Reflections from the Liminal Space: Teaching I – In the OR

(From the EiC:  This is a three part series that will run consecutively.  Michelle (a Maternal Fetal Medicine specialist), Tim (an intensivist) and Mary (a pediatric gastroenterologist) are just finishing the Royal College diploma in medical education offered at McMaster University.  More  details here.)


By: Michelle Morais  (@dr_mmorais), Tim Karachi (@TKarachi_MD) and Mary Zachos (@maryz777)

Sarah is about to finish her fellowship in Pediatric Surgery.  She was really excited to finally be done her training and to begin working as a staff.  She had spent years perfecting her surgical technique and learning the ins and outs of the common and rare surgical cases that she would be seeing and she felt ready to begin her practice looking after patients in clinic, in the OR and on the inpatient unit as well.

However, after meeting with the Department and Division Heads, Sarah is now getting nervous about starting because she is just beginning to realize all of the other responsibilities that she is going to have, including teaching clerks, residents and fellows.  Sarah has dedicated her training to learning surgical skills and the related knowledge of her specialty, but she has never really been taught about how to be an effective teacher.  She is feeling overwhelmed that it is going to be her responsibility to educate trainees and ensure they are safe and competent physicians – she’s not sure where to even begin!  She had never thought about effective teaching strategies before, or if there were better ways to teach in the OR that may differ from the clinic or inpatient setting.   Sarah definitely had some work ahead before beginning her job to try and be more prepared.

The Core

Teaching in the OR involves the integration of complex cognitive, psychomotor and affective domains.  Traditionally, surgical teaching has been founded on the principle of cognitive apprenticeship, first developed by William Halsted in the 1900s.  In this model, trainees learn by immersion – relying on sheer volume of exposure to ensure they are subjected to a variety of cases that range in complexity. Over time, they are expected to progress from being observers, to active participants requiring assistance and finally to independent practitioners.  Individual reading, didactic sessions, as well as the evolving field of simulation are meant to supplement learning.  However, constraints such as duty-hours restrictions, requirements for improved efficiency due to fiscal constraints, and advancing surgical technologies challenge the utility and effectiveness of the traditional apprenticeship model.1 Some studies suggest that graduating surgical residents note a lack of confidence in their skills and many report feeling they require further specialized training before independent practice.2 As a result, physicians are questioning the best way to deliver a surgical program.

Newer training techniques are incorporating theories related to motor skill acquisition and the broader scope of learning theories.  Fitts and Posner’s three-stage theory of motor skill acquisition is one oft quoted.3 An example of the progression through these stages could include a resident learning how to suture.  In the cognitive stage, they would be learning how to place their hands to hold a needle-driver properly and how to load the suture to best guide it through the tissues.  At this stage, their needle may not always travel in the intended direction and they may fumble with knot tying.  With further feedback and additional deliberate practice, they will progress through to the associative stage; they would be smoother with tissue handling and suture placement, but would still require significant focus on the task at hand.  Finally, in the autonomous stage, they would be able to suture a wound while carrying on a conversation about other aspects of the patient’s care.

A number of studies have tried to elucidate what separates great surgical teachers from mediocre ones and many themes seem evident.  The qualities that were most valued amongst well-rated surgeons included being sensitive to resident learning needs, provision of direct and ongoing feedback, teaching with enthusiasm, remaining calm and courteous, and allowing learners to ‘feel the pathology’.  Further to the importance of feedback, one study noted the importance of having an approach to debriefing, establishing a learning environment, engaging the learner and exploring their reactions, analyzing their performance including identifying areas for improvement, and then how to apply the information going forward.4

Another study on “master” surgeons’ philosophies of effective teaching strategies identified that common themes could be linked with pre-existing learning theories, giving these philosophies additional validity.  Many surgeons noted the importance of a stepwise progression from observation to independent practitioner, which builds on the concept of graduated responsibility described in the medical literature.  The involvement a learner has in a procedure varies depending on their previous experience and skill level.

Another theme was the concept of preparedness – residents should read and meet the patient in advance to be able to better focus learning in the OR.  This links with the learning theory of developing a mental set, which is where an individual prepares to take in and organize new learning.  The notion of repeated exposure and Ericsson’s theory of deliberate practice was also highlighted.  Ericsson’s concept of deliberate practice, popularized by Malcolm Gladwell’s novel Outliers, goes hand in hand with the Fitts and Posner model previously described.  The premise is that volume or hours dedicated to surgery alone is not enough to attain an expert level of proficiency.  Rather, it is the number of hours of deliberate practice with specific coaching and feedback that best predicts progression to an expert level of performance.

Another common theme that is evident amongst master surgeons is that they tend to break down surgeries into smaller, more manageable tasks, which is akin to the learning theory related to deconstructing complex tasks to improve knowledge transfer.  Furthermore, there is the concept of gradually building the complexity of the task the resident will undertake, or vertical transfer theory.  Simulation capitalizes on this notion, whereby residents work on acquiring a basic set of skills in the simulation lab, which then allows them to tackle more complex tasks in the OR.

Finally, the last theme that appears more common amongst expert surgeons is the idea of creating schema.  Even though surgeries can vary greatly, they all have common components, such as beginning with the entry, then exposure of the desired area, dissection to further access the area of interest, removal of organ/diseased tissue, assuring hemostasis and finally wound closure.  This lends itself to the learning theory that applying general principles is easier than discrete facts.5


Surgeons have also looked into how best to practice skills.  In one study, residents were randomized to either a group that was exposed to a series of microsurgical skills sessions that followed one another (massed learning) or a group that had the same sessions spread out over a longer period of time, interspersed with periods of rest (distributed learning).  Pre- and post-session testing was completed and then a follow-up test was completed one month after the final session for each group.  This study demonstrated that the distributed learning group had superior follow-up test results, indicating better skill retention, which is in keeping with other psychological research.  These results may be used to inform new curricula given many current surgical programs focus on more of a massed approach to acquiring new skills.6

Finally, a number of studies have looked at various techniques or strategies to enhance teaching in the OR.  One study demonstrated that the introduction of a structured preoperative and postoperative debriefing tool significantly enhanced the discussion of various elements including the patient history, knowledge and past experience, technique, potential problems, along with various components of feedback including asking how the resident thought the case went, what was learned, and what could be improved upon, followed by the staff’s impression of what was done well and what could be done better.   This tool resulted in a 239% improvement in discussing the above parameters compared to prior to the intervention.7

An alternative tool, the BID (Briefing, Intraoperative Teaching and Debriefing) model, builds on similar principles.  The idea is that during the time you are scrubbing for the surgery, the resident and staff would spend those few minutes discussing the learner’s needs for the case, with input from the staff to formulate the final learning objective(s).  This learning goal(s) would help focus teaching during the procedure, and then also inform the debriefing at the end of the case where the staff would ask the resident to reflect on how things went and give the staff the opportunity to identify any discordance between their own assessment and the learner’s self-perception, as well as provide specific goals for future improvement.8

The reason why these approaches are felt to be effective is that it first requires the learner to reflect on past experiences to identify where their learning gaps are.  This helps to consolidate information from past cases and improve long-term retention.  As well, it also helps to address the learner’s perceived needs and allows the staff to target their teaching efforts more specifically.

Finally, the dialogue at the end checks for understanding and ensures there is a shared mental model of what occurred and what the plan for improvement should be, which would hopefully translate to increased buy-in on the learner’s part.

The Denouement

Surgical teaching is complex, and programs based on apprenticeship and massed learning models are being critically reviewed and replaced with newer curricula based on learning and motor theory in an attempt to achieve competency before graduation.

After beginning to delve into the literature, Sarah has begun to develop some ideas about how she can incorporate selected strategies for her learners – she is keen to try out the BID model with her next surgery to see how things go, so she can try and refine her technique.



  1. Reznick R, MacRae H. Teaching Surgical Skills — Changes in the Wind. N Engl J Med 2006;355(25):2664-9.
  2. Haluck RS, Krummel TM. Computers and virtual reality for surgical education in the 21st century. Arch Surg. 2000;135(7):786-792.
  3. Fitts PM, Posner MI. Human performance. Belmont, CA: Brooks/Cole, 1967.
  4. Iwaszkiewicz M, DaRosa D, Risucci D. Efforts to Enhance Operating Room Teaching. J Surg Educ 2008;65(6):436-440
  5. Pernar L et al. Master Surgeons’ Operative Teaching Philosophies: A Qualitative Analysis of Parallels to Learning Theory. J Surg Educ 2012;69(4):493-498
  6. Moulton CA et al. Teaching Surgical Skills: What Kind of Practice Makes Perfect? A Randomized, Controlled Trial. Ann Surg 2006;244(3): 400–409
  7. Anderson C et al. Impact of Objectively Assessing Surgeons’ Teaching on Effective Perioperative Instructional Behaviors. JAMA Surg 2013;148(10):915-922.
  8. Roberts N et al. The Briefing, Intraoperative Teaching, Debriefing Model for Teaching in the Operating Room. J Am Coll Surg. 2009;208(2):299-303

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