Attending Feedback After Surgery: An Under-Utilized Force in Surgical Education

Aoun, Salah G.; El Ahmadieh, Tarek Y.; Yip, Byron K.; Batjer, Hunt H.; Bendok, Bernard R.

doi: 10.1227/01.neu.0000419709.17781.8a
Science Times

The Accreditation Council for Graduate Medical Education (ACGME) has defined 6 core competencies that are now required for all surgical residency programs.1 While their importance is recognized, the crucial matter of how to evaluate residents' technical skill competency progression from novice to proficient while providing them with constructive feedback remains largely unanswered. Feedback is defined as “the control of a system by reinserting into the system the results of its performance.”2 Feedback has been proven to enhance skill and performance in various fields ranging from rocket science, to business administration, psychology, and education.2 Established guidelines for effective feedback state that it should be expected by both the provider and the recipient prior to its administration. Additionally it should be based on objective descriptive data of actions and facts instead of intents and interpretations, and focused on behaviors that are remediable. It is important to distinguish feedback from evaluation. The following questions thus arise: Is the current operative and post-operative feedback provided by faculty at academic institutions sufficient? Are the adopted methods suitable and do they encourage the development of a healthy mentor-mentee relationship? Which issues should feedback focus on and how should it be delivered? How can we make the evaluation process reliable and productive while keeping it efficient in a way that would not unnecessarily burden the faculty?

In an effort to shed additional light on this controversial topic, Jensen et al, in the April issue of “The American Journal of Surgery,” published a survey of residents and faculty at the Department of Surgery at the University of Washington.3 During the fall quarter of 2008, a 22-item questionnaire based on a 7-point Likert scale ranging from strong disagreement to strong agreement was distributed to all rotating General Surgery residents during weekly educational conferences, and to General Surgery faculty members at the annual General Surgery retreat. Questions addressed 2 main topics: 1) the importance of operator feed-back regarding different key components of a surgical procedure such as preoperative planning, respect for tissue and instrument handling, and 2) the participant's perception of frequency, timing and overall satisfaction with the feedback received or provided. The objective of the survey was to compare and contrast the perceptions of residents and faculty members regarding operative feedback.

The survey population consisted of 167 residents and 90 faculty members. The response rate was 75% for the residents and 52% for the faculty. The proportions of the participants' academic levels were judged to be representative of the program population. The responses of both faculty and residents were congruent on the importance of providing immediate post-operative feedback, and the educational topics that would benefit most from this interaction (Figure). All respondents also agreed that there was a crucial difference between intra-operative teaching and operative feedback. On the other hand there was a disagreement between residents and faculty on their perception of the frequency, amount, specificity and overall adequacy of provided feedback (Table 1 in the original manuscript). Faculty more readily believed it to be largely sufficient while residents expressed a need for additional feedback. The authors also state that while written feedback may be an ideal way to remedy these misperceptions, it may constitute a burden too heavy and too time-consuming to the faculty to be adopted consistently due to demands in a fast-paced clinical environment. Instead, they suggest that a structured oral face-to-face session taking place directly after surgery may be useful both to praise the residents for a job well done and to direct their attention to areas where additional focus and effort is needed.

In the current era of ACGME accreditation requirements and work-hour limitations there can be no doubt as to the necessity of improving efficiency in the learning process of residents. Current ACGME program requirements for graduate medical education state that when it comes to practice-based learning and improvement, formative evaluation feedback should be incorporated into daily practice.4 While both faculty members and residents seem to recognize how crucial operative feedback is to improving surgical performance as highlighted by Jensen et al, defining the best way of implementing it into daily hospital routine without making it time consuming and cumbersome remains a major unanswered issue. This is especially problematic since the impact of feedback does not seem to depend on its written or oral format but instead on the frequency of its administration, with maximal efficiency when it is provided on a day-by-day basis as part of the normal workflow.5 Greater awareness by attending physicians regarding the value residents place on feedback, will likely help enhance the quality of resident education. Brief pre- and postoperative discussions could go a long way to advancing resident education. Repeating the survey conducted in this paper locally on an annual basis may help programs and individual faculty gauge the quality of their feedback during and after surgery.

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1. Batjer HH, Aoun SG, Rahme RJ, Bendok BR. Congress of Neurological Surgeons Honored Guest Talk: Honoring our Public Responsibility: Creating Milestone and Matrix Based Training in an Era of Duty Hour Restrictions 2011, October 1-6, 2011; Washington, DC.
2. Ende J. Feedback in clinical medical education. JAMA. 1983;250(6):777–781.
3. Jensen AR, Wright AS, Kim S, Horvath KD, Calhoun KE. Educational feedback in the operating room: a gap between resident and faculty perceptions. Am J Surg. 2012;204(2):248–255.
4. ACGME. Program requirements for graduate medical education.
5. Elnicki DM, Layne RD, Ogden PE, Morris DK. Oral versus written feedback in medical clinic. J Gen Intern Med. 1998;13(3):155–158.
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