is always this issue of the medical legal issues as well. With an ever-increasing litigious population out there, we have staff surgeons are less and less likely to relinquish control to learners as we have to consider that in our educational process as well.

What are some techniques that you have discovered or that you use that have been successful or very helpful as a teacher?

I guess I want to first point out here that operative teaching really begins outside of the operating room. The validity of things like a skills lab or a virtual reality train or surgical videos, is an entirely different conversation. But I think most academic surgeons unanimously agree that these things play a critical role in training. Trainees must also fulfill their responsibility by coming to the operating room with a detailed knowledge of anatomy, indications for surgery, steps of the procedure and potential complications. Again, I think a lot of this stuff happens even before we hit the operating room. Specific to the conversation in terms of operative teaching, I have adopted an operative teaching technique that was first described in the colorectal literature called The ‘BID’ Teaching Model. The “B” stands for briefing, “I” stands for intraoperative teaching, and “D” stands for debriefing. Knowing these challenges that we face, specifically the time crunch, this was developed as a time efficient learner-centered teaching tool. Let us break it down, if you don't mind, just a little bit more.

Briefing takes all of five minutes. It is going to happen at the scrub sink. You are supposed to scrub for four minutes anyway. This is a perfect time to sit there with your learner and go through some of the preoperative things. This time really should be used to become acquainted with the skill level of the learner. Questions like “what is your experience with this procedure? How many of these procedures have you done or what parts of the procedure do you feel comfortable with?” Those are the kinds of questions that should be used here. You should also use this time to spell out very specific learning objectives. Depending on the learner’s level of prior experience, you can identify certain parts of the procedure that you could focus on during that time. It should not be the expectation of the learner or really of the staff that the learner always needs to do the entire procedure. They can just do parts of certain procedures. Additionally, by having these discussions before going to the operating room, you are really engaging that learner and helping them integrate what they are about to learn. Once you get into the operating room, becomes the entire operative teaching part, the age-old question here is how much autonomy are we to give our learners? I think the answer largely depends on the learner, which again, is why the briefing portion of this model is still very important. Understanding the level of the learner is critical to appropriate delegation of responsibility. A common complaint that I hear from learners is over supervision in the operating room. To avoid this, I try to employ the swish model, sort of a progressive autonomy.

The swish model comes with four stages. The first stage is show and tell. The attending is basically doing the procedure but narrating along the way exactly what they are doing. The learner is primarily learning through observation. The next stage is active help. Here the attending leads the resident by optimizing exposure, demonstrating technique, and there is active coaching going on as the learners progress in their abilities. Then you get to the third stage, which is passive help, where the attending follows the lead of the resident but acts as a capable first assist. I kind of refer to this as smart help, where you are helping them smartly as a very capable first assistant. The final stage is supervision only or what we refer to as dumb help, where the attending quietly monitors patient safety and progress. But you are not giving any unsolicited advice and you are waiting for cues from them about what you should do next as their assistant. I think an important part to note here is that you can move up and down within these stages within the same procedure. That depends on your comfort level or the learner’s level of expertise. It also depends a little bit on the predefined objectives that you set during the briefing session.

As a gynecologist, I will use hysterectomy as the example. If a learner tells me they want to work on the bladder flap in this procedure, maybe I am more of a passive help at the time of the bladder flap dissection. In other parts of the procedure that they are less comfortable on or for the efficiency of the procedure to keep things moving, maybe I am more active help at different points in the procedure as well.

Finally comes the debriefing. This is where you employ the idea of deliberate practice. You take these predefined areas of focus that you jointly decided upon in the briefing section and you provide immediate, detailed feedback about their performance. In doing so, I try to remember the four Rs: reflection, rules, reinforcement, and remediation. For reflection, it is as simple as “how do you think that went?” to engage the learner. It helps integrate what they just learned and went through and optimizes their experience. The next is rules. What I am doing with this is I try to just drop some kind of a pearl of wisdom. Maybe we were focusing on the bladder flap dissection again. I say, “you know, always remember that when dissecting the bladder, the fat stays with the bladder.” Just a little pearl of wisdom that they can always remember to help them with specific pre-defined objectives. Again in the briefing section, reinforcement. Here is what I think you did well. It takes all of one second to say and then remediation in the future, “maybe try to work on this.” Here you are giving them very detailed feedback, again, in a very time efficient manner.

I want to go back to the briefing part. During that time do you ask the learner what he or she wants to focus on during that procedure?

Absolutely. It is not a pre-defined objective by me. It is really by them. You know, “what today do you want to work on? Where do you feel the weakest?” I really let them drive the learning experience. That then feeds into the four Rs and the feedback that you give. During the debrief part, you focus on that instead of all of the possible things that you could focus on during a procedure. I think as teachers, we often feel overwhelmed by these feedback forms and the amount of time that some of these things take.

Does teaching in the surgical suite add to or cause any problems related to completing procedures or taking the time for teaching?

Yes and no. It is pretty well defined in the literature and I think we can all agree that teaching does add a little bit of time to the operating room or to the procedure. I do not think we can deny that, but I think that is something that we accept and that we enjoy doing. It becomes a part of our operating experience. The nice thing about this model, again, is it helps the efficiency by the briefing and the debriefing, again, is less than five minutes. The intraoperative teaching helps you focus the learning and the teaching in the operating room. You are focusing on certain parts of the procedure, but you are not letting learners flounder by trying to learn it all on their own. I think that we really want to design problems when there are no specific objectives set aside or there is lack of preparation by the trainee because we have not given them appropriate expectations or there is uncertainty by the faculty about what the resident is capable of doing on their own. I think all of this just helps the efficiency significantly and there should not be a huge detriment to the time we spend in the operating room.

Are there any other words of wisdom or advice that you would have to teaching in the operating room?

Sure, it is unlikely for residents to prepare for cases if they are not receiving instruction during the case or feedback from disinterested faculty. The trainees really must know and perceive that their trainers have a sincere interest in their education or they themselves will begin to question their own motive of self-improvement. Teaching in the operating room really starts with us. Then always remember that you never know when these trainees may operate on you, so take the time to train them well.

I want to thank Dr. McDonald for her time and information related to teaching in the operating room. I also want to let people know that you can contact us if you have questions or request further information.

Use the email address that you see on your screen: OCRME-PrescriptPad@uiowa.edu. The interview, transcript, and podcast will be available on our website (https://medicine.uiowa.edu/ocrme/teaching-development/teaching-prescription-pad) so that you may access and continue learning with the information at this point.

We want to thank you for joining us in this session and hope you come back and check out some more of our teaching prescription pad interviews.