August 27th, 2020
“Use The Force”: How Do We Teach in the Operating Room?
As I embark on my chief year in general surgery, the aspect I look forward to most is taking junior residents through operations. I am grateful to have had excellent teachers over the past 5 years, and I appreciate the opportunity to pay forward this mentorship. But taking what you have learned and teaching someone else turns out to be a very different challenge than learning itself! Suddenly, you realize your attendings have been doing a lot of behind-the-scenes legwork to make the operations look simple and to set you up for success.
For me, two things have set apart the best teachers: patience and communication. Patience is intricately linked with humility and remembering that “I too was in this position once.” In some ways, this is inherent to one’s personality and character; everyone can strive to be more patient, but I think this quality is hard to change. On the other hand, while everyone enters residency with different baseline communication skills, with self-reflection and practice, communication skills are amenable to improvement.
Communication is hard. The following three practices help me communicate better in the OR and make teaching more enjoyable.
Do the heavy lifting upfront
Many within the surgical education community encourage trainees and supervising physicians to have preoperative briefings to discuss operative approach and focus areas. I try to have this discussion with my attendings and have found it quite helpful to my own learning. When I operate with a junior resident, I try to discuss my game plan with them in advance, or send them my notes on the specifics of the procedure the night before. I have found that this elevates the level of discussion we have in the OR — from “how should we enter the abdomen?” to “here’s how you can optimally position your body, give better tension with your left hand, and make a cleaner incision with your right hand, in order to enter the abdomen more efficiently.” Instead of just learning what the moves are, we get to focus on how to do them efficiently.
Own the responsibility for understanding
One of my college professors used to say, “The responsibility for understanding should be on the teacher, not the learner.” So rather than asking “Do you understand?” he would ask, “Have I explained myself properly?” Taking a resident through a cholecystectomy, I tried to explain a set of moves to him: “Use your hook to get around that structure, turn 90 degrees, pull out, and burn.” “Uh-huh.” Something didn’t sound quite right, so I paused and asked “Just to confirm, does that make sense – what I said?” “Maybe not completely.” We were able to clarify, and the honesty was appreciated. As surgery residents, we become really good at saying “yes” — If someone asks us to get something done, we say “yes” and then figure out how to make it happen. Sometimes residents apply the same mindset in the OR and might feel reluctant to speak up when they are confused. In these situations, it is all the more important for the teacher to confirm that their directions are understood.
Tailor the approach to the individual and the situation
In these first 8 weeks of chief residency, I have become more attuned to the differences in personality, learning style, and experience among junior residents. In the OR, some residents appear very confident, whereas others are still finding their groove. Some have had more experience with certain procedures. Some respond very well to constant feedback, whereas others need encouragement. I myself have probably been in each of these positions at different points of residency! The best teachers understand that the needs of the learner are different for each learner — and in each situation! Modifying your teaching style constantly is hard, but once you figure out how to tailor your instruction, it is very gratifying to see your trainee achieve his or her maximum potential!
Despite my focus on clarity of communication, sometimes there are teaching moments that are beyond words and intellectual understanding. In the OR, one of my attendings occasionally exhorts, “Be an athlete!” It’s hard to explain exactly what he means or how it helps, but usually, I am able to re-attempt the maneuver with more agility and finesse! Last month when operating with one of my favorite attendings, I was struggling to laparoscopically drive a suture needle through a certain tissue into the right spot. He had me pause, he turned to me, and he said, “Use The Force!” The needle went exactly where it needed to go. Teaching and learning have a lot to do with patience and communication, but sometimes they verge on the realm of faith and understanding one’s heart!