By MJ Taravella, MD
It’s hard to believe at this stage of my career, but I began teaching residents in the operating room at the University of Colorado in 1987 (30 years ago!). Certainly much has changed in this time, not the least of which is our approach to surgery. In general, the old adage, “see one, do one, teach one,” and the apprenticeship model have evolved to a more evidenced based approach to teaching.1 So what is my current approach?
1) Learning procedures starts outside of the OR.
2) Safety first. In the operating room, this is paramount and supersedes the trainees’ need for experience and learning.
- There is a cognitive component to any procedure, and trainees must demonstrate knowledge of the indications, methods and potential complications of procedures.
- Fortunately, there are many good resources at the present time at our fingertips. However, the amount of material available can be overwhelming. It is up to the supervising physician to recommend appropriate relevant articles and pare the information down to the essentials.
- Videos illustrating the finer points of a given procedure are often helpful.2
- Wet lab practice and simulation have proven to be effective in teaching many procedures.3
- Observation of experienced surgeons in the operating room is a necessary step prior to allowing a novice surgeon to operate. However, this should be “active” observation. That is, the attending surgeon should engage and probe the learner to ensure that every step in the procedure is thoroughly understood by the novice. The number of cases to be observed as an assistant surgeon will vary with the complexity of the case and the ability of the learner to absorb the nuances of the different aspects of a given procedure.
3) Post procedure feedback is essential.
- A culture of safety starts from the top down. In the OR, it is the primary responsibility of the attending surgeon to instill in team members (including residents) the concept of “safety first,” and allow the resident or fellow to respectfully bring up concerns impacting safety in a non-punitive environment while always preserving patient confidentiality.
- There is no room for attempts at intimidation of those we are trying to teach. Fear is seldom conducive to effective learning.
- At the same time, it is appropriate to refuse permission for unprepared learners to perform a given procedure if in the judgment of the supervising surgeon it is unsafe to do so. This alone is usually enough to motivate most novice surgeons.
- There is an art to supervising novice surgeons in terms of balancing safety and learning. It is often helpful to allow beginning surgeons to perform parts of cases, especially if less technically challenging, and then progress to more difficult aspects as abilities warrant.
- Novice surgeons should be prepared to allow more experienced hands to guide them over the tough spots and the supervising surgeon must be able to recognize when a novice is struggling. The art of appropriate and timely intervention and complication prevention is one that comes through experience and observation.
- It is helpful to immediately provide feedback to the novice surgeon following the procedure (debrief)—not only pointing out deficits, but just as importantly, letting them know what they did right.
- Video of the procedure is extremely helpful to identify areas needing improvement. It allows for review of the procedure in a relaxed and less stressful teaching environment.
- Surgical proficiency is a core competency for all surgical subspecialties; however, documenting proficiency may vary widely from one program to another. Standardized forms completed by the supervising surgeon immediately following a procedure are useful tools to accomplish this.4
- Tracking outcomes including complications is important. It allows the supervising surgeon to assess progression and identify problems that need to be addressed. Results can be compared to departmental and national norms.
Teaching surgery to my younger colleagues has been very rewarding, and at the same time, challenging. Teaching a procedure forces one in to a deeper understanding of that procedure: it has always been my view that if you can’t articulate what you are doing then you don’t fully understand it. At the same time, there is no doubt that teaching requires learning on the part of the supervising surgeon if it is to be done well. I have no doubt that I am a better surgeon than I otherwise would be if I did not have the privilege and opportunity to teach.
- Busch KM, Keshava HB, Kuy S, Nezgoda J, Allard-Picou A. Teaching in the OR: New lessons for training surgical residents. Bull Am Coll Surg. 2015. 100(8): 29-34.
- Soucisse ML, Boulva K, Sideris L, Drolet P, Morin M, Dubé P. Video Coaching as an Efficient Teaching Method for Surgical Residents-A Randomized Controlled Trial. J Surg Educ. 2016 Oct 5. pii: S1931-7204(16)30156-8.
- Thomsen AS, Smith P, Subhi Y, Cour M, Tang L, Saleh GM, Konge L. High correlation between performance on a virtual-reality simulator and real-life cataract surgery. Acta Ophthalmol. 2016 Sep 29. doi: 10.1111/aos.13275. PMID: 27679989
- Taravella MJ, Davidson R, Erlanger M, Guiton G, Gregory D. Characterizing the learning curve in phacoemulsification. J Cataract Refract Surg. 2011 Jun; 37(6):1069-75.