The operating room is acknowledged to be a key learning environment for surgical trainees, and there is a growing body of literature that refers to “technical” and “nontechnical” skills involved in surgical training. Some authors have attempted to make explicit these terms,1,2 but this binary distinction may not adequately capture all content areas required to achieve surgical expertise. The underlying question about what surgeons learn in the operating room, therefore, may not be adequately addressed by this categorization, and so this study aimed to inductively map and explicate what surgeons perceive they learn in the operating room.
A large body of literature has been devoted to reporting differences between the skills of fully trained surgeons and those of trainee surgeons, with the implication that the differences are attributed to skills learned in the operating room, such as time to complete a particular defined surgical task,3,4 hand-path length,4,5 number of movements,6 smoothness of hand movements,7 and force–torque signatures of particular movements.8 Differences have also been found in the way that novice and expert surgeons move their eyes when looking at the operative field, and studies have found that eye tracking can reliably distinguish between expert and novice surgeons.9,10 Yet, although attending surgeons may be faster, smoother, and move their eyes differently compared with trainee surgeons, these measurable outputs may represent secondary end points of learning rather than capturing the curriculum of the operating room.
Metrics provided by advanced surgical simulators point to the fact that time taken, instrument path length, and smoothness of motion are not necessarily good measures of surgical ability, as increasingly simulators also rate surgeons in terms of the “appropriateness of their actions.” This provides insight into the quality of the surgical work. The ProMIS (Haptica) and LapMENTOR (Simbionix) simulators penalize the surgeon if he or she dissects in the incorrect place or cuts an incorrect structure (regardless of speed or smoothness of action). These errors may be weighted in terms of severity to generate an error score. These types of error scores have been shown to reliably differentiate between fully trained surgeons and trainees, suggesting that procedure-specific content such as the surgeon’s choice of where to dissect next, may be content areas of postgraduate surgical learning.6,11
The learning of how to identify structures and interpret the tissues during an operation does not easily fit within the binary discourse on “technical” and “nontechnical” skills. It is clear that highly specialized knowledge of specific anatomy is required to achieve surgical expertise; yet, book knowledge alone might not adequately equip the trainee surgeon with the skills to find the correct plane for dissection during an operation. We therefore investigated in an inductive way—without prior supposition or prior categorization—what surgeons perceive they learn in the operating room.
We used a grounded theory design, through which content categories emerged from the data, which may be termed an immersion or a crystallization approach.12 The method is described in accordance with the Consolidated Criteria for Reporting Qualitative Research guidelines.13
We gathered participant-reported data during 2010 and 2011, using semistructured interviews at four different hospital sites. We obtained signed informed consent from all participants and audio recorded the interviews, performing the subsequent analysis from transcripts. Ethics approval for this study was granted by the St. Mary’s research ethics committee at St. Mary’s Hospital, London, United Kingdom. This was formally discussed at a full ethics committee hearing and given approval reference 10/H0712/1.
We sampled general surgeons, both attendings and residents, at four different UK National Health Service (NHS) hospital sites, making this a multisite study. Two large university teaching hospitals and two district general hospitals were selected to enable data capture at contrasting institutions. Purposive sampling enabled in-depth information to be collected about the emergent themes. Initially, we selected at each institution an attending surgeon who was thought to be receptive to the study and one of that surgeon’s junior residents. Further potential participants were nominated by participants as surgeons who were able to articulate their insights into learning (a form of snowball sampling). Potential participants were approached initially by e-mail, and face-to-face interviews were arranged outside of work hours at a neutral location.
It became apparent during the study that junior and senior trainees perceived that they were learning different things in the operating room, and, therefore, this directed the sampling to include some very junior trainees as well as senior trainees and newly appointed attending surgeons. Gender, race, and age characteristics of the study participants broadly reflected the distribution within the sampled population.
We developed the interview topic guide based on a comprehensive review of existing literature and through consultation with surgical trainers, trainees, and educationalists (see Appendix 1 for interview topic guide). We piloted the interview topic guide with three surgeons prior to the start of data collection to ensure comprehensibility of the interview questions and to ensure that the responses would address the specific research question.
The primary researcher—A.C.C., a senior surgical resident with a master’s degree in surgical education, who was employed full-time as a researcher while working toward a PhD—conducted all of the interviews. Interviews were audio recorded, and an independent transcription agency created verbatim transcriptions from the audio recordings. A.C.C. checked the transcripts for accuracy against the original recordings and also returned the transcripts to the study participants for comments and corrections prior to analysis. No interview transcripts were amended during this process. The interviews lasted 50 minutes on average; occasionally, A.C.C. made field notes to denote particular modalities of expression that could be lost in the analysis of transcripts (e.g., “laughing”).
The data analysis was performed by a four-person team from complementary academic backgrounds: A.C.C., a higher surgical trainee; S.M., a postdoctoral educational psychologist; J.B., a postdoctoral sociologist; and R.K., a fully qualified surgeon and professor of surgical education. The transcripts were analyzed through an iterative approach by re-reading and classifying using NVivo 9 (QSR International, Doncaster, Victoria, Australia), allowing categories, and ultimately theory, to emerge from the data rather than structuring it on predefined concepts.12,14 Our analysis used a constant comparative approach where subsequent interviews were coded using the emerging coding framework. If a new theme emerged, the previous interviews were reanalyzed with the new theme also available for coding. During the data collection, the four members of the analysis team held regular discussion meetings during which commonalities and differences in the emergent themes were considered, and for data that proved troublesome to categorize or did not seem to fit with the working model, we collected further data to broaden the researchers’ understanding about that theme, and further discussion took place until coding agreement was reached. When we were satisfied that no new themes were emerging from the data, we concluded that data saturation had occurred.
After formulation of the themes and subthemes, the entire dataset was then independently recoded by two of the researchers (A.C.C. and S.M.). We completed this phase of analysis to ensure durability of the themes. The kappa coefficient for interrater agreement was 0.7 across all themes.
Twenty-two surgeons (10 attending surgeons and 12 surgical trainees; 15 males) participated in this study. This included trainees ranging from Core Training Year 1 (this is equivalent to postgraduate year 1) through Specialty Training Year 8. Participating attendings ranged from 15 to 32 years post initial medical qualification. All attendings and trainees included in the sample were working at one of the four different NHS hospital study sites.
The research team coded 277 data points (short paragraphs or phrases conveying meaning) in the transcripts. Table 1 outlines the major themes that emerged from the interview analyses and the intercoder reliability as denoted by the kappa coefficient. In this section, we provide more detail to illustrate each of the major themes.
This theme encom passed knowledge that the surgeons regarded as absolute or incontestable.
Participants described learning abstract, “textbook” anatomy, such as the name of a specific structure in a “typical” human, and the anatomical course that this structure would “typically” follow. The participants frequently framed this content area as suitable for the junior learner, noting that it should be mastered prior to learning to operate, and that operating “helps to reinforce to people where their anatomical knowledge may be lacking.” Similarly, surgeons described learning “what the instruments are, though often I have to ask or keep my ears open for what people ask for” and the equipment likely to be needed within a “typical” case. They referred to learning the steps of an operation by breaking down the task as described by one attending surgeon: “We can actually convey to people reasonably quickly and easily the constituent steps of a procedure.” Participants considered the knowledge of these steps and the order in which they should be undertaken to be factual and incontestable.
Surgeons also described learning the indications for particular operations: “So we talk around it, we talk about the indications, we talk about carotid disease.” These were the signs, symptoms, or investigative findings that would lead a surgeon to decide that an operation was necessary. Similarly, the surgeons discussed “learning about intraoperative complications … immediate and late complications specific for that procedure or generalized for the patient,” and “what kind of follow-up they need and … [whether] there are any dos or don’ts post op that they [the resident] need to know.”
This theme was striking because these matters were presented by the surgeons as factual abstract knowledge learned in the operating room and pertaining to absolute indications, acknowledged complications, and standard postoperative care, without reference to individual patient or circumstantial factors.
This major theme related to teaching and learning hand skills, frequently referred to by the surgeons as “surgical handicraft.”
Surgeons discussed the initial learning of surgical maneuvers such as one-handed knot tying:
… there are certain baseline skills which I expect people to know. So you know, a junior trainee should be able to suture and tie knots, and take clips on and off, and hold instruments properly, like retractors.
These were regarded to be basic skills, acquired early on in training. Surgeons also discussed learning fine motor control and accuracy: “… once you go beyond the basic skill set, where I’m mostly focused on [is] making sure that my suture technique is meticulous.” This was perceived to happen after the learner had mastered the basic maneuvers, and was considered an intermediate skill.
Efficiency and economy of movement were perceived as more advanced learning, emphasizing “… the way you move with an economy of movements.… Because when I first started operating I was getting terrible hand cramps because you put yourself in terrible positions.”
A particular subtheme was the learning of “hand–eye coordination, or not the hand–eye coordination, but the instrument–eye coordination … on the screen in the operating theatre.” The surgeons related that the challenge presented by laparoscopic surgery was that the learner’s gaze was directed at a video monitor, requiring the hand movements to be executed in a different directional orientation from the gaze of the learner.
All data points coded under motor skills referred to learning the control and execution of movement. Motor skills were frequently cited as being basic level, but a hierarchy within this theme existed with initial learning of basic maneuvers, followed by precision and accuracy, followed by economy and efficiency of movements.
This was a novel and important theme, which we defined as the ability of the learner to make meaning of what he or she was seeing or feeling.
The surgeons described learning to interpret visual and haptic cues as learning how to translate what they were seeing into the “known” abstract anatomy of the textbook. Subthemes related to visual cues and haptic cues.
The participants spoke about learning how to recognize subtle changes in the tissues that would signpost an upcoming anatomical structure within the dissection: “But it’s the appreciation for just slight variations in color, texture, change of your tissues when you’ll start understanding what structure is going to suddenly spring up behind a little fatty pad.”
Part of the difficulty of learning sensory semiosis was that anatomy textbooks frequently portrayed anatomy in oversimplified, diagrammatic form: “What you see in actual life is more difficult to correlate, like the vessels aren’t as obvious to me, that this is the inferior epigastric versus seeing it in a book and it’s painted in red.” Participants noted that much of what was being learnt in the operating room was what the structures really look like in vivo, in a living human.
Interpretation of haptic cues was defined as the ability of surgical learners to interpret what they are feeling by touch, both in terms of identity of a structure and pathological process involved. Participants related that they “learned to feel the difference between normal, inflammation, and malignancy.” As one surgeon noted,
you need to be able to put your fingers into a small incision and know what you are feeling—like to be able to find the appendix through a tiny incision and, more than that, you should be able to tell whether or not it is inflamed just by the feel.
The surgeons referred to sensory semiosis as a content area of learning that was relevant for all levels of surgical learner, whether it was identifying the hernia sac or the ureter in a mass of inflammatory tissue. The surgeons related that a more difficult case was when “tissue planes aren’t so easily found … the planes aren’t so easy to identify and dissect out.” They discussed that, when the tissues were more difficult to interpret, the trainee should slow down and the surgeon should learn “what feels dangerous, you know, things that are clumped together, you can’t understand, you can’t see what they are, you can’t feel what they are. I expect them [trainees] to slow down what they do.”
The surgeons in this study discussed learning adaptive strategies in the operating room to deal with anatomical variants or complications.
The adaptive strategies were likened to a toolbox of potential solutions for dealing with unexpected findings: “dealing with changes that occur in the operating theater, a bleeding vessel, for example, is what changes a registrar from a registrar to a consultant—I suppose.” There were no subthemes, but it should be noted that the term “surgical judgment” was frequently used in statements related to this theme.
Team working and managerial skills.
This theme related to learning to be part of a team, organization, or hospital system. Part of the data coded under this theme involved activities that could be described as communication skills, “the way that you extract the best out of a group of people and out of a scrub nurse, to try to help along the way with an operation,” and also situational awareness: “if I hear the sats probe noise, you know as it gets lower—the sats—the probe makes a different noise, I will then interact with the anesthetist.” These learned skills enabled surgeons to work collaboratively with other professionals, and to anticipate surgical difficulties before they arose, allowing the operation to continue without interruption.
Attitudes and behaviors.
The surgeons described learning personal values or attitudes that were regarded a part of “becoming a surgeon”: “[Trainees need to learn] resilience, taking responsibility for complications at that stage, both intraoperative that can be fixed, and also in the postoperative period.” They also discussed learning a perfectionist attitude to their work:
I think the attitude “no short cuts,” “do things correctly,” and “do things nicely.” This is something it takes a long time to learn. Because you are nearly changing the personality, you are changing the culture of the people, but this is very important, “no short cuts,” everything “done nicely” and “done quietly,” this is an attitude.
Data coded under this theme related to the personal attributes or beliefs that shaped surgeons’ behaviors. Despite these attitudes having more global implications than just in the operating room, the surgeons described them as being learnt in the operating room itself.
This investigation inductively explored surgeons’ perceptions of the content of learning in the operating room, and we have outlined six major domains of that learning: factual knowledge, motor skills, sensory semiosis, adaptive strategies, team working and managerial skills, and attitudes and behaviors. Some of these content areas are already well recognized in the surgical literature, and for this reason they will not be discussed further. Instead, we choose to draw attention to and discuss the novel theme of learning sensory semiosis.
Semiotics refers to the study of “meaning making” from signs. Academic work in this field speaks of “social semiotics”—this phraseology “draws attention to the fact that meanings always relate to specific societies and their cultures.”15 In this context, the appearance of the operative field and the “feel” of the tissues held particular meaning for the cultural group represented in our study—surgeons. The “signs” that convey messages to individuals within this particular cultural group are referred to by sociologists as “texts,” although the material may be lexical, graphical, haptic, etc. There are, therefore, a variety of modalities in which texts are presented. The surgeons in this study described learning to interpret visual and haptic texts simultaneously—a “multimodal” presentation.15
In this study, sensory semiosis was discussed by the participants in terms of “learning how to interpret visual and haptic cues in the operating room.” This theme does not easily fit into the binary discourse of “technical” and “nontechnical” skills in surgical training because it spans across these categorizations requiring technical knowledge, perceptual ability, and contextual interpretation. Learning “sensory semiosis” has not been previously fully acknowledged in the published literature pertaining to surgery and also has implications for wider medical specialty learning.
Although it is known that gaze patterns differ between novice and expert surgeons,10,16 the reasons that the gaze patterns differ and what draws experts to focus on specific aspects of the operative field have not been articulated previously. This ability to interpret visual and haptic cues is not exclusive to surgery; in many clinical disciplines, making sense of information presented visually or by touch is an essential part of becoming a good diagnostician.17 The experienced clinician can spot abnormal findings in the hands, face, and skin and has learned what “normal” and “abnormal” look and feel like. Bleakley and colleagues18,19 refer to an aesthetic domain with reference to pathologists looking at specimen slides, radiologists looking at x-rays, and dermatologists looking at skin rashes, where visual images are the source material and learners are expected to “make sense” of what they are seeing. Sociologists have examined “meaning making” from visual images,20 but little reference has been made to “meaning making” from contemporaneous technical images such as the operative field or from haptic information.
There are a number of publications in the surgical literature that point toward haptic cues being important to surgical learners. Dunnington et al21 found that “allowing the learners to feel the pathology” was considered a marker of a good teacher. Forrest et al22 found that, amongst veterinarians, haptic perception may be a learned skill. A large number of articles in the surgical literature have examined haptic feedback in the context of virtual reality simulation23–25 and have concluded that it is important to make this sensory modality “realistic” in simulation for the surgical learner.
During operations, surgeons use their hands or surgical tools to gain information, through direct touch or by interpreting fine sensations transmitted through the surgical instruments to determine normal from pathological.26 What has not previously been made explicit is that development of haptic perception may be an important area of surgical learning. Surgeons may need to attribute specific meanings from input sensations—for example, whether the palpated structure is malignant, inflamed, or normal. This may be termed “haptic semiotics.” There is little discussion in the surgical literature around how to teach haptic cue interpretation or the impact of teaching strategies specifically addressing learning haptic perception.
Making sense of multimodal surgical “texts” requires a synthesis of both haptic and visual cues. Keehner and Lowe27 state that
in traditional open surgery, it would be difficult to identify anatomical structures using vision alone … as bleeding at the operative site often hampers visual information. Basic research in perception shows that sensory inputs are weighted according to the quality of information they provide.
The wider scientific literature suggests that when visual cues are ambiguous, they carry less weight, and haptic cues may come to dominate.28,29 This suggests that surgeons may afford some flexibility and judgment in the way they combine information from visual and haptic cues, weighting them accordingly depending on the context and the quality of the cues available to them.
It is known that direct palpation provides the best-quality haptic information, with diminishing usefulness when either conventional surgical instruments or laparoscopic instruments are used.30 In laparoscopic robotic surgery, there is no haptic feedback at all to the operating surgeon. This is important to the general surgical community as laparoscopic approaches now predominate, and during these procedures haptic cues, transmitted through long instruments and friction of the instrument in the port, are reduced, meaning that visual cues become relatively more important for semiosis.27 We would suggest that learning visual cue interpretation may assume even greater importance to the contemporary trainee because of the widespread use of laparoscopic technologies.
The participants of this study clearly articulated that a difficult case was one in which the sensory cues were more difficult to interpret. These findings strongly resonate with ideas of “slowing down when you should” and provide insights into what may prompt a surgeon to transition from automatic to effortful modes.31 Operative errors in both laparoscopic and open surgery are predominantly due to misperception rather than poor motor skills or clumsy handiwork,32 and so promoting the learning of sensory semiosis is crucial for safe surgical practice.
Having a rich bank of visual exemplars in one’s memory from experience may be an important part of making sense of visual cues.18,19 This resonates with the surgical discourse with regard to duty hours restrictions as trainees see fewer cases and may be unable to build a rich library of visual exemplars with which to make comparison.
Simulation-based learning has been endorsed as a solution to some of the difficulties of duty hours restrictions; however, identification of the plane for dissection—made by interpreting subtle differences in color or texture of the tissues, and how they dynamically respond to tension—can seldom be adequately simulated. Preferences have been expressed for cadaveric simulation over virtual reality, and this may be due to improved authenticity of visual and haptic cues.33 We postulate that one potential avenue for surgical education is the design of educational interventions that specifically address visual and haptic cue interpretation. The use of challenging video clips of laparoscopic operations from the real operating room could be used to encourage trainees to report what they are “seeing.” We propose that learning outside of the work environment should also include visual training to “educate the eye to see” and a series of haptic cue interpretation training exercises to “educate the hand to feel.”
Postgraduate learning in surgery is complex, spanning social, cognitive, and motor domains. We identified six learning domains described by the participants in this study: factual knowledge; motor skills; sensory semiosis (encompassing visual cue interpretation and haptic cue interpretation); adaptive strategies; team-working and managerial skills; and attitudes and behaviors. Although some of these domains are routinely considered when planning learning episodes or providing formative feedback, this study makes explicit other domains of surgical learning that may have been overlooked in the literature and yet are thought by surgeons to be major themes of learning in the operating room.
The strengths of this study should be viewed within its limitations. The study relies on perceptions and self-reports, which limit the generalizability and objectivity of the data obtained: This method of gathering data will miss implicit learning and the hidden curriculum. Further research should gather direct evidence of clinical teaching practice through observation in the operating room. One of the advantages of an interview study, however, is that responses can identify principles or themes of particular importance, and these perspectives—grounded, of course, in each participant’s personal experience but modulated through reflection and abstraction—can inform general issues (e.g., what are the important aspects to be learned in the operating room?) rather than specific ones (e.g., what did I or my trainee learn from this particular case at this time?). Our sample size was small, and it may not have been representative of the wider population of potential participants. Saturation, however, was reached toward the end of data collection, suggesting that themes of learning had been comprehensively mapped by the sampling strategy.
The findings of this study might be used for several educational purposes. First, this study starts to articulate the affordances of the operating room as a learning environment, and we hope that surgical trainers can use this information to develop teaching strategies to enhance the learning of sensory semiosis. Second, we have suggested that these findings prompt the development of specific training interventions for use outside the workplace—for example, to “educate the eye to see” and to “educate the hand to feel.” Third, categorization of content areas of learning in the operating room may be used to structure and give detailed feedback on trainee performance; for example, it may be helpful to comment on a trainee’s ability to discern particular structures as well as the trainee’s physical ability to control and accurately use the instruments (both of which may previously have been amalgamated under the category “technical skills”).
Further research into the processes of how clinicians learn to make sense of “signs” has relevance in many clinical disciplines and is a fertile area for future research. This is particularly important in an era of duty hours restrictions in which trainees may not be exposed to as many cases and, therefore, may not acquire the rich memory bank of exemplars required to interpret sensory cues. We recommend that further work should investigate whether specific pedagogic strategies can promote the learning of sensory semiosis.
Acknowledgments: The authors wish to thank the surgeons who gave their time to be interviewed during this study.
1. Baldwin PJ, Paisley AM, Brown SP. Consultant surgeons’ opinion of the skills required of basic surgical trainees. Br J Surg. 1999;86:1078–1082
2. Carthey J, de Leval M, Wright D, Farewell V, Reason J. Behavioural markers of surgical excellence. Saf Sci. 2003;41:405–425
3. Bermas H, Fenoglio M, Haun W, Moore JT. Laparoscopic suturing and knot tying: A comparison of standard techniques to a mechanical assist device. JSLS. 2004;8:187–189
4. Oostema JA, Abdel MP, Gould JC. Time-efficient laparoscopic skills assessment using an augmented-reality simulator. Surg Endosc. 2008;22:2621–2624
5. Datta V, Mackay S, Mandalia M, Darzi A. The use of electromagnetic motion tracking analysis to objectively measure open surgical skill in the laboratory-based model. J Am Coll Surg. 2001;193:479–485
6. Woodrum DT, Andreatta PB, Yellamanchilli RK, Feryus L, Gauger PG, Minter RM. Construct validity of the LapSim laparoscopic surgical simulator. Am J Surg. 2006;191:28–32
7. Dubrowski A, Sidhu R, Park J, Carnahan H. Quantification of motion characteristics and forces applied to tissues during suturing. Am J Surg. 2005;190:131–136
8. Rosen J, MacFarlane M, Richards C, Hannaford B, Sinanan M. Surgeon-tool force/torque signatures—evaluation of surgical skills in minimally invasive surgery. Stud Health Technol Inform. 1999;62:290–296
9. Kocak E, Ober J, Berme N, Melvin WS. Eye motion parameters correlate with level of experience in video-assisted surgery: Objective testing of three tasks. J Laparoendosc Adv Surg Tech A. 2005;15:575–580
10. Richstone L, Schwartz MJ, Seideman C, Cadeddu J, Marshall S, Kavoussi LR. Eye metrics as an objective assessment of surgical skill. Ann Surg. 2010;252:177–182
11. Francis NK, Hanna GB, Cuschieri A. The performance of master surgeons on the advanced Dundee endoscopic psychomotor tester: Contrast validity study. Arch Surg. 2002;137:841–844
12. Glaser B, Strauss A A Discovery of Grounded Theory: Strategies for Qualitative Research. 1967 Piscataway, NJ AldineTransaction
13. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): A 32 item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19:349–357
14. Bryant A, Charmaz K The SAGE Handbook of Grounded Theory. 2007 London, UK MPG Books Group
15. Kress G Multimodality. A Social Semiotic Approach to Contemporary Communication. 2010 London, UK Routledge
16. Law B, Atkins MS, Kirkpatrick AE, Lomax AJ. Eye gaze patterns differentiate novice and experts in a virtual laparoscopic surgery training environment. Proceedings of the 2004 Symposium on Eye Tracking Research & Applications. 2004 San Antonio, Tex ACM:41–48
17. Goldacre MJ, Laxton L, Harrison E, Richards J, Lambert TW, Parks R. Early career choices and successful career progression in surgery in the UK: Prospective cohort studies. BMC Surg. 2010;10:32 http://www.biomedcentral.com/1471-2482/10/32
. Accessed March 19, 2015
18. Bleakley A, Farrow R, Gould D, Marshall R. Learning how to see: Doctors making judgements in the visual domain. J Workplace Learn. 2003;15:301–306
19. Bleakley A, Farrow R, Gould D, Marshall R. Making sense of clinical reasoning: Judgement and the evidence of the senses. Med Educ. 2003;37:544–552
20. Kress G, van Leeuwen T Reading Images—The Grammar of Visual Design. 2006 New York, NY Routledge
21. Dunnington G, Darosa D, Kolm P. Development of a model for evaluating teaching in the operating room. Curr Surg. 1993;50:523–527
22. Forrest N, Baillie S, Kalita P, Tan H. A comparative study of haptic stiffness identification by vetinarians and students. IEEE Trans Haptics. 2011;4:78–87
23. Playter R, Raibert M. A virtual reality surgery simulator using advanced haptic feedback. Minim Invasive Ther Allied Technol. 1997;6:117–121
24. Panait L, Akkary E, Bell RL, Roberts KE, Dudrick SJ, Duffy AJ. The role of haptic feedback in laparoscopic simulation training. J Surg Res. 2009;156:312–316
25. Strom P, Hedman L, Sarna L, Kjellin A, Wredmark T, Fellander-Tsai L. Early exposure to haptic feedback enhances performance in surgical simulator training: A prospective randomised cross over study in surgical residents. Surg Endosc. 2006;2006:1383–1388
26. Lederman SJ, Klatzky RL. Haptic perception: A tutorial. Atten Percept Psychophys. 2009;71:1439–1459
28. Ernst MO, Banks MS. Humans integrate visual and haptic information in a statistically optimal fashion. Nature. 2002;415:429–433
29. Atkins JE, Fiser J, Jacobs RA. Experience-dependent visual cue integration based on consistencies between visual and haptic percepts. Vision Res. 2001;41:449–461
30. Bholat O, Haluk R, Kutz R, Gorman PJ, Krummel TM. Defining the role of haptic feedback in minimally invasive surgery. Stud Health Technol Inform. 1999;62:62–66
31. Moulton CA, Regehr G, Lingard L, Merritt C, Macrae H. “Slowing down when you should”: Initiators and influences of the transition from the routine to the effortful. J Gastrointest Surg. 2010;14:1019–1026
32. Way L, Stewart L, Gantert W, et al. Causes and prevention of laparoscopic bile duct injuries—analysis of 252 cases from a human factors and cognitive psychology perspective. Ann Surg. 2003;237:460–469
33. Sharma M, Horgan A. Comparison of fresh-frozen cadaver and high-fidelity virtual reality simulator as methods of laparoscopic training. World J Surg. 2012;36:1732–1737
Appendix 1 Annotated Interview Topic Guide for a Qualitative Study of Postgraduate Learning in the Operating Room, 2010–2011
This was a semistructured interview that involved sequential questions that were based on participants’ prior responses.
The interview started with an introductory question: I am interested in teaching and learning in the operating theater; are you involved in these activities, and how?
The response to this question quickly established whether the interviewee regarded himself or herself as a teacher or a learner, or in the case of senior trainees, both teacher and learner. Subsequent questions then used language tailored to this role.
If the participant had framed himself or herself as a teacher, the transition question was, What do you teach in the operating theater? This frequently elicited a response about the operative procedures within that surgeon’s practice and the level of learners that he or she is involved in teaching.
If the participant had framed himself or herself as a learner, the transition question would be, What stage are you at, and what are you learning in the operating theater?
If the participant was, for example, a teacher who had specified that he teaches laparoscopic colorectal cases to senior trainees, the key question was, Within one particular case, for example a laparoscopic colectomy, what are you trying to teach the registrar?
This specification of a particular case and level of the learner guided the participant to respond in more detail, rather than to give more general points.
Once the key question had been posed, follow-up probes were used to gain more in-depth information. An example of a follow-up probe was, You mentioned tissue handling; can you tell me more about that?
It was important that these follow-up probes were as open and unbiased as possible. The interviewer endeavored to mirror the exact language used by the respondent when asking for further description or clarification of what was meant.
At the end of the interview, the participant was given the opportunity to comment on anything further that he or she felt was relevant pertaining to teaching and learning in the operating room.