149experiences in the operating room, while our senior residents have learned to
negotiate the intricacies of the operating room quite well.
All educators can agree without references and science that an environment con-
ducive to learning will produce better-trained residents. The body of surgical educa-
tional literature focuses on surgeons and teachers and more recently toward residents
as learners. However, we have not addressed the learning environment of the operat-
ing room and how it can be optimized.
The challenges of the learning environment can be divided into these
domains [ 37 ]:
- The physical environment
- Emotional impact of surgery as work
- Challenge of the educational task
- Managing social relationships
Learners must learn to negotiate the physical environment of the operating room.
There are appropriate etiquette and protocols as learners familiarize themselves
with the operating room culture [ 38 ]. The nuisances, complexity, and particulars of
a surgical procedure determine the allocation and sequence of all work and interac-
tion, including when and how the teaching takes place. For example, a resident can
become completely detached from teaching during a case where a faculty member
is performing an independent task. This can also occur during a really complex case
where two faculty members are working together. Surgery is serious work, and
there is clear element of risk. During periods of intense concentration and team-
work, teaching material cannot be distilled easily to extract only the most interest-
ing, useful, or critical bits.
The operating room environment can be counterproductive to learning. Residents
can have the fear of appearing foolish as questions they ask and can be repeated to
them as questions they should know the answer to rather than questions that lead to
inquiry and teaching. Of course, there is a balance in expectations based on the level
of the learner, but the teaching value of the case may change based on the enabling
of inquiry allowed by the team members.
Managing the educational task is different for the level of the resident and is
also very different for other learners present like medical students. For example,
the focus of a medical student would be to gain exposure and the requisite knowl-
edge to be able to pass an exam or achieve competence for future career goals.
Relevance and utility of the learning is a significant driver. The residents’ educa-
tional task is not only to achieve evaluable competency for progression and pro-
motion but more importantly to gain the skill and knowledge to practice
independently upon graduation. This goal is often unrecognized and becomes
more urgent toward the end of training. Regardless, learners are worried about
lack of clear objectives and feedback in the learning environment to properly
manage the educational task [ 37 ].
Patricia Lyon developed an interpretive model of learning and teaching based on
her study of medical students as learners in the surgical environment [ 39 ]. Although
8 Teaching in the Operating Room