ORIGINAL REPORTS
How Surgical Mentors Teach: A Classification of In Vivo Teaching Behaviors Part 2: Physical 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 study surgical teaching captured on film
and analyze it at a fine level of detail to categorize physical teaching behaviors.
their own teaching behaviors captured on film. Interrater reliability was high using the Cohen κ, which was 0.76 for the physical categories.
DESIGN: We describe live, filmed, intraoperative nonverbal
CONCLUSIONS: Physical guidance is essential in educat-
exchanges between surgical attending physicians and their trainees (residents and fellows). From the films, we chose key teaching moments and transcribed participants’ utterances, actions, and gestures. In follow-up interviews, attending physicians and trainees watched videos of their teaching case and answered open-ended questions about their teaching methods. Using a grounded theory approach, we examined the videos and interviews for what might be construed as a teaching behavior and refined the physical teaching categories through constant comparison.
ing a surgical trainee, may be tacit, and is not always accompanied by speech. Awareness of teaching behaviors may encourage deliberate teaching and reflection on how to innovate pedagogy for the teaching operating room. ( J Surg C 2014 Association of Program Directors in 72:251-257. J Surgery. Published by Elsevier Inc. All rights reserved.)
SETTING: We filmed 5 cases in the operating suite of a
university teaching hospital that provides gynecologic surgical care.
KEY WORDS: attending physicians, fellow physician,
medical education, resident physician, surgical education, video recording COMPETENCIES: Interpersonal and Communication Skills, Patient Care, Systems-Based Practice
PARTICIPANTS: We included 5 attending gynecologic
surgeons, 3 fellows, and 5 residents for this study. RESULTS: More than 6 hours of film and 3 hours of
interviews were transcribed, and more than 250 physical teaching motions were captured. Attending surgeons relied on actions and gestures, sometimes wordlessly, to achieve pedagogical and surgical goals simultaneously. Physical teaching included attending physician–initiated actions that required immediate corollary actions from the trainee, gestures to illustrate a step or indicate which instrument to be used next, supporting or retracting tissues, repositioning the trainee’s instruments, and placement of the attending physicians’ hands on the trainees’ hands to guide them. Attending physicians often voiced surprise at the range of
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]
INTRODUCTION What do attending physicians physically do to teach surgery? Surgery is a physical discipline involving many finite, technical actions. Teaching a surgical trainee, including residents and fellows, how to accomplish an operation requires not only communicating those small technical moves but also showing them how to piece those actions together into a larger operation. Perhaps it is more important to physically show a trainee how to accomplish a surgical motion than to describe didactically how to do it. In our video analysis of live intraoperative teaching, much of intraoperative teaching is in fact nonverbal, and this analysis of our data focuses on the physical teaching that occurs in the operating room (OR). Others have used videotape analysis to observe live surgical teaching to characterize more than just the verbal exchanges between attending physicians and trainees.
Journal of Surgical Education & 2014 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2014.10.004
251
Moore et al.1 described the body positions of attending physicians and trainees during challenging surgical steps, and Bezemer et al.2 described the dynamic and fluid shifts of control between attending physicians and residents during an operation. They discovered that surgical participants observe and respond to the attending physician’s body movements and changes in hand and instrument positions. We wanted to further characterize these motions. We asked, “What physical actions and gestures do surgeons use intraoperatively when they teach surgery to residents and fellows?” We videotaped surgical cases, described physical “moment-to-moment” exchanges between surgical attending physicians and their trainees, interviewed the participants through cued recall, and classified live surgical teaching behaviors.
MATERIAL AND METHODS This study was inspired by aspects of grounded theory3 and used the constant comparative4 method to develop rich qualitative descriptions5 and categorize the physical behaviors that are involved in surgical teaching. Live surgery was observed and videotaped by 2 authors (G.S. and E.B.L.) to describe “moment-to-moment” physical (i.e., nonverbal) exchanges between surgical attending physicians, residents, and fellows. We also wished to explore how a teacher used simultaneous words and actions to teach a surgical trainee. We were especially interested in uncovering, among the familiar teaching behaviors, the tacit behaviors of teaching surgery, many of which we expected to be nonverbal, and some which we hoped attending physicians would find illuminating. We analyzed films of 5 surgical cases, including 13 surgical attending physicians, fellows, and residents. We selected cases that we suspected would be information rich, owing to the reputation of the attending surgeons as good teachers and for representing different subspecialties and varied levels of complexity. All participants signed a recruitment script. Our study was approved as “exempt” by our Institutional Review Board. All surgical cases were filmed with a Sony Handycam (MiniDV Camcorder, Model #DCR-HC28) video camera with integrated audio and focused on the upper torso of the surgeons, thus capturing hand movements and gross upper body movements. The camera was handheld and moved about the periphery of the operating team so that nonverbal exchanges between surgical mentors and trainees would be recorded. We paid special attention to nonverbal behavior such as taking away instruments and moving learners’ hands or instruments because we had already seen several teaching cases in which these nonverbal behaviors featured prominently. We intentionally chose not to analyze the rare instances in which the attending physician wordlessly operated while the trainee watched without assisting. We 252
told the participants we wanted to view them in their natural setting and that they should teach and operate as if they were not being filmed. For the bulk of the teaching cases, the videographer was ignored. Follow-up interviews were audiotaped with the attending surgeons after the case while they viewed the films of their surgeries and consisted of primarily open-ended questions about his or her surgical teaching methods. The attending physicians were able to recall a significant level of detail about their teaching during the cases. Our analytical notes from observing the surgical cases and from reviewing the films highlighted examples of physical teaching behaviors. We defined physical intraoperative teaching as any nonverbal exchange that could be construed as originating from the teaching attending physician with the possible effect of instructing the resident or fellow. We confined the physical teaching exchanges to discrete pairs of actions, sometimes accompanied by speech, alternating between the attending physician and the trainee that resulted in some guidance from the attending physician. We focused on the participants’ nonverbal interactions, including actions and gestures. We defined actions as very small, simple, and discrete movements of the body, including flexing the fingers or hands, reaching the arms, and turning the head (e.g., to get the listener to make eye contact). Here, gestures are movements mostly of the hands and the arms that stand in for another action or communication and convey meaningful information to a listener. Gesture researchers have theorized that gestures of the hands and the arms have a linguistic element to them.6,7 Speech and accompanying hand gestures are tightly synchronized with each other8 and share some perceptual and motor processes believed to underlay thought. That is, hand gestures that we use along with speech to explain something to someone serve to not only communicate but also reason about what to communicate.9-11 All data were de-identified. To collect a microlevel of data, the videotaped instances of teacher-trainee interactions were usually reviewed multiple (sometimes more than 10) times to transcribe the smallest physical actions. When transcribing these physical actions, we included the body part involved in the gesture (e.g., hand and fingers), the motion of the gesture through space, the rhythm of gesture (e.g., one point or multiple beats), the timing of the action relative to any spoken words, and the context. 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 actions and gestures and interview the participants to disambiguate the meanings or intentions of the behaviors. 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 cycled iteratively through transcription and analysis multiple times for any given episode. Physical teaching behaviors
Journal of Surgical Education Volume 72/Number 2 March/April 2015
were categorized and repeatedly combined into larger categories. Our coding was inspired by grounded theory3,4 and Sandelowski’s5 depiction of developing rich qualitative descriptions. We stopped analyzing data once we ceased to discover any new, meaningful findings or themes. An interrater reliability analysis using the Cohen kappa statistic was performed by 2 raters to determine consistency for the categories in physical 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. Our study was approved as “exempt” by our Institutional Review Board. For the readers interested in our Verbal Guidance findings, we refer them to Part 1 of our classification study.12
RESULTS We collected approximately 10 hours of film from 5 surgical cases and analyzed more than 6 hours of film before reaching data saturation. We have previously provided details of the 5 surgical cases12: all 5 cases involved gynecologic surgical subspecialists performing open or laparoscopic abdominal surgery with a third-year resident, who usually functioned as the primary surgeon. The attending physician usually functioned as a skilled assistant. We transcribed more than 250 physical teaching moments. We witnessed silent physical teaching (i.e., without corresponding verbal instruction) and physical teaching combined with verbal teaching, but very few episodes of purely verbal didactic teaching (i.e., without a corresponding action or gesture). Analysis of these live teaching moments and corresponding interviews with teaching surgeons led us to discover that teaching surgeons rely heavily on actions and gestures to teach in the OR. We saw that surgical teaching is often a quiet, intimate, intense, and complex activity that includes illustrative hand gestures, supportive physical actions, and repositioning of teaching instruments. Furthermore, when teaching surgeons were shown video clips of their teaching, most expressed surprise about the physical teaching they do. We discovered that these teaching surgeons, although being able to recall small details about how they were manually performing the surgery, were largely unaware of what they were doing with their hands while they were teaching. We coded and classified the physical surgical teaching activities into 9 physical surgical guidance categories (Table 1). Physical guidance included semantic content as rich and important as that in verbal guidance. In fact, we saw many instances in which the teaching attending physician did something with his or her hands that had obvious instructional value and was not accomplished by any words. This included some powerful teaching moments. Teaching attending physicians used 2 general types of physical guidance teaching behaviors: surgical actions and
teaching gestures. Surgical actions were used to assist the trainee in completing individual surgical steps of the procedure and included retracting, using instruments, and manipulating tissues. Gestures used the teacher’s hands, fingers, and arms and generally represented something one might act upon such as an object, a location, an idea, or an action or quality of action. Gestures included pointing or indicating, illustrating hand motion or the shape of anatomy, and depicting how to access difficult areas in the patient’s anatomy. Table 2 further defines each physical surgical guidance category, including a representative example. Interrater reliability using the Cohen κ was 0.76 for physical categories. Participants reviewing the manuscript found our categories to be representative of their teaching behaviors. There was some overlapping of our categories. Some commands (1.b) were also terse (1.f). Some retracting motions (2.e) put enough tension on the targeted tissue to possibly be considered scaffolding (2.d). Moreover, although we parsed out many teaching behaviors at a microlevel, many teaching behaviors occurred simultaneously. For example, consider an example in which the attending physician and the resident are packing the bowel within an open abdominal incision: This exchange lasts 5 seconds, includes teaching behaviors easily classified into 6 separate categories, and is noteworthy in that it illustrates how rapidly teaching behaviors cooccur. After creating an abdominal incision, the resident is packing bowel with lap sponges. Attending physician: “Sigmoid all the way to the left.” (1.b verbal/commanding) while making a clockwise circle with a flat, palm-down right hand. (2.h physical/ figurative) Resident inserts sponge. Attending physician points to left corner and beats twice with right index finger (2.b physical/deictic) and says, “There.” (1.f verbal/terse and 1.d verbal/deictic) Resident: “You want me to do the corner first?” Attending physician: “I usually do.” (1.g verbal/polite) (Case 4, 15:35-15:40) TABLE 1. Classification of Physical Manifestations of Surgical Teaching Physical Guidance 2a 2b 2c 2d 2e 2f 2g 2h 2i
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Transactional Deictic Instrument specific Scaffolding Retracting Repositioning Hands on hands Figurative Complex anatomical 253
TABLE 2. Physical Teaching Guidance: Categories of Physical Manifestations of Surgical Teaching Physical Teaching Category 2a. Transactional
2b.Deictic
2c. Instrument specific
2d. Scaffolding
2e. Retracting
2f. Repositioning
2g. Hands on hands
254
Definition
Representative Example*
The attending surgeon initiates an action that The patient’s legs are in stirrups and the immediately results in a corollary action by surgeons are transitioning from the vaginal the surgical trainee portion of the operation to the abdominal portion. Attending physician (A) grabs the left leg stirrup, squeezes the handle, and lowers the left stirrup and leg. Resident (R) immediately performs the same motion on the right, lowering the right stirrup and leg. No words are exchanged about the legs being lowered. (Case 4, 4:23-4:30) The attending surgeon points toward the A and fellow (F) are describing the pelvic surgical field or directly touches the surgical sidewall anatomy through an abdominal field incision. F: “It’s like (unintelligible) on the side. Broad ligament.” A: “Yeah. All that.” A moves his left hand with index finger extended and hand in a relaxed fist from outside the field toward the pelvic sidewall and withdraws back to outside the field. His left index finger moves toward the structure he is describing. A: “Fibroid over there.” F extends a hand toward the same structure: “I feel it.” (Case 5, 13:30-15:00) The attending surgeon points at an instrument, R makes incision into the abdomen with a touches an instrument, or hands an scalpel. A makes no comment. A obtains instrument to the trainee to indicate detailed helping forceps from the scrub technician’s table and hands them to F, who immediately information about the step to be performed uses them to elevate the tissue within the next incision and assists R on the next step of the incision. No words are exchanged. (Case 4, 8:00-8:15) The attending surgeon uses hands or an R holds a needle driver and is ready to sew instrument to directly support the tissue to be directly into the fascia of the umbilical operated on in a way that facilitates the incision. Without saying a word, A uses a hemostat to grasp and support the tissue. R trainee’s next step drives the needle and suture into the fascial tissue supported by A’s hemostat. (Case 1, 6:45-6:50) The attending surgeon uses hands or While F and R begin the hysterectomy in an instruments, commonly retractors, to move obese patient, A places malleable retractors into the incision. These malleable retractors tissues out of the way, so as to expose the push the adipose tissue to the sides and part of the surgical field the trainee is to expose the target tissue for the hysterectomy. work on next A: “So these are helpful. This is going to be difficult.” (Case 5, 10:20-10:30) The attending surgeon reaches out and A is instructing F which instrument to use to physically alters either the position or the support the ovarian tissue. F has her hand on path of the trainee’s instrument or takes it the handle of the instrument. away A: “You can hold the ovary open with this one.” A grasps the stem of the instrument and shifts it to the right, while A and F both watch the monitor. F does not remove her hand from the handle of the instrument. Both watch the position change on the monitor. A lets go of the stem and F continues operating. (Case 3, 14:50-15:50) The attending surgeon touches the trainee’s R has placed packing sponges into the hands to directly influence the next step abdominal incision, and A is repositioning the packing while instructing R very
Journal of Surgical Education Volume 72/Number 2 March/April 2015
TABLE 2 (continued) Physical Teaching Category
2h. Figurative
2i. Complex anatomical
Definition
Representative Example*
specifically how it could have been done better. Even though A has not removed her hands from the packing, R reaches her left hand into the field. A, without pausing in her verbal instruction, reaches out with her right hand, touches it to R’s left hand, and pushes R’s left hand away from the field. (Case 4, 16:35-16:50) The attending surgeon moves hands in space A is directing R how to use the LigaSure device to describe the anatomy, the instrument, or to accomplish the next step. A gestures with his right hand in space toward the motions required to accomplish a F. “When you take the LigaSure, so you surgical step have the back side sealed.” His right hand flexes into a position similar to the hand position used to operate the handle of the LigaSure device. He makes this gesture after “LigaSure.” He beats with the back of his hand to the right, as if he is pushing something away, on “back side.” (Case 5, 15:50-16:00) The attending surgeon conveys a surgical R is cutting with a bovie near the bladder. A strategy by manipulating the anatomy in a asks her how to avoid the bladder when scar very specific configuration tissue is present. R does not respond. F lifts the Foley balloon and bladder together with her hand. F compresses the bladder tissue over the Foley balloon so that its outline is evident and R can dissect without injuring the bladder. A: “This. Is the best…” R: “Oh. Feeling for the Foley bulb.” (Case 4, 13:0013:20)
A, attending physician, R, resident, F, fellow. *Underlined text contains a representative example of the category. Surrounding, nonunderlined text provides details of the interaction and context.
DISCUSSION The focus of this study was to analyze video recordings from multiple live surgical cases to capture, characterize, and categorize moment-by-moment examples of physical intraoperative teaching. The attending surgeons we studied taught verbally but also relied on a lot of actions and gestures to achieve surgical pedagogical goals. We discovered that teaching surgeons do a lot more than they might think they are doing to teach in the OR. We suspect that these tacit behaviors would have never been captured in retrospective surveys or by a trained observer in the OR and may provide a deeper understanding into how surgical teaching actually works. Two notable studies have been published that also used videotape analysis to characterize particular aspects of detailed teaching communications, which were similarly captured on film and analyzed moment to moment. Bezemer et al.2 analyzed 14 filmed laparoscopic cholecystectomies, and Moore et al.1 described film analysis from one operative step of a perirectal dissection. Moore emphasized the nonverbal communications between attending physicians and residents, especially posture and orientation
of the body and the head in signaling who is in control of the current surgical step. Both authors investigated the lively and shifting roles between teachers and trainees. Two studies by Xiaodong (Phoenix) Chen and her group allowed surgeons to view films of prerecorded intraoperative cases as we have done here in interviews with our participants. Her surgical teaching taxonomy included 3 categories: (1) teaching, which is similar to our verbal explanatory category, (2) directing, which is similar to our verbal commanding category, and (3) assisting, which could be interpreted to encompass all our physical guidance categories.13 They also discovered that the amount of guidance provided by the attending surgeon depends on the complexity of the surgical procedure, the experience of the resident, and preferences of the attending surgeon.14 Physical Guidance We were surprised, as were our participants, at the quantity of physical, often wordless, surgical teaching. We suspect that attending physicians know they teach with their hands but did not sense either how much they teach that way or the influence on learning they might have with their hands.
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Verbal guidance was rare without accompanying physical movements, and the movements generally seemed integrated with the uttered words. The surgical teachers we observed were good verbal communicators but frequently used their hands while making a point to the trainee. In her study of verbal teaching interactions between surgical attending physicians and residents, Roberts et al.15 speaks of the serendipitous teaching that can transform an ordinary intraoperative occurrence into an unplanned verbal teaching opportunity. The attending physicians in our study encountered the same types of teachable moments and, in addition to responding verbally, used actions and gestures to offer insight. The fact that these moments occurred so quickly might explain why our attending physicians were largely unaware of what their hands were doing. The spectrum of physical guidance seemed to change with the level of the attending physician’s control over the surgical step: from brief but illustrative gestures that communicated how to hold an instrument, to placing a hand on the trainee’s hand with the purpose of jointly performing a surgical action. Physical guidance seems necessary to teach complex, 3-dimensional movements in surgery. There are times when verbal instruction alone would be insufficient. Physical guidance can communicate the proper use, force, angle, and direction of an instrument. It is efficient in that it can accomplish teaching quickly without delaying the completion of the next step and interrupting the flow of the surgery. This is especially important when managing complications and during other critical moments of a surgery.1 Many of these physical interactions necessitated an unconscious reading of the actions and gestures of the other. According to linguist Clark,16 even simple interactions between 2 individuals depend heavily on their references to the physical environment, the physical actions, speech, and hand gestures to establish a common reference or “common ground” for understanding one another. For example, when a convenience store customer places a shampoo bottle on the counter, the retail clerk immediately and with very little verbal clarification understands that the customer wishes to purchase it. The bottle of shampoo, the cashier counter, the store itself, cultural rules about how to stand in line and wait to purchase, and words like “this one here” after placing the shampoo on the counter are all part of the common ground that communicate the activity taking place, namely, that the item is to be purchased. In surgery, the common ground between the attending physician and the trainee includes the anatomy, instruments, and tacit rules of surgical teaching. We chose to separate verbal from physical guidance for purposes of categorization but recognize that this is somewhat artificial. The 2 usually occurred simultaneously or within seconds of each other. Gestures and words are opportunistic and related, and their combination can be meaningfully descriptive.17,18 Because gestures and their 256
meanings often do not have a 1:1 relationship, the gesture can add information that was not in the speech. The same gestures, when paired with different utterances and context, can have entirely different meanings. Some things just cannot be communicated without an accompanying gesture. The multimedia nature of human interaction, a wide array of movement and speech and their combination, is probably behind the overlapping of our categories. Limitations Although we recruited surgeons from varying subspecialties, this study was performed at 1 institution. Yet, we suspect surgical teaching across surgical specialties is more similar than different. Our handheld camera did not allow us to visualize every person in the room simultaneously. It is possible we missed actions and gestures conducted off camera. Future Directions We hope our categorization of surgical teaching behaviors will contribute to the study of teaching pedagogy. If we are to study intraoperative teaching in a systematic manner, it is critical to use a set of reproducible, easily identifiable, and classifiable descriptions of teaching behaviors. It is also important to gather teaching behaviors from live teaching cases because many of those behaviors, often informally learned on the job, are the most natural or appropriate to the specific circumstances in which they occur. Many of our categories would be interesting for individual inquiry. Additionally, by making explicit some of the methods used for surgical teaching by excellent surgical trainers, we hope to use this information to encourage deliberate teaching. The more awareness an attending surgeon has about his or her teaching, the more he or she can use it to maximize his or her trainee’s learning. We also wish that our categories may introduce a scholarly conversation that will stimulate innovative teaching approaches and contribute to educational theory of what teaching is and how teaching happens. We suspect that surgical pedagogy is unique when compared with other pedagogy if only in the density of teaching behaviors packed into a few seconds (e.g., case 4 described in the Results section). Surgical pedagogy likely also has important similarities to teaching and coaching other kinds of performance that are complex intellectually as well as physically. For example, intraoperative teaching, especially physical guidance, is the combined and seemingly simultaneous performance of operating and teaching and learning. Finally, tacit teaching behaviors are important to examine closely for their costs and benefits to students’ learning and performance. We suspect as well that further examinations of tacit teaching behaviors, verbal or physical, may reveal something of the cognition and reasoning involved in those behaviors.
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CONCLUSION In our observations of live teaching cases, we found intraoperative teaching to be rich and complex and composed of many physical motions with pedagogical intention. It is complex in that the moment-by-moment instructional exchanges contain many different types of behaviors, many of them unknown to the participants. It is complex in that the tensions that mentors and learners describe appear interrelated. We resolved early in this work to continue asking, “What is intraoperative teaching?,” as it kept leading to more insights and uncovering more complexity. In this article, we presented a categorization of core behaviors in intraoperative teaching and argued that this is where innovation in surgical education must begin.
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S, Goldin-Meadow S. Gesture changes thought by grounding it in action. Psychol Sci. 2010;21(11):1605-1610.
12. Sutkin G, Littleton EB, Kanter SL. How surgical
mentors teach: a classification of in vivo teaching behaviors. Part 1: verbal teaching guidance. J Surg Educ. http://dx.doi.org/10.1016/j.jsurg.2014.10.003, this issue. 13. Chen XP, Williams RG, Sanfey HA, Dunnington GL.
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How do supervising surgeons evaluate guidance provided in the operating room? Am J Surg. 2012;203 (1):44-48. http://dx.doi.org/10.1016/j.amjsurg.2011. 09.003.
2. Bezemer J, Cope A, Faiz O, Kneebone R. Participation
14. Chen XP, Williams RG, Smink DS. Do residents
1. Moore A, Butt D, Ellis-Clarke J, Cartmill J. Ling-
of surgical residents in operations: challenging a common classification. Word J Surg. 2012;36(9):2011-2014. 3. Glaser BG. Basics of Grounded Theory Analysis. Mill
Valley, CA: Sociology Press; 1992.
receive the same OR guidance as surgeons report? Difference between residents’ and Surgeons’ perceptions of OR guidance. J Surg Educ. http://dx.doi.org/ 10.1016/j.jsurg.2014.04.010; [pii: S1931-7204(14) 00126-3].
4. Strauss A, Corbin J. Basics of Qualitative Research:
15. Roberts NK, Brenner MJ, Williams RG, Kim MJ,
Techniques and Procedures for Developing Grounded Theory. 2nd ed. Thousand Oaks, CA: Sage; 1998.
Dunnington GL. Capturing the teachable moment: a grounded theory study of verbal teaching interactions in the operating room. Surgery. 2012;151(5):643-650.
5. Sandelowski M. Whatever happened to qualitative
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the process of utterance. Key MR, editor. The Relationship of Verbal and Nonverbal Communication. The Hague: Mouton, 1980. p. 207-227. 7. McNeill D, Duncan S. Growth points in thinking-for-
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How Surgical Mentors Teach: A Classification of In Vivo Teaching Behaviors Part 2: Physical 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 study surgical teaching captured on film
and analyze it at a fine level of detail to categorize physical teaching behaviors.
their own teaching behaviors captured on film. Interrater reliability was high using the Cohen κ, which was 0.76 for the physical categories.
DESIGN: We describe live, filmed, intraoperative nonverbal
CONCLUSIONS: Physical guidance is essential in educat-
exchanges between surgical attending physicians and their trainees (residents and fellows). From the films, we chose key teaching moments and transcribed participants’ utterances, actions, and gestures. In follow-up interviews, attending physicians and trainees watched videos of their teaching case and answered open-ended questions about their teaching methods. Using a grounded theory approach, we examined the videos and interviews for what might be construed as a teaching behavior and refined the physical teaching categories through constant comparison.
ing a surgical trainee, may be tacit, and is not always accompanied by speech. Awareness of teaching behaviors may encourage deliberate teaching and reflection on how to innovate pedagogy for the teaching operating room. ( J Surg C 2014 Association of Program Directors in 72:251-257. J Surgery. Published by Elsevier Inc. All rights reserved.)
SETTING: We filmed 5 cases in the operating suite of a
university teaching hospital that provides gynecologic surgical care.
KEY WORDS: attending physicians, fellow physician,
medical education, resident physician, surgical education, video recording COMPETENCIES: Interpersonal and Communication Skills, Patient Care, Systems-Based Practice
PARTICIPANTS: We included 5 attending gynecologic
surgeons, 3 fellows, and 5 residents for this study. RESULTS: More than 6 hours of film and 3 hours of
interviews were transcribed, and more than 250 physical teaching motions were captured. Attending surgeons relied on actions and gestures, sometimes wordlessly, to achieve pedagogical and surgical goals simultaneously. Physical teaching included attending physician–initiated actions that required immediate corollary actions from the trainee, gestures to illustrate a step or indicate which instrument to be used next, supporting or retracting tissues, repositioning the trainee’s instruments, and placement of the attending physicians’ hands on the trainees’ hands to guide them. Attending physicians often voiced surprise at the range of
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]
INTRODUCTION What do attending physicians physically do to teach surgery? Surgery is a physical discipline involving many finite, technical actions. Teaching a surgical trainee, including residents and fellows, how to accomplish an operation requires not only communicating those small technical moves but also showing them how to piece those actions together into a larger operation. Perhaps it is more important to physically show a trainee how to accomplish a surgical motion than to describe didactically how to do it. In our video analysis of live intraoperative teaching, much of intraoperative teaching is in fact nonverbal, and this analysis of our data focuses on the physical teaching that occurs in the operating room (OR). Others have used videotape analysis to observe live surgical teaching to characterize more than just the verbal exchanges between attending physicians and trainees.
Journal of Surgical Education & 2014 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2014.10.004
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Moore et al.1 described the body positions of attending physicians and trainees during challenging surgical steps, and Bezemer et al.2 described the dynamic and fluid shifts of control between attending physicians and residents during an operation. They discovered that surgical participants observe and respond to the attending physician’s body movements and changes in hand and instrument positions. We wanted to further characterize these motions. We asked, “What physical actions and gestures do surgeons use intraoperatively when they teach surgery to residents and fellows?” We videotaped surgical cases, described physical “moment-to-moment” exchanges between surgical attending physicians and their trainees, interviewed the participants through cued recall, and classified live surgical teaching behaviors.
MATERIAL AND METHODS This study was inspired by aspects of grounded theory3 and used the constant comparative4 method to develop rich qualitative descriptions5 and categorize the physical behaviors that are involved in surgical teaching. Live surgery was observed and videotaped by 2 authors (G.S. and E.B.L.) to describe “moment-to-moment” physical (i.e., nonverbal) exchanges between surgical attending physicians, residents, and fellows. We also wished to explore how a teacher used simultaneous words and actions to teach a surgical trainee. We were especially interested in uncovering, among the familiar teaching behaviors, the tacit behaviors of teaching surgery, many of which we expected to be nonverbal, and some which we hoped attending physicians would find illuminating. We analyzed films of 5 surgical cases, including 13 surgical attending physicians, fellows, and residents. We selected cases that we suspected would be information rich, owing to the reputation of the attending surgeons as good teachers and for representing different subspecialties and varied levels of complexity. All participants signed a recruitment script. Our study was approved as “exempt” by our Institutional Review Board. All surgical cases were filmed with a Sony Handycam (MiniDV Camcorder, Model #DCR-HC28) video camera with integrated audio and focused on the upper torso of the surgeons, thus capturing hand movements and gross upper body movements. The camera was handheld and moved about the periphery of the operating team so that nonverbal exchanges between surgical mentors and trainees would be recorded. We paid special attention to nonverbal behavior such as taking away instruments and moving learners’ hands or instruments because we had already seen several teaching cases in which these nonverbal behaviors featured prominently. We intentionally chose not to analyze the rare instances in which the attending physician wordlessly operated while the trainee watched without assisting. We 252
told the participants we wanted to view them in their natural setting and that they should teach and operate as if they were not being filmed. For the bulk of the teaching cases, the videographer was ignored. Follow-up interviews were audiotaped with the attending surgeons after the case while they viewed the films of their surgeries and consisted of primarily open-ended questions about his or her surgical teaching methods. The attending physicians were able to recall a significant level of detail about their teaching during the cases. Our analytical notes from observing the surgical cases and from reviewing the films highlighted examples of physical teaching behaviors. We defined physical intraoperative teaching as any nonverbal exchange that could be construed as originating from the teaching attending physician with the possible effect of instructing the resident or fellow. We confined the physical teaching exchanges to discrete pairs of actions, sometimes accompanied by speech, alternating between the attending physician and the trainee that resulted in some guidance from the attending physician. We focused on the participants’ nonverbal interactions, including actions and gestures. We defined actions as very small, simple, and discrete movements of the body, including flexing the fingers or hands, reaching the arms, and turning the head (e.g., to get the listener to make eye contact). Here, gestures are movements mostly of the hands and the arms that stand in for another action or communication and convey meaningful information to a listener. Gesture researchers have theorized that gestures of the hands and the arms have a linguistic element to them.6,7 Speech and accompanying hand gestures are tightly synchronized with each other8 and share some perceptual and motor processes believed to underlay thought. That is, hand gestures that we use along with speech to explain something to someone serve to not only communicate but also reason about what to communicate.9-11 All data were de-identified. To collect a microlevel of data, the videotaped instances of teacher-trainee interactions were usually reviewed multiple (sometimes more than 10) times to transcribe the smallest physical actions. When transcribing these physical actions, we included the body part involved in the gesture (e.g., hand and fingers), the motion of the gesture through space, the rhythm of gesture (e.g., one point or multiple beats), the timing of the action relative to any spoken words, and the context. 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 actions and gestures and interview the participants to disambiguate the meanings or intentions of the behaviors. 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 cycled iteratively through transcription and analysis multiple times for any given episode. Physical teaching behaviors
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were categorized and repeatedly combined into larger categories. Our coding was inspired by grounded theory3,4 and Sandelowski’s5 depiction of developing rich qualitative descriptions. We stopped analyzing data once we ceased to discover any new, meaningful findings or themes. An interrater reliability analysis using the Cohen kappa statistic was performed by 2 raters to determine consistency for the categories in physical 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. Our study was approved as “exempt” by our Institutional Review Board. For the readers interested in our Verbal Guidance findings, we refer them to Part 1 of our classification study.12
RESULTS We collected approximately 10 hours of film from 5 surgical cases and analyzed more than 6 hours of film before reaching data saturation. We have previously provided details of the 5 surgical cases12: all 5 cases involved gynecologic surgical subspecialists performing open or laparoscopic abdominal surgery with a third-year resident, who usually functioned as the primary surgeon. The attending physician usually functioned as a skilled assistant. We transcribed more than 250 physical teaching moments. We witnessed silent physical teaching (i.e., without corresponding verbal instruction) and physical teaching combined with verbal teaching, but very few episodes of purely verbal didactic teaching (i.e., without a corresponding action or gesture). Analysis of these live teaching moments and corresponding interviews with teaching surgeons led us to discover that teaching surgeons rely heavily on actions and gestures to teach in the OR. We saw that surgical teaching is often a quiet, intimate, intense, and complex activity that includes illustrative hand gestures, supportive physical actions, and repositioning of teaching instruments. Furthermore, when teaching surgeons were shown video clips of their teaching, most expressed surprise about the physical teaching they do. We discovered that these teaching surgeons, although being able to recall small details about how they were manually performing the surgery, were largely unaware of what they were doing with their hands while they were teaching. We coded and classified the physical surgical teaching activities into 9 physical surgical guidance categories (Table 1). Physical guidance included semantic content as rich and important as that in verbal guidance. In fact, we saw many instances in which the teaching attending physician did something with his or her hands that had obvious instructional value and was not accomplished by any words. This included some powerful teaching moments. Teaching attending physicians used 2 general types of physical guidance teaching behaviors: surgical actions and
teaching gestures. Surgical actions were used to assist the trainee in completing individual surgical steps of the procedure and included retracting, using instruments, and manipulating tissues. Gestures used the teacher’s hands, fingers, and arms and generally represented something one might act upon such as an object, a location, an idea, or an action or quality of action. Gestures included pointing or indicating, illustrating hand motion or the shape of anatomy, and depicting how to access difficult areas in the patient’s anatomy. Table 2 further defines each physical surgical guidance category, including a representative example. Interrater reliability using the Cohen κ was 0.76 for physical categories. Participants reviewing the manuscript found our categories to be representative of their teaching behaviors. There was some overlapping of our categories. Some commands (1.b) were also terse (1.f). Some retracting motions (2.e) put enough tension on the targeted tissue to possibly be considered scaffolding (2.d). Moreover, although we parsed out many teaching behaviors at a microlevel, many teaching behaviors occurred simultaneously. For example, consider an example in which the attending physician and the resident are packing the bowel within an open abdominal incision: This exchange lasts 5 seconds, includes teaching behaviors easily classified into 6 separate categories, and is noteworthy in that it illustrates how rapidly teaching behaviors cooccur. After creating an abdominal incision, the resident is packing bowel with lap sponges. Attending physician: “Sigmoid all the way to the left.” (1.b verbal/commanding) while making a clockwise circle with a flat, palm-down right hand. (2.h physical/ figurative) Resident inserts sponge. Attending physician points to left corner and beats twice with right index finger (2.b physical/deictic) and says, “There.” (1.f verbal/terse and 1.d verbal/deictic) Resident: “You want me to do the corner first?” Attending physician: “I usually do.” (1.g verbal/polite) (Case 4, 15:35-15:40) TABLE 1. Classification of Physical Manifestations of Surgical Teaching Physical Guidance 2a 2b 2c 2d 2e 2f 2g 2h 2i
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Transactional Deictic Instrument specific Scaffolding Retracting Repositioning Hands on hands Figurative Complex anatomical 253
TABLE 2. Physical Teaching Guidance: Categories of Physical Manifestations of Surgical Teaching Physical Teaching Category 2a. Transactional
2b.Deictic
2c. Instrument specific
2d. Scaffolding
2e. Retracting
2f. Repositioning
2g. Hands on hands
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Definition
Representative Example*
The attending surgeon initiates an action that The patient’s legs are in stirrups and the immediately results in a corollary action by surgeons are transitioning from the vaginal the surgical trainee portion of the operation to the abdominal portion. Attending physician (A) grabs the left leg stirrup, squeezes the handle, and lowers the left stirrup and leg. Resident (R) immediately performs the same motion on the right, lowering the right stirrup and leg. No words are exchanged about the legs being lowered. (Case 4, 4:23-4:30) The attending surgeon points toward the A and fellow (F) are describing the pelvic surgical field or directly touches the surgical sidewall anatomy through an abdominal field incision. F: “It’s like (unintelligible) on the side. Broad ligament.” A: “Yeah. All that.” A moves his left hand with index finger extended and hand in a relaxed fist from outside the field toward the pelvic sidewall and withdraws back to outside the field. His left index finger moves toward the structure he is describing. A: “Fibroid over there.” F extends a hand toward the same structure: “I feel it.” (Case 5, 13:30-15:00) The attending surgeon points at an instrument, R makes incision into the abdomen with a touches an instrument, or hands an scalpel. A makes no comment. A obtains instrument to the trainee to indicate detailed helping forceps from the scrub technician’s table and hands them to F, who immediately information about the step to be performed uses them to elevate the tissue within the next incision and assists R on the next step of the incision. No words are exchanged. (Case 4, 8:00-8:15) The attending surgeon uses hands or an R holds a needle driver and is ready to sew instrument to directly support the tissue to be directly into the fascia of the umbilical operated on in a way that facilitates the incision. Without saying a word, A uses a hemostat to grasp and support the tissue. R trainee’s next step drives the needle and suture into the fascial tissue supported by A’s hemostat. (Case 1, 6:45-6:50) The attending surgeon uses hands or While F and R begin the hysterectomy in an instruments, commonly retractors, to move obese patient, A places malleable retractors into the incision. These malleable retractors tissues out of the way, so as to expose the push the adipose tissue to the sides and part of the surgical field the trainee is to expose the target tissue for the hysterectomy. work on next A: “So these are helpful. This is going to be difficult.” (Case 5, 10:20-10:30) The attending surgeon reaches out and A is instructing F which instrument to use to physically alters either the position or the support the ovarian tissue. F has her hand on path of the trainee’s instrument or takes it the handle of the instrument. away A: “You can hold the ovary open with this one.” A grasps the stem of the instrument and shifts it to the right, while A and F both watch the monitor. F does not remove her hand from the handle of the instrument. Both watch the position change on the monitor. A lets go of the stem and F continues operating. (Case 3, 14:50-15:50) The attending surgeon touches the trainee’s R has placed packing sponges into the hands to directly influence the next step abdominal incision, and A is repositioning the packing while instructing R very
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TABLE 2 (continued) Physical Teaching Category
2h. Figurative
2i. Complex anatomical
Definition
Representative Example*
specifically how it could have been done better. Even though A has not removed her hands from the packing, R reaches her left hand into the field. A, without pausing in her verbal instruction, reaches out with her right hand, touches it to R’s left hand, and pushes R’s left hand away from the field. (Case 4, 16:35-16:50) The attending surgeon moves hands in space A is directing R how to use the LigaSure device to describe the anatomy, the instrument, or to accomplish the next step. A gestures with his right hand in space toward the motions required to accomplish a F. “When you take the LigaSure, so you surgical step have the back side sealed.” His right hand flexes into a position similar to the hand position used to operate the handle of the LigaSure device. He makes this gesture after “LigaSure.” He beats with the back of his hand to the right, as if he is pushing something away, on “back side.” (Case 5, 15:50-16:00) The attending surgeon conveys a surgical R is cutting with a bovie near the bladder. A strategy by manipulating the anatomy in a asks her how to avoid the bladder when scar very specific configuration tissue is present. R does not respond. F lifts the Foley balloon and bladder together with her hand. F compresses the bladder tissue over the Foley balloon so that its outline is evident and R can dissect without injuring the bladder. A: “This. Is the best…” R: “Oh. Feeling for the Foley bulb.” (Case 4, 13:0013:20)
A, attending physician, R, resident, F, fellow. *Underlined text contains a representative example of the category. Surrounding, nonunderlined text provides details of the interaction and context.
DISCUSSION The focus of this study was to analyze video recordings from multiple live surgical cases to capture, characterize, and categorize moment-by-moment examples of physical intraoperative teaching. The attending surgeons we studied taught verbally but also relied on a lot of actions and gestures to achieve surgical pedagogical goals. We discovered that teaching surgeons do a lot more than they might think they are doing to teach in the OR. We suspect that these tacit behaviors would have never been captured in retrospective surveys or by a trained observer in the OR and may provide a deeper understanding into how surgical teaching actually works. Two notable studies have been published that also used videotape analysis to characterize particular aspects of detailed teaching communications, which were similarly captured on film and analyzed moment to moment. Bezemer et al.2 analyzed 14 filmed laparoscopic cholecystectomies, and Moore et al.1 described film analysis from one operative step of a perirectal dissection. Moore emphasized the nonverbal communications between attending physicians and residents, especially posture and orientation
of the body and the head in signaling who is in control of the current surgical step. Both authors investigated the lively and shifting roles between teachers and trainees. Two studies by Xiaodong (Phoenix) Chen and her group allowed surgeons to view films of prerecorded intraoperative cases as we have done here in interviews with our participants. Her surgical teaching taxonomy included 3 categories: (1) teaching, which is similar to our verbal explanatory category, (2) directing, which is similar to our verbal commanding category, and (3) assisting, which could be interpreted to encompass all our physical guidance categories.13 They also discovered that the amount of guidance provided by the attending surgeon depends on the complexity of the surgical procedure, the experience of the resident, and preferences of the attending surgeon.14 Physical Guidance We were surprised, as were our participants, at the quantity of physical, often wordless, surgical teaching. We suspect that attending physicians know they teach with their hands but did not sense either how much they teach that way or the influence on learning they might have with their hands.
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Verbal guidance was rare without accompanying physical movements, and the movements generally seemed integrated with the uttered words. The surgical teachers we observed were good verbal communicators but frequently used their hands while making a point to the trainee. In her study of verbal teaching interactions between surgical attending physicians and residents, Roberts et al.15 speaks of the serendipitous teaching that can transform an ordinary intraoperative occurrence into an unplanned verbal teaching opportunity. The attending physicians in our study encountered the same types of teachable moments and, in addition to responding verbally, used actions and gestures to offer insight. The fact that these moments occurred so quickly might explain why our attending physicians were largely unaware of what their hands were doing. The spectrum of physical guidance seemed to change with the level of the attending physician’s control over the surgical step: from brief but illustrative gestures that communicated how to hold an instrument, to placing a hand on the trainee’s hand with the purpose of jointly performing a surgical action. Physical guidance seems necessary to teach complex, 3-dimensional movements in surgery. There are times when verbal instruction alone would be insufficient. Physical guidance can communicate the proper use, force, angle, and direction of an instrument. It is efficient in that it can accomplish teaching quickly without delaying the completion of the next step and interrupting the flow of the surgery. This is especially important when managing complications and during other critical moments of a surgery.1 Many of these physical interactions necessitated an unconscious reading of the actions and gestures of the other. According to linguist Clark,16 even simple interactions between 2 individuals depend heavily on their references to the physical environment, the physical actions, speech, and hand gestures to establish a common reference or “common ground” for understanding one another. For example, when a convenience store customer places a shampoo bottle on the counter, the retail clerk immediately and with very little verbal clarification understands that the customer wishes to purchase it. The bottle of shampoo, the cashier counter, the store itself, cultural rules about how to stand in line and wait to purchase, and words like “this one here” after placing the shampoo on the counter are all part of the common ground that communicate the activity taking place, namely, that the item is to be purchased. In surgery, the common ground between the attending physician and the trainee includes the anatomy, instruments, and tacit rules of surgical teaching. We chose to separate verbal from physical guidance for purposes of categorization but recognize that this is somewhat artificial. The 2 usually occurred simultaneously or within seconds of each other. Gestures and words are opportunistic and related, and their combination can be meaningfully descriptive.17,18 Because gestures and their 256
meanings often do not have a 1:1 relationship, the gesture can add information that was not in the speech. The same gestures, when paired with different utterances and context, can have entirely different meanings. Some things just cannot be communicated without an accompanying gesture. The multimedia nature of human interaction, a wide array of movement and speech and their combination, is probably behind the overlapping of our categories. Limitations Although we recruited surgeons from varying subspecialties, this study was performed at 1 institution. Yet, we suspect surgical teaching across surgical specialties is more similar than different. Our handheld camera did not allow us to visualize every person in the room simultaneously. It is possible we missed actions and gestures conducted off camera. Future Directions We hope our categorization of surgical teaching behaviors will contribute to the study of teaching pedagogy. If we are to study intraoperative teaching in a systematic manner, it is critical to use a set of reproducible, easily identifiable, and classifiable descriptions of teaching behaviors. It is also important to gather teaching behaviors from live teaching cases because many of those behaviors, often informally learned on the job, are the most natural or appropriate to the specific circumstances in which they occur. Many of our categories would be interesting for individual inquiry. Additionally, by making explicit some of the methods used for surgical teaching by excellent surgical trainers, we hope to use this information to encourage deliberate teaching. The more awareness an attending surgeon has about his or her teaching, the more he or she can use it to maximize his or her trainee’s learning. We also wish that our categories may introduce a scholarly conversation that will stimulate innovative teaching approaches and contribute to educational theory of what teaching is and how teaching happens. We suspect that surgical pedagogy is unique when compared with other pedagogy if only in the density of teaching behaviors packed into a few seconds (e.g., case 4 described in the Results section). Surgical pedagogy likely also has important similarities to teaching and coaching other kinds of performance that are complex intellectually as well as physically. For example, intraoperative teaching, especially physical guidance, is the combined and seemingly simultaneous performance of operating and teaching and learning. Finally, tacit teaching behaviors are important to examine closely for their costs and benefits to students’ learning and performance. We suspect as well that further examinations of tacit teaching behaviors, verbal or physical, may reveal something of the cognition and reasoning involved in those behaviors.
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CONCLUSION In our observations of live teaching cases, we found intraoperative teaching to be rich and complex and composed of many physical motions with pedagogical intention. It is complex in that the moment-by-moment instructional exchanges contain many different types of behaviors, many of them unknown to the participants. It is complex in that the tensions that mentors and learners describe appear interrelated. We resolved early in this work to continue asking, “What is intraoperative teaching?,” as it kept leading to more insights and uncovering more complexity. In this article, we presented a categorization of core behaviors in intraoperative teaching and argued that this is where innovation in surgical education must begin.
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