Six ways to optimize students’ operative experience

Introduction

The surgical rotation for medical students is of particular interest because it provides them with significant and substantial exposure to the field of surgery (1). It offers students a unique exposure to complex surgical diseases and procedural skills (2). Medical students in the third and fourth years of medical school, especially those who are considering surgery as a career, should have the opportunity to join surgeons during operative procedures. This unique experience is more evident in the operating room (OR), and surgical procedures provide an attractive clinical activity in a rich environment where different teams and individuals collaborate efficiently. Furthermore, surgeons and operative teams use sophisticated devices and tools to execute invasive surgical interventions and complex procedures. It should be no surprise that students are highly encouraged to attend these operative procedures during their surgical rotations. However, there is a dearth of well-defined objectives for students who attend operative procedures to direct what they should learn and how they should learn it. Surgeons appreciate the students’ excitement to see anatomic structures, especially when they move, such as bowel or ureteric peristalsis. Visualizing is occasionally combined with abridged attempts at teaching, for example, by asking relevant anatomy questions. Regrettably, this limited teaching often reduces the robust operative experience to a mini anatomy lesson.

Surgeons realize that teaching surgery to medical students is gradually becoming challenging (3). However, OR teaching should be educationally designed to focus on more than a simple demonstration of anatomic structures. Although it is intriguing to visualise anatomic structures in real-time, this simple learning can be easily achieved in the lab or by watching videos with much greater economy. Students can and should be more involved in the OR (1).

Several methods can be used to optimize the operative learning experience. Patients’ surgical care and operative management should be the foremost priority around which student education is modeled (4). Efforts to modify the existing approaches can be augmented by reviewing the needs of all interested parties, so that a more favorable approach that complements and prepares students for the future, can be adopted (5). Establishing shared team responsibility for student operative involvement and communicating specific student expectations may improve the overall student operative experience (1,6). This article discusses operative learning approaches and recommendations to enhance students’ learning experience in the OR, especially students in the last year of medical school and those who are considering surgery as a career option. We describe the following strategies such as (I) the flipped operative classroom teaching; (II) progressive involvement in procedure skills; (III) advanced engagement in minimally invasive procedures; (IV) focusing on principles and concepts of surgery; (V) teaching comprehensive operative care; and (VI) promoting playing active role in the surgical care. Implementing these strategies is reasonably practical and not particularly demanding. Advanced arrangements and dedicated surgeons facilitate the application process.

How to optimize operative teaching?

Surgical teams may find any of the following approaches of use to enhance students’ operative learning experience:

Flipped operative room teaching

The concept of flipped classroom teaching that depends on prior learning and preparation before the educational event can be applied to other teaching settings, such as the OR (7). Learners initiate their learning and construct their knowledge based on the constructivism learning theory (8). At the planned educational session (the OR in this case), their learning is consolidated by applying knowledge, bridging gaps, clarifying misunderstandings, and connecting to other topics. The flipped operative room teaching approach has already been used with residents and has shown encouraging results (9,10). Similarly, students can be involved using the same approach with level-appropriate learning objectives, such as focusing on principles or techniques of operative surgery. Prior to the procedures, reviewing the materials based on the predetermined learning objectives enhances learning outcomes and improves the learning experience (9). Careful selection of learning objectives to correlate with rotation objectives should be considered. Appropriate objectives and learning tasks, such as indications of the procedures, alternative treatment options, possible complications, and postoperative care, are common for the student’s learning level. Students should participate in setting their learning objectives to enhance active learning (10). Regular feedback on the process and students’ input should be encouraged to modify the learning experience accordingly.

Progressive involvement of students in procedure skills

Students favor more involvement in performing surgical tasks and skills that are more than suturing skin incisions or cutting stitches (1,4). Prior to their involvement in surgical procedures in the OR, medical students should be guided and introduced to basic surgical skills in the lab, such as practice knot tying and suturing. Progressive steps such as incising the skin for port placement, cauterizing tissue, retrieving specimens, assisting in endoscopic biopsy, or removing ports at the end of the procedure are tasks considered highly esteemed by the students as experienced by the authors. Surgeons need to delegate the appropriate tasks to different levels of trainees to enhance group participation, provide the required learning opportunities to all levels, and advance learning.

Engaging students in minimally invasive surgery (MIS)

Hands-on opportunities during MIS procedures became less available to students. This limitation forces students to favor watching the procedure on the monitor without scrubbing. Active engagement becomes less likely in such situations. Hence, extra efforts to engage students become a necessity. A practical way to engage them is to create interactive discussions around the cases. Obviously, the surgical team may not be able to do that consistently for several reasons. Hence, alternative and practical methods are needed. One way to engage students is by providing prompts for discussion displayed on the OR screen (e.g., a dedicated screen or perhaps a corner of the operative monitor). These pre-prepared prompts may include questions, additional information, technical tips, or procedure descriptions to trigger group discussions, inspire learning, and share perspectives. The same approach can be used during all interventions that use cameras and monitors, such as endoscopy and interventional radiology. While not limited to students with an interest in pursuing surgery as a career, medical students may find utilization of simulators and practicing in simulation labs an important skill acquisition approach. Practicing under these conditions will enhance the student’s skills and test their interest as they navigate future career paths. Medical students in clinical years should have this opportunity available to them. Studies have shown that implementing the fundamental of laparoscopic surgery curriculum for fourth-year medical students increases confidence in laparoscopic knowledge and performance of technical skills prior to entering a surgical residency (11).

Focusing on principles of operative surgery

Practitioners commonly focus on teaching factual information that covers foundational knowledge at a lower cognitive learning level (12). Clinical training, however, requires higher learning levels than simple information recall (13,14). Hence, engaging students in learning concepts and principles of surgery enhances their clinical experience. Teaching operative surgical principles such as bleeding control, sterile techniques, and OR safety, along with concepts such as operative evaluation and decision-making, is a much more efficient use of valuable OR time when compared to information that can be studied anytime and anywhere. Students who are assigned to attend certain surgical cases would benefit from a defined curriculum that outlines the basic steps of procedures the students are participating in to allow students to read ahead of time. Additionally, the availability of online access to the thousands of videos demonstrating the performance of surgical procedures should be utilized. For example, the American College of Surgeons (ACS) video library is an excellent source of hundreds of procedures that students will benefit from watching (15). Medical student membership to ACS provides them with a plethora of resources that help guide students as they consider surgery as a career (16).

Teaching comprehensive operative care

Preoperative, intraoperative, and postoperative care are all parts of surgical learning that students should experience. Students need deliberate efforts to involve themselves in the hospital course and the intraoperative, postoperative, and follow-up care of surgical patients to construct a comprehensive knowledge base about the management of surgical diseases. Case-based learning is known to enrich clinical learning and improve performance (17). Students should follow patients from the preoperative holding area through the operative room to the recovery area. Observing the anesthesia team and nursing assessment, reviewing pathology specimens processed in the lab, and participating in the initial postoperative nursing care completes the learning schema and promotes a sense of engagement. A recent study found that developing a hospital-based perioperative surgical co-management curriculum rotation to provide educational value to fourth-year medical students learn about preoperative optimization, postoperative management of both acute medical issues and chronic comorbidities, and the interprofessional team for surgical care through inpatient rounds with a multidisciplinary team, and a case-based didactic curriculum and weekly journal clubs (18).

Promoting an active role in surgical care

Students expect more involvement in patient care and management (19). Delegating tasks and encouraging an active role for them enhances their sense of participation and their ability to apply knowledge. Tasks that are safe and appropriate to their performance level, such as patient positioning, surgical site prepping and draping, and nasogastric tube or Foley’s catheter insertion give the students a sense of active participation with the team.

Conclusions

A medical student’s surgical learning experience within the intricate environment of the OR can be maximized by focusing on multiple facets, including principles of surgical procedures, common surgical approaches and techniques, teamwork, comprehensive and perioperative care, and safe surgical practice. This can be achieved through simple prompts and short discussions that stimulate and facilitate student’s engagement, especially students in the last year of medical school.

Acknowledgments

The authors would like to thank the learners and educators who inspired and used the concept.

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Annals of Laparoscopic and Endoscopic Surgery. The article has undergone external peer review.

Peer Review File: Available at https://ales.amegroups.com/article/view/10.21037/ales-23-63/prf

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://ales.amegroups.com/article/view/10.21037/ales-23-63/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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