Introduction

A surgeon’s ability to operate safely requires advanced psychomotor skills, critical decision-making and effective teamwork skills. Surgical skills training relies on apprenticeship-style learning in the operating theatre with progressive trainee participation in supervised operations. In the operating theatre, real-world factors of case variability, operating team interaction, environment and scheduling impact learning and performance. The aim of this paper is to explore the beliefs and values about intra-operative teaching and learning that are held by surgical teachers and trainees. Footnote 1

Teachers’ perspectives

A key concern of surgical teachers is balancing trainees’ learning needs with patients’ safety. When trainees operate, teachers face increased complication rates (Wilkiemeyer et al. 2005) and opportunity costs from slower operating lists (Babineau et al. 2004). The term ‘clinical oversight’ describes how supervisors in general medicine and emergency medicine allow trainee participation in clinical activities while ensuring quality patient care (Kennedy et al. 2007). This framework is inadequate for intra-operative supervision where the clinical situation is harder to predict and rapidly changes without warning. For example, a straightforward teaching operation becomes dangerous due to atypical patient anatomy or faulty equipment. Experienced surgeons, unlike trainees, are able to recognise clinical uncertainty via cues like unusual patient characteristics, external factors and incomplete information and are able to respond appropriately (Cristancho et al. 2013). For teachers, calibrating the right amount of trainee operative independence is difficult and mistakes result in “control dilemmas” that compromise patient safety or teaching efficacy (Moulton et al. 2010).

Trainees’ perspectives

Surgical trainees want to operate and trainee satisfaction with the quality of education increases with operative opportunity (Ko et al. 2005). Teachers can motivate trainees by facilitating trainee autonomy (Dath et al. 2013). However, trainees are not consistently allowed operative opportunity (Ko et al. 2005) which they may ascribe to their own inadequacies, relationship with the teacher (Blackburn and Nestel 2014) or other systemic and personal factors that influence surgeon’s intra-operative decision-making (Leung et al. 2012). An observational study on intra-operative teaching interactions proposed that when teachers facilitated operations though “instrumental interactions” without explanation, “the learner is left to infer the lesson to be learned” (Roberts et al. 2012).

Different perspectives of teachers and trainees

Studies using recall surveys and global rating scores of teaching suggest that the quality of intra-operative teaching is perceived differently by trainees and teachers (Claridge et al. 2003; Jensen et al. 2012; Levinson et al. 2010). Trainees report being given less feedback and autonomy than teachers believe they have given. Possible explanations of this phenomenon include recall bias, aggregated data, poor feedback skills, non-recognition of feedback or different ideas of what constitutes feedback and control. Different conceptions of feedback held by teachers and trainees are supported by evidence that teachers and trainees who view the same video-recorded operation interpret guidance levels differently (Chen et al. 2014). Teachers underestimate the amount of physical guidance they give in addition to verbal feedback (Sutkin et al. 2015). Trainees also have different ideas of learning needs compared to teachers (Pugh et al. 2007). Reported dissatisfaction could stem from mismatched expectations about intra-operative learning objectives, rather than suboptimal feedback or guidance. It is difficult to effect educational change when the causes of different perspectives remain uncertain.

Learning in the workplace and theoretical framework

The operating theatre is a challenging learning environment that subjects trainees to significant stress which affects their technical performance and surgical decision-making (Wetzel et al. 2006). Additionally, the hidden curriculum of surgical culture socialises trainees “to display confidence and certainty” (Jin et al. 2012) which might deter admission of uncertainty and seeking guidance. Situated learning (Brown et al. 1989) and related theories of cognitive apprenticeship (Collins et al. 1991) and legitimate peripheral participation (Lave and Wenger 1991) examine learning occurring through social co-participation in the workplace. Legitimate peripheral participation discusses “the relations between newcomers and old-timers” and “the activities, identities, artifacts and communities of knowledge and practice” (Lave and Wenger 1991, p29) Situated learning used as an “analytical perspective” (Lave and Wenger 1991) on intra-operative training shifts the focus away from the individual learner to permit exploration of separate teacher and trainee perspectives and encourages consideration of sociocultural factors affecting the teaching–learning process. The cognitive apprenticeship model (Collins et al. 1991) translates situated learning theory into practice with teaching strategies that embrace the physical and social context by embedding learning in activity.

In this study we used situated learning (Brown et al. 1989) as the theoretical framework to explore the intra-operative experiences of pairs of surgical teachers and trainees. We sought to understand the beliefs and values of teachers and trainees about intra-operative training.

Methods

A paired case-study design (Yin 2013) was adopted to locate participants’ reactions to a single shared experience to confirm similarities and/or differences in perspectives. This method allowed naturalistic, real-time observation of behaviours including the relational elements. It enabled capture of participants’ reflections on an actual encounter rather than their thoughts about teaching–learning in general.

Ethical approval was obtained from both the University of Melbourne and the institution where the study was carried out, a large public healthcare institution in Singapore comprising several hospitals nationally accredited to provide all surgical speciality training programmes. Surgeons employed by this institution have variable teaching, administrative and research responsibilities in addition to clinical service provision. Local surgical training programmes last between 5 and 8 years. All training programmes require trainees to undergo multiple rotations in different departments to experience relevant sub-specialities. In each rotation, a trainee will work closely with one or more surgeons for a few months.

In a typical operating theatre, teams of doctors and nurses work together as the anaesthetic team and the scrub team. The scrub team comprises the operating surgeon with one or more assistants, a scrub nurse and a circulating nurse. A trainee who is present at the operation may observe, assist or be supervised in performing the operation, depending on the decision of the surgeon in-charge of the case. In this study, we focused on the experiences of both the teacher and learner when a surgeon supervises the trainee performing an operation.

Purposive and convenience sampling enabled recruitment of well-regarded teachers and their trainees. In the institution, not all surgeons are willing to teach trainees during operations and some have not had formal pedagogical training. We approached surgeons reputed to regularly teach well, that is, surgeons, about whom trainees consistently report satisfaction. These surgeons are likely to be better informants about teaching–learning behaviours than others who teach poorly or rarely. We sampled different surgical specialties to investigate generic rather than speciality-specific training. This also reduced the risk of participant identification within a small surgical community. From eligible surgeons, we invited those who were better acquainted with the principal investigator (CO, a surgeon employed in the same institution) to increase likelihood of recruitment. Consenting teachers provided email contacts of their trainees. Separately, trainees were invited to participate. After identifying consenting teacher-trainee pairs, appointment was made for direct observation of an operation followed by separate interviews.

We asked teachers to choose routine teaching operations appropriate for the trainee’s level and to use their regular scheduled lists and operating theatre staff. Routine rather than complex operations were chosen as we aimed to investigate typical intra-operative training interactions without additional stress. Ethical considerations of patient safety also directed choice of simpler routine cases as there was less chance of patient harm should unanticipated study conditions cause poorer operative performance or supervision. One researcher (CO) observed all operations documenting observed teaching–learning behaviours. CO sought to remain unobtrusive during observations by keeping silent and positioning herself out of direct line-of-sight of the teacher and trainee. Notes taken during observation were used during interviews for triangulation and clarification. Immediately after the operation, CO used a topic guide to conduct semi-structured interviews with the teacher and trainee separately. CO is an experienced interviewer and was known to teachers and trainees. Audio-recordings were transcribed verbatim. Transcripts were not returned to participants for verification because of within-pair confidentiality and the potential to disrupt relationships. The topic guide concentrated on the observed operation and included general questions on prior experience as a non-threatening way to elicit additional information (Table 1).

Table 1 Topic guide for semi-structured interviews
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Theoretically-driven inductive thematic analysis (Braun and Clarke 2006) was used. The data set included notes taken during 5 observations of average duration 80 min (range 70–120 min) and verbatim transcripts of 11 interviews of average duration 27 min (range 24–34 min The interview transcripts were open coded by CO and counterchecked by AD using a coding template informed by theories of situated learning and cognitive apprenticeship supplemented with data-derived codes.

Iterative coding and analysis was carried out with discussions (CO & AD) after analysis of the first case, the next two cases, then again after analysis of all the cases. Cases were analysed concurrently with new case accrual, allowing for review of findings before the next case. Discussion using a case-ordered descriptive matrix (Miles et al. 2014) identified key variables and evolving themes were elaborated and refined after discussion leading to the final framework.

Our unit of analysis was each teacher-trainee pair. During within-case analysis, we identified each case within the context of the operation where each case is organised by the key themes derived from the data. Within-case and cross-case analysis focused on concordance or variance of teacher-learner perceptions of their shared experience triangulated with observation data and role-related behaviour characteristics. DN undertook a final checking of concordance and variance of each case against the transcribed data. Discussions and analytic decisions were documented. The research team comprised a surgeon employed within the institution and two educationalists external to the institution. This enabled analysis from outsider perspectives and aided researcher reflexivity.

Results

We designated participants using S to denote surgeon teachers and T to denote trainees. Each participant was identified by an alphabet that corresponded to the case study, i.e. teacher SA supervised trainee TA in case study A.

Description of participants and operations

Five surgeons were matched with six trainees (Table 2). In case study B, the same surgeon supervised two trainees in turn on a single patient requiring two operations. The trainees were representative of local surgical trainees in terms of experience and demographics, while the teachers had more teaching responsibilities than others at this institution.

Table 2 Description of case studies
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Case studies on teacher-trainee perspectives

Details of each case study are given in Table 3. Cross-case synthesis reveals that teachers and trainees had shared recognition of learning in relation to technical elements of operative skill. However, there was less shared recognition of other learning points like surgical reasoning and team management skills. In two cases, trainees discussed important things they had learnt but their teachers did not mention teaching these things (Table 3B1.3, E1.3). Four teachers did not recognise when some things they wanted to teach were either not noted or not valued by the trainee (Table 3A1.2, B1.2, D1.2, E1.3). This was both teacher-related and trainee-related. This discrepancy is illustrated by Case B, where two trainees were present in the operating theatre while the teacher supervised them in turn, on the same patient. During her interview, SB thought she had emphasised a rare but important complication whereas neither TB1 nor TB2 remarked on it during their interviews, suggesting that it had not registered strongly with them. In contrast, when asked about things learnt, TB1 and TB2 highlighted similar aspects of surgical reasoning that they had learnt from SB, which SB herself had not mentioned. This lack of shared recognition of learning points and/or different learning goals resulted in teachers and trainees valuing the process differently.

Table 3 Surgeon teacher* and trainee* perspectives on teaching and learning in the operating theatre
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In all case studies, teachers and trainees expressed satisfaction with the main operation because the trainee successfully completed most of the operation without need for the surgeon to take over.

Because I think everything went smoothly, everything went the way it should go, so that’s why he didn’t take over. (TA)

Four trainees described a positive learning environment and two mentioned having learnt new things as contributing to their satisfaction with the operation. All agreed about the teaching–learning environment encountered.

I think it went quite well. I think, one, it was quite… a relaxed environment to learn, so I wasn’t scared to ask questions. Sometimes you do feel intimidated, you don’t ask questions. I think with SB, it was quite nice. (TB2)

Teachers and trainees sometimes differed on minor aspects of the operation. This occurred when the teacher and trainee focused on different learning objectives as in Case C where SC was happy with main operation performance but not skin closure, whereas TC forgot the skin closure problem because she was so excited about having successfully completed the main operation (her first time); or when there was a difference between trainee self-assessment and teacher’s assessment as in Case D where SD was dissatisfied with TD’s pre-operative ultrasound technique while TD did not realise his technique failed to meet SD’s standards.

Observed teaching and learning behaviours

The cognitive apprenticeship model (Collins et al. 1991) recommends teaching strategies using modeling, coaching, scaffolding, articulation, reflection and exploration. While the first three methods were regularly employed and experienced by participants, there was a relative lack of reflection and articulation.

For all cases, the trainee had prior experience or had observed the case modeled by the surgeon before being allowed to do it. The observer noted that all the teachers used coaching through guided practice (Shumway-Cook and Woollacott 2007), which consisted of giving regular intermittent feedback on the way the trainees were performing the various operative tasks and the achieved results. Specific feedback about technique was reduced during parts of the operation familiar to the trainee and was replaced by other forms of guidance like warning about risks and justification of surgical reasoning.

Trainees occasionally did not register verbal feedback when they were concentrating on the operation. Besides verbal feedback, four teachers also frequently used physical feedback, to demonstrate manoeuvres or by direct contact to move the trainee’s hands appropriately. Trainees found physical feedback useful when learning the specific operative technique (Table 3C2.1, E1.1)

I think when he turned my hand, and then I realised that I was making it very difficult for myself, when I could actually overcome the problem by just turning my hand. (TC)

In one case, the teacher (SD) temporarily took over tissue dissection to show the trainee the correct plane. In two cases, the teacher had to temporarily change places with the trainee to visually check the trainee’s work. Their trainees understood the need for these steps and appreciated the guidance given.

Aspects of scaffolding with provision of support fading in tandem with increasing learner competence were described by all teachers and recognised by most trainees. During the observed operations, every teacher provided the trainee with subtle support (e.g. arranging ergonomic positioning of equipment, readjusting theatre lighting or enabling tissue retraction). Teachers also discussed using scaffolding methods like teaching surgery in steps and by allowing progressive trainee autonomy.

And there are different levels of training. One you scrub, with the person to show, one you don’t scrub, and then you watch, and then you decide call for help lah. Because the independent surgery and bringing-through surgery there’s different learning values. (SE)

All teachers used guided practice for coaching. Trainees shared other experiences of being allowed independent exploration (discovery practice (Shumway-Cook and Woollacott 2007)) which was liked, but tempered by anxiety about patient safety. Only two surgeons discussed exploration as a teaching strategy and both highlighted that this was limited by the surgeon’s threshold for risk.

Some teaching–learning strategies were used infrequently. Only one trainee (TC) reported that she regularly reflected on the learning experienced in the operation (Table 3C2.2), and none of the teachers demonstrated or mentioned using methods to facilitate trainee reflection. In contrast, several teachers showed evidence of practising reflection on their own surgical and teaching practice.

Because there’s certain way I do things. Usually I hardly explain, but there’s always a reason, lah, cause I always…[launches into prolonged description justifying the specific surgical technique] (SB)

So let me clarify, so you were teaching him the way you do things because? (Interviewer)

Because I think my way is easier! Yes, I think my way is easier because I’ve crystallised what are the challenges on table. (SB)

Articulation was not used as a strategy by the participants. However, it was noted that the process of the interview required several trainees to articulate when explaining the specifics of the operation, which subsequently helped them to recognise and organise the things they had learnt.

General ideas about intra-operative teaching–learning

Participants all held strong beliefs about different systemic and cultural factors that govern teaching–learning behaviours and opportunities in the operating theatre. Several expressed concern about reduced operative opportunities for trainees compared to previous years.

If you interview each trainee now, the training opportunities are a lot less. We can say there are simulators, that the learning curve is shortened, but nothing beats cutting on a real patient, lah. And the amount of cutting now, from when I was a registrar to consultant, for a registrar, is definitely less.(SD)

Discussion

Our study shows that teachers and trainees who experience the same teaching operation often differ in their recall of the teaching–learning related to aspects of practice such as surgical reasoning and team management skills, while there was strong agreement on technical elements of operative skills. Teachers and trainees differed in the value they attached to what was taught and learnt because of non-recognition of learning points and/or different learning goals. Nevertheless, all teachers and trainees in our study were satisfied with the teaching operation. The reasons contributing to satisfaction were learning new things, an encouraging learning environment, successful operative outcome and the trainee’s ability to complete most of the operation without the surgeon taking over.

Our findings suggest that contrary to previous studies (Claridge et al. 2003; Jensen et al. 2012; Levinson et al. 2010) dissatisfaction with the quality of intra-operative teaching may be unrelated to quality of feedback and amount of autonomy given. In our study, even the two trainees who preferred being given greater autonomy were satisfied with the intra-operative teaching. With regard to the quality of feedback, we found that there was good, specific verbal and physical feedback given frequently and that trainees mostly recognised and appreciated feedback. The few occasions where feedback was not recognised were because the trainee was preoccupied with operative tasks. Even though the teachers in this study understood the importance of scaffolding, several overestimated the trainee’s ability to listen well when operating. Considering that operative conditions in our study were ideal, it is probable that in more challenging situations, stress would definitely reduce the trainee’s ability to recognise and respond to feedback (Wetzel et al. 2006). Physical feedback on the other hand, was very effective in teaching operative technique, and some teachers found demonstrating by movement easier than explaining. Physical feedback likely aids trainees in learning to recognise haptic and visual cues (sensory semiosis) that have been described as an important subdomain of operative skills learning (Cope et al. 2015). Another form of feedback was to take-over dissection, indirectly by using the retractor or directly, to show the trainee the correct tissue plane. Although taking-over may be related to other factors than trainee incompetence such as time pressures or to demonstrate alternative techniques, both teachers and trainees recognised that taking-over too much of the operation would significantly impact trainee satisfaction.

Trainees have different ideas of learning needs compared with teachers (Pugh et al. 2007). This is intuitively understandable as the learner is often unable to tell what he does not know (Eva et al. 2004). Four trainees had self-assessment of operative skills that differed from teacher assessment, one lower and three higher. Only two teachers reported regularly asking their trainees about learning goals before the operation. We recommend that teachers should negotiate learning goals with the trainee prior to the operation to maximise learning from every teaching case (Roberts et al. 2009; Ahmed et al. 2013). For example, if anticipating time pressure, let the trainee choose which part of the operation to perform, rather than simply taking-over when time runs out.

The paradox of expertise is that the teacher who has crossed the threshold to expertise may no longer be able to appreciate the viewpoint of the learner (Kneebone 2009). As in Case B, the trainee may sometimes need to ask the teacher to explain aspects of surgical reasoning or operative technique. Such behaviour would be discouraged if prevailing surgical culture promotes confidence and certainty (Jin et al. 2012). Hence teachers need to ensure the intra-operative learning environment allows trainees to display uncertainty without repercussion. The paradox of expertise also makes it difficult for the expert surgeon to deconstruct what has already become intuitive, hence some teachers may find it easier to demonstrate the whole operative manoeuvre rather than describe the component parts.

Intra-operative training is time-consuming. In the last decade, most countries have introduced restrictions on trainee duty-hours so as to reduce fatigue-induced patient safety errors. Duty-hour restrictions range from a 48-h working week mandated by the European Working Time Directive to an 80-h working week in the United States. This has resulted in reduced operative training opportunities for the surgical trainee (Purcell-Jackson and Tarpley 2009) and significant global concern that shortened training time precludes achieving surgical expertise. As it is difficult to control the situated learning curriculum in a busy operating room, we should revisit notions of what should be taught-learnt intra-operatively for better curriculum planning.

Simulation training is increasingly promoted as an efficient method to replace intra-operative teaching. However, a US surgical resident is estimated to spend 20 % of the workweek in the operating room (Chung and Ahmed 2007) compared to less than 3 % in the simulation lab (Singh et al. 2014). The transfer of technical skills learnt from simulators to practice has been demonstrated only in laparoscopy and endoscopy, not open surgery (Fonseca et al. 2013) while teaching of surgical judgement using simulation still requires significant teacher involvement to provide feedback (Andersen 2012). In our study, all participants indicated their preference for authentic activity in surgical skills teaching. The cases exemplified the situated learning concept of learning with tools (Brown et al. 1989) as participants described learning from different surgeons about operative decision-making and techniques not found in textbooks in response to unique situations (e.g. changing hand direction to traverse a smaller-than-usual opening). This may explain why senior trainees (Boyd et al. 2006) and surgeons do not believe that simulation can replace the hours spent in the operating theatre for advanced surgical training. However, simulation training can be re-conceptualised as more than just psychomotor task-training in the skills laboratory. Integrated skills training where simulator-based resources are provided alongside the clinical workplace allows safe contextual learning. (Kneebone et al. 2004). Unfortunately this integrated approach is constrained by present systems of training and clinical care delivery.

We need to find ways of enhancing intra-operative training. Our study showed that teachers and trainees typically remembered the technical learning points while learning points like surgical reasoning or team management skills sometimes did not register within the teacher-trainee pair. Teachers and trainees had strong impressions about technical skills probably because both were actively involved and invested in that aspect. A study on surgeons’ perception of operative room learning has subcategorised technical skills into the domains of sensory semiosis, motor skills and adaptive strategies (Cope et al. 2015). All our study participants were able to provide detailed descriptions about tissue recognition, the mechanics and considerations of operative techniques suited to the specific case. For other skills, the lack of recall in some cases was related to trainee’s level of development, as the more junior trainee either did not grasp the concept or did not register the teaching. In other cases, the reason seemed to be that the individual valued learning technical operative skills above other skills. It suggests that teachers need to accurately assess the trainee’s intra-operative cognitive load to reduce extraneous load (van Merrienboer and Sweller 2010) and be explicit when teaching non-technical skills in particular.

Despite medical education being traditionally described as a form of apprenticeship (de Cossart 2005), there is little in the healthcare literature regarding cognitive apprenticeship models for teaching. It has been described in student internships (Stalmeijer et al. 2009), paediatric resident-preceptorship relationships (Balmer et al. 2008), interdisciplinary consultations (Pimmer et al. 2012), but not in surgical disciplines. In our study, teaching strategies commonly applied were modeling, scaffolding, and coaching while articulation, reflection and exploration were less commonly employed. While exploration is limited by other factors of patient safety and surgeon threshold for risk, reflection and articulation are two strategies that can improve intra-operative training. Teachers can encourage reflection by modeling their own reflection processes and by requiring the trainee to articulate about parts of the operation that went well or poorly (Ahmed et al. 2013).

During the interviews, all participants when discussing intra-operative training raised many systemic and cultural barriers that prevented access to practice (Lave and Wenger 1991). High quality intra-operative training requires system and cultural change in addition to improving teaching methods.

Strengths and limitations

A strength of the study design was that it ensured the observer, teacher and trainee all shared a single reference point on which to base discussion of beliefs and values about intra-operative teaching and learning. Case study methodology enabled the foregrounding of the context and relations as emphasised by situated learning theory. Our study provided in-depth direct investigation of operating theatre teaching–learning, a situation that is not commonly accessible.

Some limitations remain since special preparations and the observer’s presence may have altered the participants’ behaviours. The participating surgeons were potentially different from typical teachers so we directed trainees to discuss prior experiences with other teachers. Possible bias remains from CO’s “dual position as both cultural member and cultural commentator” (Braun and Clarke 2006, p94) as surgeon teacher employed in the same institution. As an experienced surgeon educator, CO could easily navigate the operating theatre environment and identify teaching–learning behaviours during observations. It is possible that participants self-censored with a familiar interviewer. Alternatively, since CO is viewed as community-insider, it might instead have encouraged more open sharing by participants. CO was familiar with the vernacular lexicon of participants and the institutional sociopolitical culture which likely enriched data gathering and analysis. To guard against bias from over- or misinterpretation, CO regularly clarified her observations and understanding directly with the participants during the interviews. Potential bias during data analysis was also mitigated by alternate views of other study team members who are non-surgeon educationalists from external institutions.

Conclusions

Teachers and trainees often differ in what they recall and value about intra-operative teaching and learning, especially surgical reasoning and team management skills. Satisfaction with intra-operative training is largely related to successful operative outcome where the trainee completes the operation without the surgeon taking-over, learning new things and the learning environment. It is important to consider the situated learning curriculum that occurs in the operating theatre and utilise appropriate teaching strategies.