Exploring how surgical educators teach trainees

2.2a Narrative

Although medical students may enter residency from universities that incorporate CBME into their undergraduate medical school curricula, the landscape of a surgical residency is one that new residents will find unfamiliar and thus will have to adapt to new methods of training. Residency is typically referred to by the year of training (such as post-graduate year [PGY] 1-5+), with a general understanding by program directors and residents of what is required per each year of training; however, with the launch of residency-focused competency-based frameworks such as CBD, the year of training may eventually become irrelevant, as CBD will be using

established competency milestones that residents must meet in order to move forward in the program until graduation.

In the current “time-spent” model of postgraduate surgical residency, trainees are expected to spend a certain amount of time in both didactic and hands-on training, the latter of which increases as the resident progresses through the program. During this time, residents are expected to gain more and more independence as their program progresses and as they meet the expectations of each year’s requirements and exams. There exists the question as to whether this current model ensures that all residents receive equivalent training and that they are competent to independently practice following residency and fellowship. Recent studies have shown that surgical residents tend to report less exposure (including just observation) to surgical cases and actual operating time than residency program directors believe should be required.1 _{This is likely due to the fact that there are fewer and fewer opportunities for surgical}

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residents to actual operate due to factors such as technological advances, an increased demand for efficiency in the OR, monetary restraints (especially in a publically-funded healthcare

system), increasing concerns about patient safety, and the mandated reduction in resident and fellow work hours, each of which results in less time for residents to learn and surgical

educators to teach during live surgeries.2

Due to this reduction in actual OR time, surgical educators at many centres have begun incorporating surgical simulation into their residency curricula, which is a topic that will be covered later in this thesis. The introduction of CBD into Canadian residency programs will eliminate the time-spent model, thereby theoretically allowing for enough surgical exposure for residents before they graduate and go on to practice independently. However, since it has not yet begun its roll-out into surgical residency, it will take several years to determine the

feasibility and success of CBD within surgical residency. Individual residency programs still have specific “milestones” that must be met within each year of residency that are based on CBME frameworks such as CanMEDS and ACGME, and although these may differ between programs, all residents in a given surgical residency program must pass examinations that are mandated by accreditation agencies (which differ based on location) in order to proceed on to the next year of residency.

Because of the limitations surgical residents face with regards to getting enough live surgical experience, surgical educators are pressured to determine the most effective and efficient ways to teach in the intraoperative setting. Surgical teachers use various techniques to ensure that

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trainees receive the most comprehensive and best hands-on education as possible for a given surgical case, yet these techniques are rarely described in the literature. Surgical educators typically receive no formal training on intraoperative teaching, and therefore may often rely on using the methods by which they were taught as residents themselves. A crucial part of the long, complex process of surgical training occurs in the OR where the surgeon teacher and the trainee spend time interacting, making the role of communication between the teacher and learner one of significant interest when studying the techniques used to teach in the OR. Attention has recently been paid to the role of the teacher, how best to prepare surgical educators in academic institutions, and to the role of institutions themselves and the academic teaching mission in general.3,4 _{However, the paucity of literature dedicated to how surgical} educators teach while in the OR led our research team to conduct a qualitative study with the objective of learning the specific approaches and techniques surgeons use while teaching in the OR.

We conducted nine focus groups of surgeon teachers from each division within the Department of Surgery at McMaster University. The data revealed the major themes of motivation,

responsibility, management, and feedback, with multiple subthemes identified for each category. Communication was determined to be a concept that pervaded all themes. The identified themes align well with each of the CanMEDS roles. Each of these primary themes will be discussed in this chapter section. (Of note, results surrounding each theme were presented at the Association for Surgical Education annual congress and other local meetings over a three-

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year time span, each under the same group of authors.) Published work 2 describes the theme of the role motivation plays during intraoperative teaching.

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