139training in 2010 and 2011 performed one-third of essential common operations as
defined in the Surgical Council on Resident Education (SCORE) curriculum a
median of less than five times and four of these a median of zero times [ 2 ]. The
effects of these increased demands compared to available time can be seen in the
fact that over one-quarter of surgery residents worry about their confidence to per-
form procedures independently upon graduation [ 3 ]. A recent survey of surgery
fellowship program directors found that 21% felt that new fellows were unprepared
for the operating room with 30% unable to independently perform a laparoscopic
cholecystectomy and 66% unable to operate on their own for 30 min unsupervised
in a major operation [ 4 ]. Although this survey was based on the opinion of program
directors and is not a scientific assessment of actual operating skills, the findings are
concerning given the amount of time and effort that goes into training residents and
the great responsibilities they have after graduation.
The pressures on teaching physicians and the landscape of the modern academic
medical center have also changed dramatically in the last century. Although we
would like to separate the financial and educational aspects of teaching hospitals
and medical schools, they are inextricably joined. In decades past, only a small frac-
tion of the operating costs of medical schools was directly derived from clinical
revenue. Through 1965 a typical medical school relied on faculty practice for only
about 6% of their budget, while 60% came from federal research spending [ 5 ]. After
the advent of Medicaid and Medicare in 1965 and through the fee-for-service era,
the clinical revenue of academic hospitals grew, and by 1980 approximately half of
a typical medical school’s budget came from its clinical practice [ 5 ]. Within our
current managed care era, influence from insurance companies has shortened hospi-
tal stays, decreased payments, and increased demands on clinicians to see more
patients in less time which in turn decreases time for clinical teaching. These pres-
sures along with increased concerns over patient safety and public accountability
have led to decreased time and freedom for resident education and autonomy in the
operating room. Faculty teaching in the operating room must therefore adapt to
maximize the time available.
The educational environment in which we are teaching in the operating room has
also changed over the last several decades. New research has provided insights into
education that can be utilized to make the most of the time we do have to teach in
the operating room. We would not ignore clinical research in our field that guided
us to better patient care, and we should not ignore education research that benefits
our residents. We must also factor in generational differences between current resi-
dents and their teaching faculty and how these differences affect learning and teach-
ing in the operating room. Although there are many timeless principles regarding
operative education, the way in which these principles are applied to different learn-
ers in different situations can have a great impact on their effectiveness. A more
detailed discussion of generational differences is covered elsewhere in this book,
but the current millennial generation’s desire for more direct constant feedback,
assimilative learning style, and technological prowess should be harnessed if we are
to make the most of educational time in the operating room. As stated by Ian Jukes,
“We must prepare students for their future, not our past” [ 6 ].
8 Teaching in the Operating Room