Most young practitioners experience the following: one day they are still on vacation after taking part 1 of the American Board of Orthopaedic Surgery examination and the next day they are an attending and become “the doctor in charge.” The practical and emotional transition of that sudden change can be as traumatic as the fractures on their operative schedule.1 We are taught as residents on how to speak and interact with patients, how to decide whether a surgery is right, and then how to actually perform that surgery as part of an operative team, but we are not given a structured instruction on how to become a teacher. This gap felt by a young practitioner is most accentuated in the setting of an operating room (OR) where the stakes are high and with residents whose learning is most dependent on the specific interaction with an operative attending. Because of this, we focus specifically on the teaching of residents (referred to as “student” in the general sense) as it pertains mainly to operative procedures (although a surgeon does teach in other settings). Although every specialty performs surgeries of varying difficulty, orthopaedic trauma has the greatest daily intersection of unpredictability (elective, scheduled, urgent, emergent) and variability (anatomic site, fixation options/soft tissue considerations, and balancing care of the polytrauma patient). But, instead of accepting fatalistic inadequacy, the orthopaedic traumatologist can use these challenges to become superb operative educators.
To set realistic expectations for this exercise, we will state at the onset that the process of learning to become a better teacher requires preparation through (1) active learning/practice, (2) time and experience, (3) a certain bit of intrinsic charisma/ability. Also, focusing on just the modifiable element (1—active learning/practice), our goal is to provide you with 5 easy-to-digest concepts to help build an educational framework (Table 1) linked to 5 realistic tools for you to become a better teacher (Table 2). To clarify, this is not a comprehensive review of educational philosophy. And to emphasize, even the “best” teachers can help their students learn even better.
FIVE EDUCATIONAL CONCEPTS
You may notice that the concepts here—although they depend on the actions of the teacher—are focused on the learner. So consider how you can modify the way you think and do to improve what is actually learned.
- 1. It is all about the learner2
This may be difficult for many surgeons to internalize. Being a master teacher meant (and sometimes still means) that you are superb in your ability to convey information, much like a master surgeon performs a beautiful operation. But for young and less experienced surgeons, the act of teaching is not a performance for the audience to behold, it is the act of transferring knowledge and skill to the learner. If the student did not learn it, you did not teach it well enough! It is important to convey that the student also has the responsibility to make the surgical experience more meaningful by advance preparation and willingness to learn. You, as a teacher, can help guide them by planning in advance and conveying your expectations.
- 2. Active learning is better
Educational and psychologic studies have shown this to be so true that it is nearly irrefutable.3 But do not just intellectualize it; internalize it and practice it. Make them read before your case (or your lecture) and let it be clear that it is expected and with consequences (accountability drives learning, 4 below). Use the Socratic method, that is, teaching through interactive reasoning, not simple “pimping” for facts. For example, instead of “Bob, what is the acceptable and typical wrong entry sites for a piriformis nail?”; you can start with “What are the forces that act on the proximal femur?” Then pause so that the whole audience—one or 2 learners scrubbed with you or an auditorium full—will think about it and perceive they can get called on (5 below). Then, you can move on to “Bob, what deformity…” and then connect that to the consequences of a lateral starting site, etc.
Much of learning physical/manual skills involves feedback.4 Getting the content of the feedback right may not be so hard but the timing is trickier. Forget Milestones and Next Accreditation System while you are in the OR. Your student will learn more if you give feedback that immediately follows the action, thought, or speech that you want to improve. Summative evaluations happen later, but formative feedback happens now! (see To-Do 3).
- 4. Accountability drives learning5
To be more practical and dogmatic about it, this is not about having formal written goals (although, those can be very helpful). It is about giving the resident a lay of the land, setting expectations (for what they should learn and how they should learn it), and then holding them accountable by assessing their learning in ways that mean something to them (summative evaluation, your verbal/written feedback on their preoperative plan, reference to their work in front of their peers, etc).
- 5. Good stress increases learning
Insurmountable stress or prolonged stress is bad for the immune system, longevity, and for learning. That is right, abject embarrassment in front of peers, although they may seem entertaining to you, do not help the student learn. But the right amount of stress heightens alertness and improves performance.6 So, let the resident struggle a bit and search for the answer before providing constructive relief.
FIVE ACTIONS TO ADOPT
There are many ways to make teaching more effective. But consider these 5 To-Dos, 4 of which build on the educational principles above.
- 1. See blood on the ground
This was great advice from our mentor (David L Helfet, personal communication). Until you have seen it, done it, and learned it yourself, how can you teach it? You need to be respected as a surgeon before you are respected as a teacher. This is not educational philosophy; it just makes sense.
- 2. Have a preoperative plan
If you set the expectation and make residents accountable—it drives learning—and use it as a teaching tool; then making physical preoperative plans stops being painful, or at least worth the pain. There are many formats—some write every single step, others draw pictures—but doing it consistently allows for better learning in 3 ways. It builds accountability, allows for more “doing” time in the OR, and makes learning active. To expound, first, setting the expectation of a great plan means the resident will be driven to meet those expectations, and thereby learn. And by connecting the preparation with actual teaching/doing in the OR, you can further incentivize the learner. Second, it is simple math. By doing the preparatory work before the surgery, the resident has more time to do and you have more time to teach during the case. Third, active is better than passive, but interactive is even better. Consider having a brief discussion about the case (it only takes a few minutes) so that you are at least starting on the same page (eg, resident is thinking Kocher–Langenbeck in lateral position when you already know you are going Stoppa supine). Then, consider the written/drawn plan and give it back to the resident with feedback (Fig. 1). Finally, discuss changes briefly before the case (scrub time could; suffice) and make sure you follow To-Do 3. By the way, a little, controlled, timed stress is good for learning, so challenge them to make the plans really good.
- 3. Fix what you can, immediately
They say timing is everything, in addition to content, of course. We all say that feedback is good but not all feedback is the same. Summative feedback (say, at the end of a rotation) is easy for the learning to take as evaluation, as something they cannot change now. If feels very personal but often does not provide enough concrete material to affect change on its own. However, formative feedback that is given immediately can affect change especially when given with instruction or demonstration. If a resident does not drill the right way, do not ignore it and just take it away; resist the urge to criticize in a vacuum. Give instruction on why it was wrong and explain what makes it right—just a few seconds. Yes, a little, controlled, timed stress is good for learning.
- 4. Good, better, and ugly
When it comes to wrap-up time after case(s), Pendleton et al7 had it right with a structured feedback. This format reinforces good behavior and then seeks to improve rather than going straight into criticism and creating a high stress, low learning situation. The abridged version is the following: (1) learner—what went well, (2) teacher—what went well, (3) learner—what to change, (4) teacher—what to change. Our one modification would be to include (5) what was a complete disaster. In the surgical realm, these rare instances should be acknowledged soon after the case rather than left unspoken. Also, have we already said that a little, controlled, timed stress is good for learning? In this regard, we recommend challenging the resident to fully engage, be honest and thorough about 1, 3, and 5.
As mentioned before, becoming a good teacher, or more accurately, a better teacher requires active learning and practice and not just time alone. Go local. We recommend that you continue to implement our To-Dos but to also obtain timely feedback from your students and fellow teachers. Reach out, a little or a lot. Realize that you are not alone at your institution, let alone our profession. Many universities have teaching curricula (at Penn: http://www.med.upenn.edu/fapd/AdvanceTeachingEffectivenessResourcePage.shtml) that you can take advantage of without leaving your campus. In addition, organizations such as the AO incorporation faculty development and teaching education into their surgeon courses (https://aotrauma.aofoundation.org/Structure/education/faculty-development/Pages/faculty-development.aspx), and the AAOS will hold their 47th Course for Orthopaedic Educators in 2014 (http://www7.aaos.org/education/courses/course_detail.aspx?ProductId=25988). Teach a teacher.8 As an educator, perhaps one satisfaction greater than guiding a student through successful learning is to guide them as a teacher. Can you transfer some of your teaching skills to a senior resident and help them guide a junior? Now, that is a job well done.
Although the task of becoming a great teacher can be challenging for a young practitioner in transition, there are numerous basic and sophisticated resources that can be used. By starting with a few principles and attainable steps, the young orthopaedic traumatologist can transform the OR into an educational theater.
1. Leopold SS. Editorial: transition from training to practice—Is there a better way? Clin Orthop Relat Res. 2014;472:1351–1352.
2. Biggs J. Teaching for Quality Learning at University: What the Student Does. London, United Kingdom: Society for Research into Higher Education; 1999:20–30.
3. Bain K. What the Best College Teachers Do. Cambridge, MA: Harvard Press; 2004.
4. Champagne BJ. Effective teaching and feedback strategies in the OR and beyond. Clin Colon Rectal Surg. 2013;26:244–249.
5. Reznick RK, MacRae H. Teaching surgical skills—changes in the wind. NEJM. 2006;355:2664–2669.
6. Duncko R, Cornwell B, Cui L, et al.. Acute exposure to stress improves performance in trace eyeblink conditioning and spatial learning tasks in healthy men. Learn Mem. 2007;14:329–335.
7. Pendleton D, Scofield T, Tate P, et al.. The Consultation: An Approach to Learning and Teaching. Oxford, United Kingdom: Oxford University Press; 1984.
8. Mann KV, Sutton E, Frank B. Twelve tips for preparing residents as teachers. Med Teach. 2007;29:301–306.