Surgeon-driven learning occurred in two ways. The first was best exemplified in the session of the junior surgeon, who arrived with specific questions in mind. Indeed, this surgeon had the option of choosing either of two recorded cases, and he selected the more technically challenging one to review. Explaining that there was “a preventable intraop event,” his goal for the session was to “go over anything we could have done differently.” Throughout his coaching session, he explicitly queried the coach for advice about a range of topics, from positioning of the patient and assistants to dissection techniques. For example, when discussing placement of the incision:
Surgeon: What was your approach for (these cases), in general?
Coach: Depended on whether they were….on one side or the other, then I tended to roll up the patient up and do it through some transverse kind of thing.…I think it largely depends on whether you think that…you might need to go off to the side up into the chest and down the midline…I don’t think I ever worried much about which incision was better; it was just which one could you see better through…and what would be the biggest problem.
All surgeons used an explanatory technique to engage the coach at some point during their session; they fast-forwarded to points of interest and narrated the events being replayed. This technique was most frequently used by the chief resident, the chief resident’s attending surgeon, and the very senior surgeon, with 7–8 instances appearing in each case. However, its intent seemed to differ with seniority. The attending surgeons generally provided a rationale for their on-screen actions and/or for choosing a particular moment to review:
Surgeon: What I do is dissect or transect distally then do the left gastric, then transect proximally…meticulously doing the dissection. It’s interesting to me that when, and I do the same with an esophagogastrectomy for a GE junction lesion, it’s interesting to me that when the thoracic guys do this, they essentially just take a white load across the left gastric. Now does that make a difference? I don’t know…I do spend a little bit of time doing that. The other reason I do that, it also gives me something to do while the pathologists are telling me about the margins.
In contrast, the chief resident’s accounts of various clips were less specific, perhaps intentionally so, to allow the coach to interject as opportunities for teaching points arose:
Surgeon: So this is where we’re coming…underneath the (organ).
In either scenario, the coach was able to take advantage of the narrative cue and move the discussion forward. In response to one surgeon’s explanation of his movements, the coach provided cautionary words:
Surgeon: I always keep my left hand on the mesocolon so that you’re separating the…mesocolon off of the omentum or the adhesions in the lesser sac.
Coach: I buggered a middle colic one time…doing exactly that maneuver of trying to get the stomach up off of the transverse mesocolon.
The chief resident’s introduction of his dissection of the porta, while less self-analytic, was nevertheless met with a teaching point:
Surgeon: Here’s where I start things out. I was trying to find the tip (of the clamp) and I think I was catching the tissue in the tip.
Coach: Writers (from a well-known institution) make a big point out of dividing the common bile duct and I think…it’s a help…I think the artery is, as well.
Depending on the individual surgeon’s level of responsiveness to each, the coach switched between several different techniques of prompting discussion. In the first, reflection was triggered with a direct question. As illustrated in the following example, the coach’s question activated an introspection that gradually led the surgeon to realize that he might benefit from changes to his routine practice:
Coach: Why do you stand on the left there?
Surgeon: Pretty much I’m always on the left because when I was a resident, the operative surgeon was on the right, and when you graduated to being an operative surgeon, you got to stand on the right, so I always felt like, for the resident, if they are on the left, they felt like they are the assistant…Well, actually you’re right. They should be on the left when you are going into the pelvis. And I’ve got to admit, I’ve stood on the left so much that I was just more comfortable on the left, and then, when I first started working as an attending, dissecting the pelvis, I had more control if I was on the left.
At times, the same technique required more clarification of the teaching point; the surgeon had to be guided towards a particular thought process:
Coach: So you’re above the duodenum taking down the porta? So you’re doing that before dealing with the gallbladder?
Surgeon: We have not dealt with the gallbladder at this point.
Coach: Why not?
Surgeon: We skeletonized the portal structures, identified our vasculature, the GDA – we didn’t have imaging, so I think we looked for, but did not find a replaced right. After we kind of skeletonized that all out, then we took the gallbladder down and transected the common duct.
Coach: You can usually tell a replaced right hepatic by the location with respect to the common bile duct.
This prodding did ultimately result in surgeon self-contemplation. Afterwards, the operative attending admitted, “I usually make the tunnel before dividing anything. Probably in this case, I didn’t need to do that. We could have taken down the gallbladder.”
The coach’s second technique utilized explicit suggestions, and was employed most frequently with the chief resident and the junior attending. Noting particular moments on the video, the coach offered alternative approaches. For example, regarding the chief resident’s incision and retractor placement, he explained:
Coach: The trouble with using…the Richardson-type retractor on the liver is that the angle is such that your hand bumps into it. If you use a malleable, you can fold it back under, and it allows the person working from the patient’s left side to get his hand in without hitting your knuckles against the retractor quite so much.
When the chief resident replied that he remembered having more trouble with “the inferior portion,” the coach agreed and offered additional input:
Coach: Well, it looks like you’re struggling with the inferior portion, too, and that ought to be basically no retraction at all – if you’ve got a big enough incision…It looks to me like you’re struggling there with the incision…You need more to the right because you’re trying to get posterior.
Similarly, he proposed a different incision to the junior attending:
Surgeon: Because the tumor seemed to be coming up behind and around it…we intended to take the kidney.
Coach: Which does raise…the question of whether T-ing off the incision to the right would’ve been helpful to you. That is, starting low, then coming over…If you think that it’s all the way around the kidney, then some exposure toward the back there can be helpful.
The surgeon responded that he had been debating this technique, but had “tended to stay midline.” Using video replay, the coach highlighted the surgeon’s struggle to dissect the kidney to illustrate his reasons for suggesting another incision:
Surgeon: You just don’t have that much girth to deal with, so you can kind of reach down there and easily feel where the kidney is. And so that dissection, sometimes I’ll do it bluntly if I know that, because once you slide that, then you could actually mobilize that out of the retroperitoneum.
Coach: It looks like where you are there, that you are having trouble at the lower end, and…sensing you’re having difficulty would make you move to taking the kidney out…It’s just having the incision back posterior just facilitates that getting the kidney up into the air and that end of it.
When we followed-up with this surgeon, he reported that he had adopted the coach’s approach in a subsequent case and had found it advantageous.
Feedback was occasionally framed in terms of resident performance; references to the residents who were present in the case, but not present for the review session, eased the discomfort of self-evaluation and elicited discussion. As the coach explained it, invoking the resident “makes our interaction less confrontational.” He attempted this technique in every session, whether he was making a specific, corrective teaching point:
Coach: When somebody’s picking their way through it like this, I always insisted they take up a knife to do it. And the reason is then they would have what looks to them like a lot of bleeding. It’s always lots more than they thought they ought to have, but it’s all perfectly minor league stuff…Just as a lesson to what you can get away with.
or generally fostering a sense that he and the surgeon were colleagues with a common learning goal:
Coach: See, I’m not sure what he’s accomplishing with this maneuver. Looks like he’s still got adhesions to the patient’s presumably left side there and can’t see what he’s doing and just feeling, and it’s not going to move things along. He’s going to have to take down these adhesions in order to get at the pelvis.
Reactions to it were variable. Some surgeons were particularly responsive; once the assessments were directed at their resident’s performance, they became noticeably less inhibited, participating more fully in the session and accepting feedback more readily. On occasion, the surgeon expressed frustration with the resident, and the coach, in order to make an effective teaching point, merely had to suggest a solution. In this way, the following quote emphasizes the utility of the session in helping surgeons optimize use of their assistants:
Surgeon: There were at least 4–5 times that I couldn’t see the field because (Resident)’s paws were in the way.
Coach: Well, the solution to that is to change retractors, change from self-retaining to assistant-retaining.
The technique, however, was less successful in other instances. One surgeon felt compelled to defend his resident, and was therefore less likely to benefit from the teaching point or the sense of alliance that the coach was trying to create by evoking him:
Coach: Holding the knife like a pencil. Afraid they might cut something.
Surgeon: Yeah, it’s one of our technically best residents, I think…And this particular resident actually, he can do a lot on his own…For a fourth year, he is quite stellar.
Following this response, the coach switched to validation to preface his teaching points for the remainder of the session. His success is seen in the surgeon’s affirmative response, and reflects both the variability in surgeons’ responses and the coach’s ability to astutely respond to these cues:
Coach: Both you and the resident were very skillful at not wasting time and wasting motions…with pawing over things and hemming and hawing over stuff. What you see a lot is people who don’t have their mind made up about where they’re going to go and what they’re going to do, and they paw at the tissue…You guys clearly had a game plan and went to it. I think this is a wonderful example of that.
Surgeon: What we had talked about was, even before we had gotten started, was we went over the films and said, “Okay, this is what we are going to expose first, and then we are going to work on this part, and this is going to be the hard part.” And then, intra-operatively, we just say, “I think we’ve sort of worn out how much we can do from there right now. Let’s just go to a different area, and we just kept essentially going back and forth to the superior to the inferior extent.”
Coach: It is helpful to remember to move your traction-retraction.
Surgeon: Yeah, that’s another thing – that’s a good point.
Coach: Everybody loses sight of the retractor…as they’re burrowing forth, away.