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.

AAMC CGEA 2017 ABSTRACT

Intelligent Cooperation: A Framework of Pedagogic Practice in the Operating Room

Gary Sutkin, Eliza Beth Littleton, and Steven L. Kanter

^aDepartments of Biomedical and Health Informatics and Obstetrics and Gynecology, University of Missouri–Kansas City School of Medicine, Kansas City, Missouri, USA;

^bDepartment of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA

Phenomenon: Surgeons who teach in the operating room must maintain patient safety while addressing the trainee's learning needs. Two teaching theories, cognitive apprenticeship¹ and surgical coaching,^2,3 have been applied to surgical pedagogy but fail to capture the way surgery and surgical teaching progress at a rapid and granular level. Intraoperative teaching requires a surgical attending to give constant formative feedback on multiple small steps within a surgery.

Approach: We used a constructivist grounded theory approach and reviewed more than 400 teaching moments from videos of five live teaching surgeries to answer the question, “How do attending surgeons and their trainees simultaneously accomplish a safe surgery and satisfy the trainee's learning objectives?” Teaching surgeons were interviewed postoperatively while watching cued videos of selected moments from their cases. Transcribed data underwent open and axial coding. These codes were compared to literature search findings and refined into major themes, which were constructed into a larger framework. We iteratively reviewed teaching moments in the films until data saturation was achieved.

Findings: A novel framework that we call Intelligent Cooperation 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 uncovering the trainee's learning needs. The framework encompasses three themes: (a) attendings and trainees cooperating with each other, often using actions and gestures and very few words, to achieve pedagogic goals (Coordination); (b) teaching associated with one very small step of the surgery, and rarely extended beyond that step (Small Steps); and (c) a trainee's gap in their understanding of the surgery being revealed and bridged one step at a time (Learner's Needs). This framework evolved from our prior work^4,5 and describes how attending surgeons and their trainees cooperate, second by second, within the context of the surgery, in accordance with opportunistic learning goals, to further the progress of the surgical case. These cooperative moments involve small interactions, or teaching exchanges, composed of utterances, actions, and gestures and provide the backbone of surgical teaching and learning. The utterances include highly specific verbal teaching behaviors, such as terse commands, indirect-referring words like here and this, explanations, polite expressions, humor, and mini-lectures. The actions and gestures include highly specific physical teaching behaviors, such as repositioning trainees' instruments and hands, pointing, supporting and retracting tissues, and illustrating with gestures. Teachers and trainees appear to be equal partners in the teaching exchanges despite being unequal in knowledge and responsibility.

Insights: Intelligent Cooperation is a framework with the power to explain how surgery and surgical teaching progress at a rapid and granular level, which current theories fail to capture. Intelligent Cooperation requires the attending to do more than just make their thoughts visible and provide more than just constructive feedback and personalized instruction. The attending must provide minute-by-minute scaffolding, consistent with on-the-fly needs assessments, and work together with the resident to accomplish the step. We propose that a surgical teaching case is composed largely of iterations of these small, intelligent, cooperative exchanges and that what drives these steps is intense, tacit intellectual and physical cooperation between an attending and a trainee surgeon.

Additional information

Notes on contributors

Anna T. Cianciolo

Anna T. Cianciolo, Ph.D., is Associate Professor, Department of Medical Education at Southern Illinois University School of Medicine and Editor of Teaching and Learning in Medicine. Her research focuses on understanding and improving the performance of individuals, teams, and groups as they seek to solve the complex problems of academic health care, including diagnosis, collaborative learning, and clinical teaching and supervision.

Xiaodong (Phoenix) Chen

Xiaodong (Phoenix) Chen, Ph.D., is an Instructor at Harvard Medical School and an Educational Specialist at Brigham and Women's Hospital. She has been an Academy Fellow of Medical Education Research at Harvard Medical School. Her research interest focuses on medical trainees' transition to independent practice, including resident autonomy, surgeons' guiding behavior in the operating room, learning in high-stress environments, and faculty development in teaching.

Alexandra Cope

Alexandra Cope, Ph.D., FRCS, is a general and colorectal surgeon at Frimley Health Foundation Trust in the United Kingdom. Her Ph.D. at Imperial College London examined teaching and learning behaviors in the operating room. She has been an NIHR Academic Clinical Lecturer in Medical Education at University of Leeds and a research fellow and Emerging Leadership Fellow at the Royal College of Surgeons of England.

Timothy Koschmann

Timothy Koschmann, Ph.D., is a Professor of Medical Education at Southern Illinois University School of Medicine. He does fieldwork in settings in which physicians and surgeons receive their clinical training with a special interest in the practical organizations of instruction and learning.