This article, from the “To the Point” series that is prepared by the Association of Professors of Gynecology and Obstetrics Undergraduate Medical Education Committee, is a review of considerations for teaching the medical student in the operating room during the obstetrics/gynecology clerkship. The importance of the medical student operating room experience and barriers to learning in the operating room are discussed. Specific considerations for the improvement of medical student learning and operating room experience, which include the development of operating room objectives and specific curricula, an increasing awareness regarding role modeling, and faculty development, are reviewed.
As obstetrician/gynecologists, we spend a significant portion of time in the operating room (OR). In a study that was aimed to understand reasons for pursuing obstetrics/gynecology as a career, residents rated surgical opportunities to be the highest among many motivating factors. Medical students on the obstetrics/gynecology clinical clerkship will participate in and learn from surgical procedures. Teaching and learning in the OR is often directed towards resident needs, with prioritizing technical skills needed for competency rather than focusing on medical student learning needs and experiences. An observational study by Irani et al found that an average of 55% of OR educational time in general surgery was spent on technical teaching for the resident; only 10% of each case was spent teaching core clerkship objectives. Such observations may lead both educators and students to question the value of the medical student OR experience in the obstetrics/gynecology clerkship.
Investigators have sought to understand student perceptions of the OR experience. Students believe that the OR is a challenging learning environment, report unfavorable OR experiences, and have mixed beliefs regarding the utility of the OR experience. They identify apprehension, anxiety, fear, shame, and being overwhelmed as initial emotions and barriers to student learning in the OR. Additional barriers include emphasis on patient safety, concerns for surgical efficiency, the presence of multiple learners in the OR, physical constraints with decreased visibility, and the increased use of minimally invasive techniques that may isolate learners. Perceived benefits of the student surgical experiences include improved knowledge of the surgical procedure, anatomy, anesthetics, and sterile technique. Students also express that the OR experience is useful in deciding future specialty choice, and studies indicate that positive OR experiences can influence students to consider surgical specialties as a career choice.
In the emerging era of Entrustable Professional Activities (EPAs) and Milestones, it is also useful to consider how student OR experiences fulfill these requirements. The Accreditation Council for Graduate Medical Education Obstetrics and Gynecology Milestones state that a graduating medical student who is pursuing an obstetrics/gynecology residency should demonstrate knowledge of basic abdominal and pelvic anatomy; demonstrate basic surgical principles, which include the use of universal precautions and aseptic technique; and position patients appropriately for surgery. In the realm of interpersonal and communication skills, the incoming resident should understand the importance of relationship development, information gathering and sharing, and teamwork. The OR is a useful place for students to achieve these milestones. The relevant EPAs for OR learning and experience include EPA 8, which is competency in transitions of care; EPA 9, which is to collaborate as a member of an interprofessional team; EPA 11, which is to obtain informed consent; EPA 12, which is to perform general procedures of a physician, and EPA 13, which is to identify system failures and contribute to a culture of safety and improvement. These EPAs underscore the relevance of the student’s active involvement in the surgical environment.
Considerations for obstetrics/gynecology student OR teaching
Learning objectives
Outlining goals, setting learning objectives, and clarifying expectations for student performance can increase student satisfaction with the learning experience, the obstetrics/gynecology clinical clerkship, and the OR experience in particular. Through a survey study, Fernando et al found that the attending physician and students identified a knowledge of standard OR etiquette and protocols; the ability to scrub adequately and adhere to sterile technique; the awareness of risks to self, staff, and patients; and an appreciation for careful perioperative monitoring to be essential student skills. In a study with the use of focus groups, students and faculty members prioritized 4 categories as important for student learning in the OR: (1) development of a foundation of clinical knowledge, (2) surgical technique and skill acquisition, (3) personal insight into career choice, and (4) understanding surgical culture and OR functioning. The Association of Professors of Gynecology and Obstetrics (APGO) has objectives that are specific to the OR that are listed in educational topic 41, “Gynecologic Procedures,” of the tenth edition of the APGO Medical Student Educational Objectives, which can be useful with the development of student learning objectives for the OR experience.
Curriculum in the OR
Curricula to enhance the student learning experience in the OR can be built once objectives are outlined. Curriculum changes can range from low-cost and easily implemented logbooks to time and faculty intensive skills-training sessions ( Table ). However, the first element of a curriculum should focus on making the students and educators aware of learning objectives. Student handbooks or orientation materials can list the key learning objectives for the OR. Faculty members and residents can be made familiar with objectives through electronic mail or laminated postings in each OR. Meetings can be held with OR nursing staff to familiarize them with the educational program, the role of the OR in student education, and the expected learning outcomes.
| Initiative | Brief description/method of delivery | Intended outcome |
|---|---|---|
| Learning objectives | Specific operating room learning objectives to include clinical knowledge and technical skills | Align educators and learners to goals to focus learning experiences and maximize time spent in the operating room |
| Distribution to students, faculty members, and operating room staff | ||
| Logbook/experience cards | Checklist approaches to specific operating room elements intended for students | Increase student engagement and participation |
| Guided learning modules | Written templates or computer-based instruction to guide student learning during specific operating room experiences | Focus operating room learning, improve knowledge retention, and satisfaction with operating room experience |
| Skills training | Skills laboratories for various technical skills, which can include faculty-guided learning, peer-assisted learning, video instruction, and mental imagery | Increase student comfort and participation in operating room experience |
| Increase technical skills | ||
| Increase interest in obstetrics/gynecology as a career | ||
| Self-reflection/self-awareness exercises | Facilitated reflection or self-motivated assignments | Increase student awareness of the operating room environment |
| Increase student interest in a surgical career |
The APGO student logbook can be used as an easy, low-cost curricular addition that allows students to record their OR experiences during the obstetrics/gynecology core clerkship. The logbook maps entries to educational topic 41 (“Gynecologic Procedures”) and includes items such as observe hysterectomy, observe laparoscopy, insert Foley catheter, demonstrate knot tying, gynecology preoperative note, gynecology brief operative note, and gynecology postoperative progress note. Hampton et al included a student experience card as part of an obstetrics/gynecology OR curriculum that incorporated experiences that were suggested by APGO and those experiences that were identified as important through student and faculty focus groups. Evans and Gusberg similarly describe OR assessment cards that represent a checklist approach to promote student engagement in the OR. Through such cards, students are asked to assess their experience with regard to (1) introduction to the OR team, (2) the opportunity to review the preoperative imaging, indications for surgery, relevant anatomy, and operative findings, and (3) the opportunity to discuss expected outcomes and participate in some technical capacity. A review of checklists or logbooks can inform students of learning opportunities, and implementation as part of a larger curriculum can increase student engagement in the OR and enhance the student learning experience.
Curriculum strategies to help students remain engaged and learn in the OR have also been described. Written templates that are designed to guide learning during observation in the OR can help the student remain focused and capture the learning event in written record. Computer-based instructional content for review by students to aid in the transition from classroom and self-instruction to learning in the OR environment may be useful. Hampton et al developed and implemented three 15-minute modules: (1) introduction to OR culture and functioning, (2) How to get the most out of assisting with a hysterectomy, and (3) How to get the most out of assisting with a laparoscopy. The use of these modules in addition to other curricular elements (such as orientation of faculty members and students to objectives, student experience log, and a reflective assignment) improved knowledge retention, increased student satisfaction with student-faculty interactions in the OR, and improved faculty teaching evaluations during the obstetrics/gynecology clerkship.
Skills training during the obstetrics/gynecology clerkship orientation also increases student satisfaction with the obstetrics/gynecology clerkship experience. Researchers have shown that skills training in the obstetrics domain of vaginal delivery boosts student confidence, clinical participation, and examination performance. Thus, OR skills orientation for students during the obstetrics/gynecology clerkship may enhance student ability to experience the OR as more conducive to learning and increase student participation. With increased knowledge and comfort in skills, students can focus their learning energy on the opportunities available in the OR instead of on obtaining basic OR skills. Surgical scrubbing and knowledge of instruments have been reported as highly important skills for students entering the OR. Confidence in, comfort with, and knowledge of these introductory skills translated to confidence, comfort, and knowledge for more complex skills, such as surgical instrumentation and knot tying. OR orientation sessions can include hand washing, gowning, and gloving; OR protocols; an introduction to common instruments and equipment, and a discussion of what behaviors to avoid in the OR. Using this type of orientation has been shown to increase student participation in the operation and inclusion in the surgical team. Gynecology-specific simulation curricula during the obstetrics/gynecology clerkship, which include skills such as intrauterine device insertion and removal, dilation and curettage procedure, and basic laparoscopy skills, have demonstrated improved confidence in performing procedures and have been shown to increase interest in pursuing a surgical field and in women’s health.
Self-reflection and self-awareness exercises are curricular elements that can help students gain a better understanding of their comfort in the OR, response to the surgical environment, and their interest in surgery as a future career choice. Trained facilitators can be used to guide students through suitable responses to difficult or tense OR situations in teamwork. Alternatively, students can complete self-reflective assignments on their own, perhaps focusing on how the surgical experience in the OR during the obstetrics/gynecology clerkship influenced consideration of future plans or career choices.
Curricular teaching strategies
The traditional obstetrics/gynecology clerkship may include disparate experiences in the OR with several different faculty members and residents. More novel Longitudinal Integrated Clerkship models likely allow for more faculty continuity in the OR. Reid et al investigated a surgical apprenticeship model in which students apprenticed directly with faculty members on a 1-on-1 basis. Students who participated in this model had a more positive view of surgeons and were more likely to participate in the OR and patient treatment, compared with students in the usual clerkship model. It may be useful to consider using apprenticeship models during traditional obstetrics/gynecology clerkships to enhance student OR participation and improve student perception of surgical faculty members.
The importance of role modeling within the OR has been described by many investigators ; however, surgical faculty members may not understand just how influential they are regarding student surgical experience or career choice. Positive behaviors can influence students to consider surgical specialties ; negative behaviors may deter students from considering surgical fields. The main themes of calm, teamwork, respect, teaching, patient communication, and providing comfort have been identified as exemplary behaviors modeled to medical students within the OR. Some of the most important role-modeling may come from resident physicians with whom the students spend most of their time on the clerkship. Residents demonstrate many qualities that are described in outstanding clinical mentors, and several studies show that medical students perceive residents as their main source of OR teaching. Faculty physicians can use the teaching strategy of recruiting residents as teachers in the OR setting to create an educational multiplier that allows faculty members to do multilevel teaching, while addressing learners at each level.
The use of learner-provided objectives in the OR followed by a debriefing or the use of methods to increase student feedback may improve the OR experience. The Briefing–Intraoperative Teaching–Debriefing model focuses both the educator and student on specific learning objectives for the case to guide intraoperative teaching. Briefing is aimed at the assessment of the needs of the learner and the establishment of learning objectives to guide both learner and teacher. Intraoperative teaching should focus on the learning objectives that are set during the briefing. Debriefing allows for reflection, reinforcement, correction, and establishment of rules. The feasibility and success of the incorporation of structured immediate feedback sessions for third-year medical students during their surgery clerkship was investigated by Garner et al during a cross-over study. Students who were instructed to seek daily feedback from faculty surgeons reported significantly more feedback and specific instructional guidance; faculty members did not report fatigue with providing feedback to the students, with their perceptions of the students remaining positive. Incorporation of feedback into the OR is another teaching strategy that can be implemented potentially to improve the student surgical experience.
There are several ways OR skills programs can be carried out outside of the OR. Faculty availability and time are often an issue for scheduling training laboratories. Peer-assisted learning can be a useful teaching method for OR skills and has been shown by some to be more effective than resident-assisted learning. Peer-assisted learning can be more informal and allow learners to raise areas of concern as well as have material placed in meaningful contexts for their level of learning. Shippey et al randomly assigned medical students to 1 of 3 interventions for teaching subcuticular suturing: instructional video, instructor supervision by faculty members, or independent practice. All 3 student groups demonstrated performance gains after each teaching intervention; however, students who used the instructional video were the only group who demonstrated sustained improvement in skills when tested 1 week after the intervention. This reinforces that video instruction and the ability to capitalize on learner-centered and active rather than passive learning can be beneficial to skills retention. Finally, mentally rehearsing OR skills such as suturing may enhance student attainment of OR skills. The impact of mental imagery on student OR skills education was investigated by Sanders et al. Medical students were assigned randomly to 1 of 3 instructional groups to learn suturing: (1) 3 sessions of suturing a pig’s foot, 2 sessions of physical practice on a pig’s foot, and 1 session of mental imagery rehearsal or (2) 1 session of physical practice on a pig’s foot and 2 sessions of imagery rehearsal. Groups performed only slightly differently over the time of the study, which indicates that mental imagery rehearsal was as effective as physical practice in learning surgical skills by medical students. It can also be useful to use other medical professionals, such as nursing staff or physician assistants, to teach skills. This, along with peer-assisted learning, video-assisted learning, and mental imagery practice, offers an alternative to time-intensive OR skills teaching and rehearsal with faculty members.
Faculty development
One of the most cited barriers to effective learning for the medical student in the OR is adverse and unwelcoming surgeons and OR staff attitudes. Therefore, enhancing surgical faculty teaching abilities within the OR through faculty development can offer great potential for improving student perceptions of the OR learning environment. Confidential, objective, individualized faculty feedback has been shown to improve faculty OR teaching significantly. OR assessment cards can be completed and reviewed with specific faculty members to provide directed feedback regarding student experiences in the OR. Sharing faculty members’ course evaluations can be another way to facilitate feedback and faculty members awareness of their impact on student learning. In any faculty development effort, the importance of faculty members’ attitudes towards the learner should be emphasized and underscored.
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