ORIGINAL REPORTS
How Surgical Mentors Teach: A Classification of In Vivo Teaching Behaviors Part 1: Verbal Teaching Guidance Gary Sutkin, MD,* Eliza B. Littleton, PhD,† and Steven L. Kanter, MD†,‡ *
Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens Hospital, Pittsburgh, Pennsylvania; †Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and ‡University of Missouri-Kansas City School of Medicine, Kansas City, Missouri OBJECTIVES: To illuminate surgical teaching at a fine level of
detail by filming intraoperative communication between surgical attending physicians and trainees and provide a naturalistic categorization and analysis of verbal teaching behaviors.
DESIGN: Live, intraoperative verbal exchanges between
surgical attending physicians and their trainees (residents and fellows) were filmed, and key verbal teaching moments were transcribed. In follow-up interviews, attending physicians and trainees watched video clips of their teaching case and answered open-ended questions about their surgical teaching methods. Using a grounded theory approach, we examined the videos and interviews for what might be construed as a teaching behavior and refined verbal teaching categories through constant comparison. SETTING: We filmed 5 cases in the operating suite of a
university teaching hospital that provides gynecologic surgical care. PARTICIPANTS: We included 5 attending gynecologic
surgeons, 3 fellows, and 5 residents for this study. RESULTS: More than 6 hours of film, 3 hours of interviews,
and more than 400 verbal teaching utterances from our participating attending surgeons were transcribed. We found that attending surgeons used unique types of verbal guidance to describe relevant anatomy, explain the rationale behind a specific surgical action, command the trainee to perform the next step, reference a specific aspect of the surgery, and provide an indirect verbal construct. Attending physicians prefixed speech with polite terms and used terse language, colorful verbal analogies, and sometimes humor. Our participants denied a significant Hawthorne effect. Interrater reliability was high using Cohen κ with 0.77 for the verbal categories.
Correspondence: Inquiries to Gary Sutkin, MD, Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens Hospital, 300 Halket Street, Pittsburgh, PA 15213; e-mail: [email protected]
CONCLUSIONS: Our categorization of live intraoperative
verbal teaching can provide a measurable, replicable basis for studying how spoken guidance can lead to the best intraoperative learning. Because surgical teaching occurs on a microscopic level, film review is important when analyzing intraoperative teaching behaviors. ( J Surg 72:243-250. C J 2014 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: attending physicians, fellow physician,
medical education, resident physician, surgical education, video recording COMPETENCIES: Interpersonal and Communication Skills, Patient Care, Systems-Based Practice
That ability to impart knowledge ... what does it consist of? ... a deep belief in the interest and importance of the thing taught, a concern about it amounting to a sort of passion. A man who knows a subject thoroughly, a man so soaked in it that he eats it, sleeps it and dreams it— this man can always teach it with success, no matter how little he knows of technical pedagogy. This passion, so unordered and yet so potent, explains the capacity for teaching that one frequently observes in scientific men of high attainments in their specialties— for example, … Halsted and Osler—men who knew nothing whatever about the so-called science of pedagogy, and would have derided its alleged principles if they had heard them stated. — H.L. Mencken, 19221
INTRODUCTION How do expert surgical trainers teach in the operating room (OR)? The operating theater is a complex high-stress environment with many participants, and teaching surgeons
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have multiple competing responsibilities, one of which is to teach the trainees, including residents and fellows, participating in the surgery. There is a paucity of information about what makes for effective surgical teaching.2 Surgery is still taught via an apprenticeship model, in which resident learning is dependent on the patients on service and the teaching expertise of their attending surgeons. Expert teaching surgeons are able to use each surgical case as a deliberate teaching moment, maximizing resident learning.3 Most surgical teachers rely on memories of ways their favorite surgical attending physicians taught or use their own personal teaching experiences. We know that there are surgeons who seem to possess an intuitive knack for excellent surgical teaching, but successful teaching behaviors have not been well defined. To our knowledge, no one has videotaped teachers’ speech, actions, and gestures during actual surgical teaching cases and classified them according to how they might contribute to instruction of the trainee. Surgical trainees and attending physicians have been surveyed about their preferences for intraoperative teaching.4-7 These surveys found that trainees prefer to learn from attending physicians with surgical expertise and knowledge, who encourage resident participation in the surgeries, have a positive attitude toward teaching, and are calm and courteous. Although these studies were valuable for identifying positive and negative characteristics of surgical teachers, they focused on recall instead of observable behaviors. We were stimulated by the perspective of the activity theory8 and the idea that learning arises from interacting socially in the world of work and school. The activity theory inspires us to view the details of learning interactions a bit like those of a script, e.g., who are the “actors?” Where is the setting? What are the tools and resources that the actors rely on? What are the rules that actors follow? The activity theory scenarios enable a broad, coherent, and inclusive view of our participants’ teaching and its context. This is why we decided to directly observe and classify behaviors that could be considered “instructive” in the OR as they happened, in vivo, and why we knew that these behaviors could most reliably be captured on videotape. We asked, “What verbal utterances do surgeons use intraoperatively when they teach surgery to residents and fellows?” To answer this question, we videotaped surgical cases, analyzed verbal “moment-to-moment” exchanges between surgical attending physicians and their trainees, interviewed the participants through cued recall, and classified actual surgical teaching behaviors.
MATERIAL AND METHODS Using a naturalistic inquiry9 approach inspired by aspects of grounded theory,10,11 2 authors (G.S. and E.B.L.) observed and videotaped live surgery to describe “moment-to244
moment” verbal exchanges between surgical attending physicians, residents, and fellows, specifically the speech used by teaching attending physicians in OR teaching. We audiotaped interviews with the participants soon after the case. Participants and Setting We recruited a convenience sample of 13 participants, including 5 attending gynecologic surgeons, 3 fellows, and 5 residents and filmed 5 surgical cases over a 5-month period. The cases were selected for representing different subspecialties within our busy OR and varied levels of complexity. Additionally, the teaching attending physicians we selected were known to be active teachers during their cases. We suspected their cases would be information rich and provide insight into intraoperative teaching. Although medical students were sometimes present during the surgeries and captured on video, they were not the focus of the investigation. Our participants were all primarily surgical gynecologists who came from disparate subspecialties and consented to being filmed in a teaching case. Teaching cases were selected based on whether the participants had agreed to participate and when the videographers could be available to film. We asked our participants to sign a recruitment script and reviewed the goals and procedures with university surgeons, a department chairperson, and hospital and university attorneys with expertise in legal and ethical aspects of researching medical education. Our study was approved as “exempt” by our Institutional Review Board. All cases took place at a large university teaching hospital that provides care to women mostly. The OR staffs approximately 17,000 cases per year. Most of the surgeons are highly subspecialized and teach fellows, residents, and medical students. The training program annually consists of 36 to 40 residents and 18 surgical fellows from 4 obstetrics & gynecology subspecialties: female pelvic medicine and reconstructive surgery, minimally invasive surgery, gynecologic oncology, and reproductive endocrinology and infertility. Filming All surgical cases were filmed by a videographer or the author (G.S.) using a handheld Sony Handycam (MiniDV Camcorder, Model #DCR-HC28) video camera with integrated audio. We tried various filming distances until we found one ideal for capturing discrete and interpretable voices on audio. Still, there were interruptions of noise from machines and other conversations in the OR. We explained to the participants that we wanted to understand natural teaching behaviors in the OR and that they should act as if no videographer was present. The authors who filmed the teaching cases seemed to be accepted by the surgical team as observers. For the bulk of the teaching case, the videographer was ignored.
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Interviews with Participants Follow-up interviews were scheduled with attending surgeons according to their availability, often weeks after a surgery and on an occasion, months afterward. Despite the time delay, by watching the film clips, each attending physician was able to recall a significant level of detail about his or her operation and teaching. Attending physicians watched moments of the surgery chosen by 2 authors (G.S. and E.L.) for their instructiveness, and each attending physician viewed between 35 and 50 minutes of his or her case. The interviews were audiotaped and transcribed. Each surgeon was asked both open-ended questions about his or her surgical teaching methods, and clarifying questions regarding specific teaching incidents caught on film. Each surgeon was also asked about his or her level awareness of the filmographer’s presence during the surgical case. Film and Audio Review Our analytical notes from directly observing the surgeries and from reviewing the films of the cases highlighted the verbal utterances of and interactions between the participants. We defined utterances as units of speech that can be as small as a place-holding “um” and are often delineated by the speaker’s pauses or silence. We de-identified the data by assigning unique participant numbers to each case, such as “attending 1, case 2.” To collect these microlevel of data, the videotaped instances of teacher-trainee interaction were usually reviewed multiple (sometimes greater than 10) times to transcribe even the briefest verbal expressions. Although all videos were examined in full, only episodes containing teaching behaviors were transcribed. The research team consisted of an attending gynecologic surgeon with 14 years of teaching experience (G.S.) and a cognitive psychologist with no experience in the OR (E.L.). We met several times to examine and discuss those exchanges, analyze films before or after the exchanges, and interview the participants to disambiguate the meanings or intentions of the behaviors. We cycled iteratively through transcription and analysis multiple times for any given episode.
with our own values as surgical educators and instructional researchers. We approached the data without any a priori coding schemes, allowing as much of the data to surprise us and define themselves as possible. We examined our analytical notes for what might be construed as a teaching behavior. We remained open to emerging categories of behaviors and defined intraoperative teaching liberally as any verbal exchange originating from the teaching attending physician with the possible effect of instructing the resident or fellow. Specifically, we defined instructive teaching exchanges as pairs of action, speech, or both alternating between the attending physician and the trainee that resulted in some guidance from the attending physician. Each exchange was defined as complete when ending with guidance from the attending physician. Exchanges seemed to circumscribe one task at a time, emphasize one teaching point, and focus on precise and fine-grained actions and moments within the surgical case. We chose to transcribe and analyze episodes that seemed particularly critical in the procedure or heavy in instruction. Teaching behaviors were categorized and repeatedly combined into larger categories whenever possible to create a more concise list, but no codes were outright excluded. We settled disagreements about inclusion by consensus of 2 authors (G.S. and E.L.). Emerging codes were compared with fresh data, and the codes were further refined. Data collection and analysis ceased once no new themes were discovered—this could be regarded as a point of data saturation. Coding definitions and instructions were developed to reliably code the data. Interrater Reliability and Member Checking An interrater reliability analysis using the Cohen kappa statistic was performed by 2 raters, one who was an author (E.L.) and one an external reviewer, to determine consistency for the categories in verbal guidance as a group. Finally, we showed 3 participants our findings to assure that we were being faithful to the perceptions and beliefs of our participants. For the readers interested in our Physical Guidance findings, we refer them to Part 2 of our classification study.12
Analysis Using a naturalistic inquiry approach, and inspired by grounded theory,10 we used the constant comparative method11 to categorize and describe the verbal behaviors that are involved in surgical teaching. We performed our observations as naturalistically as possible to have the best chance of capturing authentic teaching behaviors. Nothing about the setting involving teaching was contrived. Our purpose was to develop rich qualitative descriptions9 with the words and events used by our participants in their everyday setting to produce straightforward descriptions of intraoperative teaching behaviors. We came to this analysis
RESULTS We collected approximately 10 hours of film from 5 surgical cases and analyzed more than 6 hours of film. Details of the 5 surgical cases are included in Table 1. We transcribed more than 400 verbal utterances that could be classified as teaching moments. Each one was replayed approximately 8 to 15 times. We reached data saturation when we had watched an additional 1 hour of surgery (approximately 20 minutes from 3 of the cases) and noted no new categories, no changes to the definitions of our categories, and no new
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TABLE 1. Description of Surgical Cases Case Number
Specialty*
Type of Surgery
Laparoscopic or Open†
1
Minimally invasive Diagnostic laparoscopy gynecologic surgery
Laparoscopic
2
Minimally invasive Total laparoscopic gynecologic surgery hysterectomy with ablation of endometriosis Reproductive Removal of ovarian dermoid endocrinology and infertility Female pelvic Total abdominal medicine and hysterectomy and sacral reconstructive colpopexy surgery Gynecologic Total abdominal oncology hysterectomy and pelvic lymph node dissection
Laparoscopic
3 4
5
Laparoscopic Open
Open
Participants‡ Attending physician and third-year resident Attending physician and third-year resident Attending physician, fellow, and thirdyear resident Attending physician, fellow, and thirdyear resident Attending physician, fellow, and thirdyear resident
Surgical Role of Attending Physician§ Primary surgeon First assistant Second assistant Second assistant
Second assistant
*These are all subspecialties of obstetrics and gynecology. Open refers to surgery performed through an open abdominal incision. ‡ All residents were general obstetrics and gynecology residents. Obstetrics and gynecology is a categorical 4-year residency. All fellows were training in that particular subspecialty. § Most common role played by surgical attending physicians as determined by the investigator. Primary surgeon refers to the teaching attending physician performing most of the surgery, with the resident assisting. First assistant refers to the teaching attending assisting the resident, who functions as the primary surgeon. Second assistant refers to the teaching attending physician assisting the fellow in the teaching of the resident, who functions as the primary surgeon. †
relationships between the categories. Ultimately, we were assured the categories encompassed all the data from the films. We recorded and transcribed approximately 3 hours of interviews. We discovered that when interviewed, the teaching surgeons recalled small details, including their thoughts at the time and even what they were doing off camera. Although each of the 5 teaching surgeons had unique teaching styles and personalities, the surgical teaching we saw had a common appearance. The attending surgeons we witnessed were consistently and actively involved in teaching the junior trainees, especially the residents and fellows. The residents performed most of the steps of each surgery, with direct verbal or nonverbal guidance from the attending physician or both the fellow and the attending physician. Almost every surgical action involved the careful verbal guidance of the resident. Rarely, the attending physician would perform the task while explaining his or her actions. We witnessed very few moments of a teaching surgeon operating without assistance or in silence. We coded and classified the verbal surgical teaching activities into 11 verbal surgical guidance categories (Table 2). Our transcripts (both film data and interviews) included technical surgical language. Most verbal utterances made by the teaching attending physicians were directed at the trainees and related to the surgery, usually to the current surgical step. Table 3 further defines each verbal surgical guidance category, including a representative example. The teaching behaviors we chose stood out because they 246
recurred, residents responded to them, and attending surgeons talked about them during their interviews as important themes. Interrater reliability was relatively high using Cohen κ with 0.77 for verbal categories. Participants reviewing the manuscript found our categories to be representative of their teaching behaviors. When asked about the possibility of a Hawthorne effect, all interviewed participants reported being occupied by the surgery, their teaching duties, and the various distractions in the room. All reported being generally unaware of the presence of a videographer. One told us, “[The videographer] was very, you know, it was easy to forget about her after the first five minutes. There’s so much going on. I can’t believe how much I have to pay attention to during the case.” The manuscript was reviewed by 3 participating surgeons who said the results and conclusions were consistent with their views on surgical teaching.
DISCUSSION This study uses moment-by-moment analysis of live video recordings from multiple surgical cases to characterize and categorize verbal intraoperative teaching. We discovered that surgical teaching involves a combination of discreet verbal communications, each containing complex messages. Our findings add to the findings by Roberts et al. who studied films from 4 surgeries of general surgery attending physicians teaching residents in the OR to code and classify
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TABLE 2. Classification of Verbal Manifestations of Surgical Teaching Verbal Guidance 1a 1b 1c 1d 1e 1f 1g 1h 1i 1j 1k
Didactic Commanding Explanatory Deictic Indirect Terse Polite Planning Figurative Off-talk Quizzing
broad categories of intraoperative verbal instruction. They divided their verbal interactions into those that moved the operation forward, those that added to the resident’s knowledge, those that did both simultaneously, or a fourth category “banter.”13 Although the latter may be similar to our off-talk category, the other 10 verbal guidance categories provide much more detail of surgical attending physicians’ verbal teaching behavior. Filming Teaching Behaviors Film review was key to closely capturing these discreet, in vivo verbal utterances. Some notable discourse and conversational analysis have been conducted with video recordings to illustrate how pairs of attending physicians and trainees14-16 and attending physicians and support staff17,18 use language and gesture to interact with and understand each other. In particular, the research in discourse and interaction show how people reference ideas and actions in the high stakes and constrained communication in the OR. Such research can be usefully applied to understanding pedagogy and teaching, as we do here. Hu et al.19 showed how videotapes of intraoperative performance can be used by an experienced coach to provide individualized feedback to attending surgeons about their surgical technique and intraoperative decisions. Koschmann et al.15 also supply theory for how to approach video analysis for the study of instruction. Broad Definition of Surgical Teaching We were intentionally broad in the design of our primary research question, “What do teaching surgeons actually do when they teach surgery?” This left us amenable to capturing tacit teaching exchanges and was reinforced by our iterative process of data analysis. The more we transcribed and analyzed, the more subtle teaching behaviors were discovered and the broader our definition of surgical teaching became. Our categories expand on the findings by Blom et al.,20 who videotaped 8 laparoscopic cholecystectomies, and by
Hague et al.,21 who took field notes from multiple types of general surgery cases. Both studies categorized verbal teaching behaviors between the senior surgeon and the surgical resident. Some of their findings were similar to our findings, including categories of explaining, commanding, questioning, referring to instruments, indicating direction, and joking. It is noteworthy that Blom et al. found that analysis of the videotape required 3 times the duration of the original recording tape. We found the time required for videotape analysis to be significantly higher. Strengths and Limitations Our analysis was limited by the quality of the audio and video recording of our equipment. We used a personal handheld camera to capture video and audio from all participants, and we could easily have missed or misinterpreted things that were said quietly or physical motion that was occluded from our view. Use of individual microphones for each participant and high-definition video equipment would likely lead to more accurate data collection. Yet, even our inexpensive equipment allowed us to see surgical teaching happen at a microlevel. We found the videotape to be essential to adequately observe the complex details of surgical teaching. Many of our best examples were only uncovered by multiple rewinds of the videotape. We expect that a field observer taking notes in the OR would not be able to document all these details. Because we filmed intraoperatively, we did not capture any preoperative or postoperative teaching discussions, both of which are important to surgical learning.2,22 It is possible we missed important examples of surgical teaching, such as needs assessment and surgical planning, that occur the day before the surgery, at the scrub sink, or in the recovery room. The briefing, intraoperative teaching, and debriefing model for surgical teaching provides an excellent approach for identifying surgical learning needs, teaching to them, and stimulating reflection following a teaching surgery.23 Although our study was limited to 5 teaching surgeons and 8 trainees at 1 institution, we collected more than 400 teaching moments and reached data saturation. The value of our approach is a rich and consistent picture of several teaching surgeons’ teaching activity. All participating attending surgeons agreed to be filmed and interviewed about teaching and thereby represent a self-selected group of teachers. Hawthorne Effect and Memory Before filming, we explained to the participants that they should act as if no videographer was present, and in followup interviews, our participants said they were concentrating on the surgical case and the teaching and were generally unaware of being filmed. Although we assume that being
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TABLE 3. Verbal Teaching Guidance: Categories of Verbal Manifestations of Surgical Teaching Verbal Teaching Category
Representative Example*
Definition
1a. Didactic
The attending surgeon comments descriptively about the current step or relevant anatomy
1b. Commanding
The attending surgeon instructs the surgical trainee what to do next with a highly specific command
1c. Explanatory
The attending surgeon discusses the rationale behind a particular step of the surgery
1d. Deictic
The attending surgeon uses words that are flexible in meaning and usage, points to a specific referent that the attending surgeon assumes the surgical trainee is aware of; and relies on the context to be correctly interpreted
1e. Indirect
The attending surgeon uses a verbal construction that is easily interpreted as a command that is different from the verbal construction’s literal meaning
1f. Terse
The attending surgeon delivers a laconic utterance, most often monosyllabic, usually used to correct, direct, stop, encourage, or praise the surgical trainee’s actions The attending surgeon issues a polite comment or prefix to a statement that although might imply an entreaty for discussion is usually interpreted by the surgical trainee as a direct command
1g. Polite
1h. Planning
248
The attending surgeon discusses with the surgical trainee a plan for more than one step beyond the current one, often in the context of what is currently happening
Attending surgeon (A) is using a laparoscopic pointer to manipulate the tissues while describing the anatomy to the resident (R). A: “That’s the end of it. That’s the end of that appendix right there.” (Case 1, 18:15-19:00) A is holding an electrocautery instrument in his right hand, preparing to ablate endometriotic lesions, while R is holding the camera and scope, and both intently watch the monitor. A issues 2 commands to R to assist in the cauterization of the endometriosis: (1) to manipulate the bowel away from the lesion and (2) to move the scope closer to the lesion for greater magnification. A: “I’m going to have you pull the bowel in this direction now. Now we’re good. Camera in.” A activates electrocautery. (Case 2, 13:30-14:25) A and R are preparing to insert a laparoscopic port. A describes the rationale for the location of the skin incision: “So now we make an incision about 1/3 of the distance from the SIS to the umbilicus. That’s equivalent with McBurney’s point [in order] to avoid a vessel.” (Case 1, 11:30-11:40) A, fellow (F), and R are separating an ovarian cyst from an ovary. Multiple laparoscopic instruments have been exchanged through the ports in the past 2 minutes, and A has just issued many highly specific commands. A: “Can you keep this organized?” F: “Yeah. We’re good.” A: “Very impressive. Okay.” (Case 3, 14:50-15:50) A and R are working on a Pfannenstiel incision. F is not participating at the moment and holds a right-angle retractor close to her chest. A: “I wish I could see.” F immediately places the retractor into the incision, thus increasing the visibility. A: “There you go.” (Case 4, 5:50-6:00) A is observing F make a vertical midline abdominal incision. F holds the bovie. A: “Cut. Go. With that.” F wordlessly activates the bovie and incises the tissue. A: ”Yeah” (Case 5, 12:10-12:20) R and F across from each other, using laparoscopic graspers to remove a dermoid laparoscopically, while A stands next to them. F holds a suction irrigator and is discussing the size of the incision in the ovarian cortex relative to the size of the dermoid cyst. F: “Should we extend this incision? Do you guys think?” A does not say “no,” but instead answers F’s question with a question: “You think so?” F: “If not, can I replace this with a grasper?” A, agreeing with F’s decision to not extend the incision: “Yes. That’s what I would do.” A hands her a grasper, which F inserts. The incision is not altered. (Case 3, 1:25-1:50) A is discussing the next 2 steps necessary to excise the cyst from the ovary: “All right, let’s do irrigation, and let’s do bipolar.” (Case 3, 14:50-15:50)
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TABLE 3 (continued) Verbal Teaching Category
Definition
Representative Example*
1i. Figurative
The attending surgeon uses a verbal analogy to describe a surgical step
1j. Off-Talk
The attending surgeon uses humor or discusses something unrelated to the surgery
A: “That’s what I tell everyone in the operating room: the pelvis is a bowl and you’re shaking hands to open up your spaces.” (Case 5, from interview) A and R are inserting a trocar through the umbilicus for a laparoscopic case. A: “What’s the most dangerous part of laparoscopy?” R does not answer audibly. A: “Besides me operating.” A goes on to explain that laparoscopic entry is dangerous because it is “completely blind.” He further demonstrates the importance of inspecting the underlying viscera immediately after inserting the scope. (Case 2, 3:18-4:00)
1k. Quizzing
The attending surgeon uses Socraticlike questioning to assess the surgical trainee’s knowledge, often introducing a discussion of that topic
A is discussing laparoscopic port placement while inserting a trocar trough a lateral abdominal incision. As the port enters the abdominal wall, A asks the medical student, “Which vessel am I avoiding?” A proceeds to explain the relationship of the epigastric vessels to the port site. (Case 1, 11:40-12:35)
A, attending surgeon; R, resident; F, fellow. *Underlined text contains a representative example of the category. Surrounding, nonunderlined text provides details of the interaction and context.
filmed suppresses some teaching behaviors, such as cursing or losing their temper, we encountered many examples of off-color humor and pointed correction of the surgical trainees. We were unable to conduct in-depth interviews with our participating surgeons immediately following the surgery because of time constraints. Although it is possible that their memories could become less accurate with the passage of time, watching the film enabled them to recall significant details, which was clear and concise enough to suggest they were remembering what they were thinking at that moment in the surgery. Ericsson and Simon24 first showed that asking people to explain previous events in memory was less reliable than thought, although other verbal reports such as think-aloud or retrospective reports were much more reliable. Most people recall events when they are cued even weeks later in retrospective cued recall experiments, although some individuals are less reliable than others,25 which is why these methods are used often.
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ACKNOWLEDGMENTS The authors wish to thank Dr. Shekar Davarya, whose work on the pilot project provided both data and inspiration for this analysis.
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How Surgical Mentors Teach: A Classification of In Vivo Teaching Behaviors Part 1: Verbal Teaching Guidance Gary Sutkin, MD,* Eliza B. Littleton, PhD,† and Steven L. Kanter, MD†,‡ *
Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens Hospital, Pittsburgh, Pennsylvania; †Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and ‡University of Missouri-Kansas City School of Medicine, Kansas City, Missouri OBJECTIVES: To illuminate surgical teaching at a fine level of
detail by filming intraoperative communication between surgical attending physicians and trainees and provide a naturalistic categorization and analysis of verbal teaching behaviors.
DESIGN: Live, intraoperative verbal exchanges between
surgical attending physicians and their trainees (residents and fellows) were filmed, and key verbal teaching moments were transcribed. In follow-up interviews, attending physicians and trainees watched video clips of their teaching case and answered open-ended questions about their surgical teaching methods. Using a grounded theory approach, we examined the videos and interviews for what might be construed as a teaching behavior and refined verbal teaching categories through constant comparison. SETTING: We filmed 5 cases in the operating suite of a
university teaching hospital that provides gynecologic surgical care. PARTICIPANTS: We included 5 attending gynecologic
surgeons, 3 fellows, and 5 residents for this study. RESULTS: More than 6 hours of film, 3 hours of interviews,
and more than 400 verbal teaching utterances from our participating attending surgeons were transcribed. We found that attending surgeons used unique types of verbal guidance to describe relevant anatomy, explain the rationale behind a specific surgical action, command the trainee to perform the next step, reference a specific aspect of the surgery, and provide an indirect verbal construct. Attending physicians prefixed speech with polite terms and used terse language, colorful verbal analogies, and sometimes humor. Our participants denied a significant Hawthorne effect. Interrater reliability was high using Cohen κ with 0.77 for the verbal categories.
Correspondence: Inquiries to Gary Sutkin, MD, Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens Hospital, 300 Halket Street, Pittsburgh, PA 15213; e-mail: [email protected]
CONCLUSIONS: Our categorization of live intraoperative
verbal teaching can provide a measurable, replicable basis for studying how spoken guidance can lead to the best intraoperative learning. Because surgical teaching occurs on a microscopic level, film review is important when analyzing intraoperative teaching behaviors. ( J Surg 72:243-250. C J 2014 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: attending physicians, fellow physician,
medical education, resident physician, surgical education, video recording COMPETENCIES: Interpersonal and Communication Skills, Patient Care, Systems-Based Practice
That ability to impart knowledge ... what does it consist of? ... a deep belief in the interest and importance of the thing taught, a concern about it amounting to a sort of passion. A man who knows a subject thoroughly, a man so soaked in it that he eats it, sleeps it and dreams it— this man can always teach it with success, no matter how little he knows of technical pedagogy. This passion, so unordered and yet so potent, explains the capacity for teaching that one frequently observes in scientific men of high attainments in their specialties— for example, … Halsted and Osler—men who knew nothing whatever about the so-called science of pedagogy, and would have derided its alleged principles if they had heard them stated. — H.L. Mencken, 19221
INTRODUCTION How do expert surgical trainers teach in the operating room (OR)? The operating theater is a complex high-stress environment with many participants, and teaching surgeons
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243
have multiple competing responsibilities, one of which is to teach the trainees, including residents and fellows, participating in the surgery. There is a paucity of information about what makes for effective surgical teaching.2 Surgery is still taught via an apprenticeship model, in which resident learning is dependent on the patients on service and the teaching expertise of their attending surgeons. Expert teaching surgeons are able to use each surgical case as a deliberate teaching moment, maximizing resident learning.3 Most surgical teachers rely on memories of ways their favorite surgical attending physicians taught or use their own personal teaching experiences. We know that there are surgeons who seem to possess an intuitive knack for excellent surgical teaching, but successful teaching behaviors have not been well defined. To our knowledge, no one has videotaped teachers’ speech, actions, and gestures during actual surgical teaching cases and classified them according to how they might contribute to instruction of the trainee. Surgical trainees and attending physicians have been surveyed about their preferences for intraoperative teaching.4-7 These surveys found that trainees prefer to learn from attending physicians with surgical expertise and knowledge, who encourage resident participation in the surgeries, have a positive attitude toward teaching, and are calm and courteous. Although these studies were valuable for identifying positive and negative characteristics of surgical teachers, they focused on recall instead of observable behaviors. We were stimulated by the perspective of the activity theory8 and the idea that learning arises from interacting socially in the world of work and school. The activity theory inspires us to view the details of learning interactions a bit like those of a script, e.g., who are the “actors?” Where is the setting? What are the tools and resources that the actors rely on? What are the rules that actors follow? The activity theory scenarios enable a broad, coherent, and inclusive view of our participants’ teaching and its context. This is why we decided to directly observe and classify behaviors that could be considered “instructive” in the OR as they happened, in vivo, and why we knew that these behaviors could most reliably be captured on videotape. We asked, “What verbal utterances do surgeons use intraoperatively when they teach surgery to residents and fellows?” To answer this question, we videotaped surgical cases, analyzed verbal “moment-to-moment” exchanges between surgical attending physicians and their trainees, interviewed the participants through cued recall, and classified actual surgical teaching behaviors.
MATERIAL AND METHODS Using a naturalistic inquiry9 approach inspired by aspects of grounded theory,10,11 2 authors (G.S. and E.B.L.) observed and videotaped live surgery to describe “moment-to244
moment” verbal exchanges between surgical attending physicians, residents, and fellows, specifically the speech used by teaching attending physicians in OR teaching. We audiotaped interviews with the participants soon after the case. Participants and Setting We recruited a convenience sample of 13 participants, including 5 attending gynecologic surgeons, 3 fellows, and 5 residents and filmed 5 surgical cases over a 5-month period. The cases were selected for representing different subspecialties within our busy OR and varied levels of complexity. Additionally, the teaching attending physicians we selected were known to be active teachers during their cases. We suspected their cases would be information rich and provide insight into intraoperative teaching. Although medical students were sometimes present during the surgeries and captured on video, they were not the focus of the investigation. Our participants were all primarily surgical gynecologists who came from disparate subspecialties and consented to being filmed in a teaching case. Teaching cases were selected based on whether the participants had agreed to participate and when the videographers could be available to film. We asked our participants to sign a recruitment script and reviewed the goals and procedures with university surgeons, a department chairperson, and hospital and university attorneys with expertise in legal and ethical aspects of researching medical education. Our study was approved as “exempt” by our Institutional Review Board. All cases took place at a large university teaching hospital that provides care to women mostly. The OR staffs approximately 17,000 cases per year. Most of the surgeons are highly subspecialized and teach fellows, residents, and medical students. The training program annually consists of 36 to 40 residents and 18 surgical fellows from 4 obstetrics & gynecology subspecialties: female pelvic medicine and reconstructive surgery, minimally invasive surgery, gynecologic oncology, and reproductive endocrinology and infertility. Filming All surgical cases were filmed by a videographer or the author (G.S.) using a handheld Sony Handycam (MiniDV Camcorder, Model #DCR-HC28) video camera with integrated audio. We tried various filming distances until we found one ideal for capturing discrete and interpretable voices on audio. Still, there were interruptions of noise from machines and other conversations in the OR. We explained to the participants that we wanted to understand natural teaching behaviors in the OR and that they should act as if no videographer was present. The authors who filmed the teaching cases seemed to be accepted by the surgical team as observers. For the bulk of the teaching case, the videographer was ignored.
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Interviews with Participants Follow-up interviews were scheduled with attending surgeons according to their availability, often weeks after a surgery and on an occasion, months afterward. Despite the time delay, by watching the film clips, each attending physician was able to recall a significant level of detail about his or her operation and teaching. Attending physicians watched moments of the surgery chosen by 2 authors (G.S. and E.L.) for their instructiveness, and each attending physician viewed between 35 and 50 minutes of his or her case. The interviews were audiotaped and transcribed. Each surgeon was asked both open-ended questions about his or her surgical teaching methods, and clarifying questions regarding specific teaching incidents caught on film. Each surgeon was also asked about his or her level awareness of the filmographer’s presence during the surgical case. Film and Audio Review Our analytical notes from directly observing the surgeries and from reviewing the films of the cases highlighted the verbal utterances of and interactions between the participants. We defined utterances as units of speech that can be as small as a place-holding “um” and are often delineated by the speaker’s pauses or silence. We de-identified the data by assigning unique participant numbers to each case, such as “attending 1, case 2.” To collect these microlevel of data, the videotaped instances of teacher-trainee interaction were usually reviewed multiple (sometimes greater than 10) times to transcribe even the briefest verbal expressions. Although all videos were examined in full, only episodes containing teaching behaviors were transcribed. The research team consisted of an attending gynecologic surgeon with 14 years of teaching experience (G.S.) and a cognitive psychologist with no experience in the OR (E.L.). We met several times to examine and discuss those exchanges, analyze films before or after the exchanges, and interview the participants to disambiguate the meanings or intentions of the behaviors. We cycled iteratively through transcription and analysis multiple times for any given episode.
with our own values as surgical educators and instructional researchers. We approached the data without any a priori coding schemes, allowing as much of the data to surprise us and define themselves as possible. We examined our analytical notes for what might be construed as a teaching behavior. We remained open to emerging categories of behaviors and defined intraoperative teaching liberally as any verbal exchange originating from the teaching attending physician with the possible effect of instructing the resident or fellow. Specifically, we defined instructive teaching exchanges as pairs of action, speech, or both alternating between the attending physician and the trainee that resulted in some guidance from the attending physician. Each exchange was defined as complete when ending with guidance from the attending physician. Exchanges seemed to circumscribe one task at a time, emphasize one teaching point, and focus on precise and fine-grained actions and moments within the surgical case. We chose to transcribe and analyze episodes that seemed particularly critical in the procedure or heavy in instruction. Teaching behaviors were categorized and repeatedly combined into larger categories whenever possible to create a more concise list, but no codes were outright excluded. We settled disagreements about inclusion by consensus of 2 authors (G.S. and E.L.). Emerging codes were compared with fresh data, and the codes were further refined. Data collection and analysis ceased once no new themes were discovered—this could be regarded as a point of data saturation. Coding definitions and instructions were developed to reliably code the data. Interrater Reliability and Member Checking An interrater reliability analysis using the Cohen kappa statistic was performed by 2 raters, one who was an author (E.L.) and one an external reviewer, to determine consistency for the categories in verbal guidance as a group. Finally, we showed 3 participants our findings to assure that we were being faithful to the perceptions and beliefs of our participants. For the readers interested in our Physical Guidance findings, we refer them to Part 2 of our classification study.12
Analysis Using a naturalistic inquiry approach, and inspired by grounded theory,10 we used the constant comparative method11 to categorize and describe the verbal behaviors that are involved in surgical teaching. We performed our observations as naturalistically as possible to have the best chance of capturing authentic teaching behaviors. Nothing about the setting involving teaching was contrived. Our purpose was to develop rich qualitative descriptions9 with the words and events used by our participants in their everyday setting to produce straightforward descriptions of intraoperative teaching behaviors. We came to this analysis
RESULTS We collected approximately 10 hours of film from 5 surgical cases and analyzed more than 6 hours of film. Details of the 5 surgical cases are included in Table 1. We transcribed more than 400 verbal utterances that could be classified as teaching moments. Each one was replayed approximately 8 to 15 times. We reached data saturation when we had watched an additional 1 hour of surgery (approximately 20 minutes from 3 of the cases) and noted no new categories, no changes to the definitions of our categories, and no new
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TABLE 1. Description of Surgical Cases Case Number
Specialty*
Type of Surgery
Laparoscopic or Open†
1
Minimally invasive Diagnostic laparoscopy gynecologic surgery
Laparoscopic
2
Minimally invasive Total laparoscopic gynecologic surgery hysterectomy with ablation of endometriosis Reproductive Removal of ovarian dermoid endocrinology and infertility Female pelvic Total abdominal medicine and hysterectomy and sacral reconstructive colpopexy surgery Gynecologic Total abdominal oncology hysterectomy and pelvic lymph node dissection
Laparoscopic
3 4
5
Laparoscopic Open
Open
Participants‡ Attending physician and third-year resident Attending physician and third-year resident Attending physician, fellow, and thirdyear resident Attending physician, fellow, and thirdyear resident Attending physician, fellow, and thirdyear resident
Surgical Role of Attending Physician§ Primary surgeon First assistant Second assistant Second assistant
Second assistant
*These are all subspecialties of obstetrics and gynecology. Open refers to surgery performed through an open abdominal incision. ‡ All residents were general obstetrics and gynecology residents. Obstetrics and gynecology is a categorical 4-year residency. All fellows were training in that particular subspecialty. § Most common role played by surgical attending physicians as determined by the investigator. Primary surgeon refers to the teaching attending physician performing most of the surgery, with the resident assisting. First assistant refers to the teaching attending assisting the resident, who functions as the primary surgeon. Second assistant refers to the teaching attending physician assisting the fellow in the teaching of the resident, who functions as the primary surgeon. †
relationships between the categories. Ultimately, we were assured the categories encompassed all the data from the films. We recorded and transcribed approximately 3 hours of interviews. We discovered that when interviewed, the teaching surgeons recalled small details, including their thoughts at the time and even what they were doing off camera. Although each of the 5 teaching surgeons had unique teaching styles and personalities, the surgical teaching we saw had a common appearance. The attending surgeons we witnessed were consistently and actively involved in teaching the junior trainees, especially the residents and fellows. The residents performed most of the steps of each surgery, with direct verbal or nonverbal guidance from the attending physician or both the fellow and the attending physician. Almost every surgical action involved the careful verbal guidance of the resident. Rarely, the attending physician would perform the task while explaining his or her actions. We witnessed very few moments of a teaching surgeon operating without assistance or in silence. We coded and classified the verbal surgical teaching activities into 11 verbal surgical guidance categories (Table 2). Our transcripts (both film data and interviews) included technical surgical language. Most verbal utterances made by the teaching attending physicians were directed at the trainees and related to the surgery, usually to the current surgical step. Table 3 further defines each verbal surgical guidance category, including a representative example. The teaching behaviors we chose stood out because they 246
recurred, residents responded to them, and attending surgeons talked about them during their interviews as important themes. Interrater reliability was relatively high using Cohen κ with 0.77 for verbal categories. Participants reviewing the manuscript found our categories to be representative of their teaching behaviors. When asked about the possibility of a Hawthorne effect, all interviewed participants reported being occupied by the surgery, their teaching duties, and the various distractions in the room. All reported being generally unaware of the presence of a videographer. One told us, “[The videographer] was very, you know, it was easy to forget about her after the first five minutes. There’s so much going on. I can’t believe how much I have to pay attention to during the case.” The manuscript was reviewed by 3 participating surgeons who said the results and conclusions were consistent with their views on surgical teaching.
DISCUSSION This study uses moment-by-moment analysis of live video recordings from multiple surgical cases to characterize and categorize verbal intraoperative teaching. We discovered that surgical teaching involves a combination of discreet verbal communications, each containing complex messages. Our findings add to the findings by Roberts et al. who studied films from 4 surgeries of general surgery attending physicians teaching residents in the OR to code and classify
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TABLE 2. Classification of Verbal Manifestations of Surgical Teaching Verbal Guidance 1a 1b 1c 1d 1e 1f 1g 1h 1i 1j 1k
Didactic Commanding Explanatory Deictic Indirect Terse Polite Planning Figurative Off-talk Quizzing
broad categories of intraoperative verbal instruction. They divided their verbal interactions into those that moved the operation forward, those that added to the resident’s knowledge, those that did both simultaneously, or a fourth category “banter.”13 Although the latter may be similar to our off-talk category, the other 10 verbal guidance categories provide much more detail of surgical attending physicians’ verbal teaching behavior. Filming Teaching Behaviors Film review was key to closely capturing these discreet, in vivo verbal utterances. Some notable discourse and conversational analysis have been conducted with video recordings to illustrate how pairs of attending physicians and trainees14-16 and attending physicians and support staff17,18 use language and gesture to interact with and understand each other. In particular, the research in discourse and interaction show how people reference ideas and actions in the high stakes and constrained communication in the OR. Such research can be usefully applied to understanding pedagogy and teaching, as we do here. Hu et al.19 showed how videotapes of intraoperative performance can be used by an experienced coach to provide individualized feedback to attending surgeons about their surgical technique and intraoperative decisions. Koschmann et al.15 also supply theory for how to approach video analysis for the study of instruction. Broad Definition of Surgical Teaching We were intentionally broad in the design of our primary research question, “What do teaching surgeons actually do when they teach surgery?” This left us amenable to capturing tacit teaching exchanges and was reinforced by our iterative process of data analysis. The more we transcribed and analyzed, the more subtle teaching behaviors were discovered and the broader our definition of surgical teaching became. Our categories expand on the findings by Blom et al.,20 who videotaped 8 laparoscopic cholecystectomies, and by
Hague et al.,21 who took field notes from multiple types of general surgery cases. Both studies categorized verbal teaching behaviors between the senior surgeon and the surgical resident. Some of their findings were similar to our findings, including categories of explaining, commanding, questioning, referring to instruments, indicating direction, and joking. It is noteworthy that Blom et al. found that analysis of the videotape required 3 times the duration of the original recording tape. We found the time required for videotape analysis to be significantly higher. Strengths and Limitations Our analysis was limited by the quality of the audio and video recording of our equipment. We used a personal handheld camera to capture video and audio from all participants, and we could easily have missed or misinterpreted things that were said quietly or physical motion that was occluded from our view. Use of individual microphones for each participant and high-definition video equipment would likely lead to more accurate data collection. Yet, even our inexpensive equipment allowed us to see surgical teaching happen at a microlevel. We found the videotape to be essential to adequately observe the complex details of surgical teaching. Many of our best examples were only uncovered by multiple rewinds of the videotape. We expect that a field observer taking notes in the OR would not be able to document all these details. Because we filmed intraoperatively, we did not capture any preoperative or postoperative teaching discussions, both of which are important to surgical learning.2,22 It is possible we missed important examples of surgical teaching, such as needs assessment and surgical planning, that occur the day before the surgery, at the scrub sink, or in the recovery room. The briefing, intraoperative teaching, and debriefing model for surgical teaching provides an excellent approach for identifying surgical learning needs, teaching to them, and stimulating reflection following a teaching surgery.23 Although our study was limited to 5 teaching surgeons and 8 trainees at 1 institution, we collected more than 400 teaching moments and reached data saturation. The value of our approach is a rich and consistent picture of several teaching surgeons’ teaching activity. All participating attending surgeons agreed to be filmed and interviewed about teaching and thereby represent a self-selected group of teachers. Hawthorne Effect and Memory Before filming, we explained to the participants that they should act as if no videographer was present, and in followup interviews, our participants said they were concentrating on the surgical case and the teaching and were generally unaware of being filmed. Although we assume that being
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TABLE 3. Verbal Teaching Guidance: Categories of Verbal Manifestations of Surgical Teaching Verbal Teaching Category
Representative Example*
Definition
1a. Didactic
The attending surgeon comments descriptively about the current step or relevant anatomy
1b. Commanding
The attending surgeon instructs the surgical trainee what to do next with a highly specific command
1c. Explanatory
The attending surgeon discusses the rationale behind a particular step of the surgery
1d. Deictic
The attending surgeon uses words that are flexible in meaning and usage, points to a specific referent that the attending surgeon assumes the surgical trainee is aware of; and relies on the context to be correctly interpreted
1e. Indirect
The attending surgeon uses a verbal construction that is easily interpreted as a command that is different from the verbal construction’s literal meaning
1f. Terse
The attending surgeon delivers a laconic utterance, most often monosyllabic, usually used to correct, direct, stop, encourage, or praise the surgical trainee’s actions The attending surgeon issues a polite comment or prefix to a statement that although might imply an entreaty for discussion is usually interpreted by the surgical trainee as a direct command
1g. Polite
1h. Planning
248
The attending surgeon discusses with the surgical trainee a plan for more than one step beyond the current one, often in the context of what is currently happening
Attending surgeon (A) is using a laparoscopic pointer to manipulate the tissues while describing the anatomy to the resident (R). A: “That’s the end of it. That’s the end of that appendix right there.” (Case 1, 18:15-19:00) A is holding an electrocautery instrument in his right hand, preparing to ablate endometriotic lesions, while R is holding the camera and scope, and both intently watch the monitor. A issues 2 commands to R to assist in the cauterization of the endometriosis: (1) to manipulate the bowel away from the lesion and (2) to move the scope closer to the lesion for greater magnification. A: “I’m going to have you pull the bowel in this direction now. Now we’re good. Camera in.” A activates electrocautery. (Case 2, 13:30-14:25) A and R are preparing to insert a laparoscopic port. A describes the rationale for the location of the skin incision: “So now we make an incision about 1/3 of the distance from the SIS to the umbilicus. That’s equivalent with McBurney’s point [in order] to avoid a vessel.” (Case 1, 11:30-11:40) A, fellow (F), and R are separating an ovarian cyst from an ovary. Multiple laparoscopic instruments have been exchanged through the ports in the past 2 minutes, and A has just issued many highly specific commands. A: “Can you keep this organized?” F: “Yeah. We’re good.” A: “Very impressive. Okay.” (Case 3, 14:50-15:50) A and R are working on a Pfannenstiel incision. F is not participating at the moment and holds a right-angle retractor close to her chest. A: “I wish I could see.” F immediately places the retractor into the incision, thus increasing the visibility. A: “There you go.” (Case 4, 5:50-6:00) A is observing F make a vertical midline abdominal incision. F holds the bovie. A: “Cut. Go. With that.” F wordlessly activates the bovie and incises the tissue. A: ”Yeah” (Case 5, 12:10-12:20) R and F across from each other, using laparoscopic graspers to remove a dermoid laparoscopically, while A stands next to them. F holds a suction irrigator and is discussing the size of the incision in the ovarian cortex relative to the size of the dermoid cyst. F: “Should we extend this incision? Do you guys think?” A does not say “no,” but instead answers F’s question with a question: “You think so?” F: “If not, can I replace this with a grasper?” A, agreeing with F’s decision to not extend the incision: “Yes. That’s what I would do.” A hands her a grasper, which F inserts. The incision is not altered. (Case 3, 1:25-1:50) A is discussing the next 2 steps necessary to excise the cyst from the ovary: “All right, let’s do irrigation, and let’s do bipolar.” (Case 3, 14:50-15:50)
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TABLE 3 (continued) Verbal Teaching Category
Definition
Representative Example*
1i. Figurative
The attending surgeon uses a verbal analogy to describe a surgical step
1j. Off-Talk
The attending surgeon uses humor or discusses something unrelated to the surgery
A: “That’s what I tell everyone in the operating room: the pelvis is a bowl and you’re shaking hands to open up your spaces.” (Case 5, from interview) A and R are inserting a trocar through the umbilicus for a laparoscopic case. A: “What’s the most dangerous part of laparoscopy?” R does not answer audibly. A: “Besides me operating.” A goes on to explain that laparoscopic entry is dangerous because it is “completely blind.” He further demonstrates the importance of inspecting the underlying viscera immediately after inserting the scope. (Case 2, 3:18-4:00)
1k. Quizzing
The attending surgeon uses Socraticlike questioning to assess the surgical trainee’s knowledge, often introducing a discussion of that topic
A is discussing laparoscopic port placement while inserting a trocar trough a lateral abdominal incision. As the port enters the abdominal wall, A asks the medical student, “Which vessel am I avoiding?” A proceeds to explain the relationship of the epigastric vessels to the port site. (Case 1, 11:40-12:35)
A, attending surgeon; R, resident; F, fellow. *Underlined text contains a representative example of the category. Surrounding, nonunderlined text provides details of the interaction and context.
filmed suppresses some teaching behaviors, such as cursing or losing their temper, we encountered many examples of off-color humor and pointed correction of the surgical trainees. We were unable to conduct in-depth interviews with our participating surgeons immediately following the surgery because of time constraints. Although it is possible that their memories could become less accurate with the passage of time, watching the film enabled them to recall significant details, which was clear and concise enough to suggest they were remembering what they were thinking at that moment in the surgery. Ericsson and Simon24 first showed that asking people to explain previous events in memory was less reliable than thought, although other verbal reports such as think-aloud or retrospective reports were much more reliable. Most people recall events when they are cued even weeks later in retrospective cued recall experiments, although some individuals are less reliable than others,25 which is why these methods are used often.
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