157Mental rehearsal can also play a role in promoting resident learning as regards to
nontechnical training. Rehearsal of tasks is well studied in sports and music and
also supported as an effective strategy in surgery [ 50 ]. Residents can again focus on
needs assessment exercises, which rehearse critical oversteps in their mind without
physical movement or equipment.
There are definite difficulties in carrying nontechnical skills from an operating
room to a simulated environment. In other words, deconstructing a task or a set of
steps can be challenging when it is not real. Cognitive psychology research teaches
us that it is hard to capture critical decision-making steps because experts rely on
knowledge that has become automated and is no longer accessible to consciousness
and therefore difficult to recall [ 51 ]. Tackling a task like life-threatening bleeding
from the vena cava results in an expert surgeon following a series of steps like hold-
ing pressure, clamping, asking for sutures, looking at monitors, communicating
with anesthesia, asking for blood, and requesting backup just to name a few. Expert
surgeons have somehow learned these tasks and can negotiate difficult situations
while maintain patient safety. The attending may not be able to impart similar
knowledge in a mental rehearsal or simulation exercise. Steps can be taken to for-
ward the cause using cognitive task analysis in which automated skills are decon-
structed to create a checklist of critical decision-making steps and options to avoid
error and teach decision-making. Incorporating cognitive task analysis has proven
to be an effective tool in improving insertion of percutaneous tracheostomy [ 52 ].
Creating a checklist for more complex surgery can be cumbersome; it can be a
focused effort on critical aspect of a case, for example, control of the dorsal venous
complex during a radical prostatectomy.
Briefing, intraoperative teaching, and debriefing:
- Briefing: needs assessment and setting specific performance targets
- Can be one or multiple objectives
- Could be based on stage of learning
- Intraoperative teaching
- Attending teaches to the objective
- Redefines objectives as needed
- Provides coaching to accomplish objective
- Debriefing
- Feedback after the case which addresses the objective(s)
- Create learning plan
- Review progress on stages within learning model
Conclusion
Teaching in the operating room is a complex task with many challenges. It is
clear that improvements need to be made on how residents are taught, evalu-
ated, assessed, and graduated to be able to not only perform safe and effective
procedures but also manage difficult situations and the operating room envi-
ronment. The concepts of creating a learning environment, thoughtful assess-
ments, needs assessment, clear expectations, commitment and preparedness,
entrustability, learning model, feedback, needs assessment, acquiring technical8 Teaching in the Operating Room