Perceptions and Guiding Strategies to Regulate Entrusted Autonomy of Residents in the Operating Room: A Systematic Literature Review.

OBJECTIVE: To provide a systematic literature review of intraoperative entrusted autonomy for surgical residents. Specifically, perceptions from residents and supervising surgeons, supervising behavior and influencing factors on intraoperative teaching and learning are analyzed. BACKGROUND: Increasing demands on surgical training and the need for effective development of technical skills, amplify the importance of making the most of intraoperative teaching and learning opportunities in the operating room. It is critical for residents to gain the greatest benefit from every surgical case and to achieve operative competence. METHODS: A systematic literature search identified 921 articles from 2000 to 2022 that addressed surgical education/training, intraoperative supervision/teaching, autonomy and entrustment. 40 studies with heterogeneous designs and methodologies were included. RESULTS: Four themes were established in the analysis: patient safety, learner, learning environment and supervising surgeon. The patient is identified as the primary responsibility during intraoperative teaching and learning. Supervisors continuously guard patient safety as well as the resident's learning process. Ideal intraoperative learning occurs when the resident has optimal entrusted autonomy during the procedure matching with the current surgical skills level. A safe learning environment with dedicated time for learning are prerequisites for both supervising surgeons and residents. Supervising surgeons' own preferences and confidence levels also play an important role. CONCLUSIONS: This systematic literature review identifies patient safety as the overriding principle for supervising surgeons when regulating residents' entrusted autonomy. When the supervisor's responsibility toward the patient has been met, there is room for intraoperative teaching and learning. In this process the learner, the learning environment and the supervising surgeon's own preferences all intertwine, creating a triangular responsibility. This review outlines the challenge of establishing an equilibrium in this triangle and the broad arsenal of strategies supervising surgeons use to keep it in balance.

Recognition of the pattern of complex fractures of the elbow using 3D-printed models.

AIMS: This study aimed to answer the following questions: do 3D-printed models lead to a more accurate recognition of the pattern of complex fractures of the elbow?; do 3D-printed models lead to a more reliable recognition of the pattern of these injuries?; and do junior surgeons benefit more from 3D-printed models than senior surgeons? METHODS: A total of 15 orthopaedic trauma surgeons (seven juniors, eight seniors) evaluated 20 complex elbow fractures for their overall pattern (i.e. varus posterior medial rotational injury, terrible triad injury, radial head fracture with posterolateral dislocation, anterior (trans-)olecranon fracture-dislocation, posterior (trans-)olecranon fracture-dislocation) and their specific characteristics. First, fractures were assessed based on radiographs and 2D and 3D CT scans; and in a subsequent round, one month later, with additional 3D-printed models. Diagnostic accuracy (acc) and inter-surgeon reliability (κ) were determined for each assessment. RESULTS: Accuracy significantly improved with 3D-printed models for the whole group on pattern recognition (acc2D/3D = 0.62 vs acc3Dprint= 0.69; Δacc = 0.07 (95% confidence interval (CI) 0.00 to 0.14); p = 0.025). A significant improvement was also seen in reliability for pattern recognition with the additional 3D-printed models (κ2D/3D = 0.41 (moderate) vs κ3Dprint = 0.59 (moderate); Δκ = 0.18 (95% CI 0.14 to 0.22); p ≤ 0.001). Accuracy was comparable between junior and senior surgeons with the 3D-printed model (accjunior = 0.70 vs accsenior = 0.68; Δacc = -0.02 (95% CI -0.17 to 0.13); p = 0.904). Reliability was also comparable between junior and senior surgeons without the 3D-printed model (κjunior = 0.39 (fair) vs κsenior = 0.43 (moderate); Δκ = 0.03 (95% CI -0.03 to 0.10); p = 0.318). However, junior surgeons showed greater improvement regarding reliability than seniors with 3D-printed models (κjunior = 0.65 (substantial) vs κsenior = 0.54 (moderate); Δκ = 0.11 (95% CI 0.04 to 0.18); p = 0.002). CONCLUSION: The use of 3D-printed models significantly improved the accuracy and reliability of recognizing the pattern of complex fractures of the elbow. However, the current long printing time and non-reusable materials could limit the usefulness of 3D-printed models in clinical practice. They could be suitable as a reusable tool for teaching residents.Cite this article: Bone Joint J 2023;105-B(1):56-63.

The Supervisor's Toolkit: Strategies of Supervisors to Entrust and Regulate Autonomy of Residents in the Operating Room.

OBJECTIVE: To identify what strategies supervisors use to entrust autonomy during surgical procedures and to clarify the consequences of each strategy for a resident's level of autonomy. BACKGROUND: Entrusting autonomy is at the core of teaching and learning surgical procedures. The better the level of autonomy matches the learning needs of residents, the steeper their learning curves. However, entrusting too much autonomy endangers patient outcome, while entrusting too little autonomy results in expertise gaps at the end of training. Understanding how supervisors regulate autonomy during surgical procedures is essential to improve intraoperative learning without compromising patient outcome. METHODS: In an observational study, all the verbal and nonverbal interactions of 6 different supervisors and residents were captured by cameras. Using the iterative inductive process of conversational analysis, each supervisor initiative to guide the resident was identified, categorized, and analyzed to determine how supervisors affect autonomy of residents. RESULTS: In the end, all the 475 behaviors of supervisors to regulate autonomy in this study could be classified into 4 categories and nine strategies: I) Evaluate the progress of the procedure: inspection (1), request for information (2), and expressing their expert opinion (3); II) Influence decision-making: explore (4), suggest (5), or declare the next decision (6); III) Influence the manual ongoing action: adjust (7), or stop the resident's manual activity (8); IV) take over (9). CONCLUSIONS: This study provides new insights into how supervisors regulate autonomy in the operating room. This insight is useful toward analyzing whether supervisors meet learning needs of residents as effectively as possible.

Explicit teaching in the operating room: Adding the why to the what.

CONTEXT: Residents need their supervisors in the operating room to inform them on how to use expertise in present and future occasions. A few studies hint at such explicit teaching behaviour, however without explaining its underlying mechanisms. Understanding and improving explicit teaching becomes more salient nowadays, as access of residents to relevant procedures is decreasing, while end-terms of training programs remain unchanged: high quality patient care. OBJECTIVES: A structured analysis of (1) the practices supervisors use for explicit teaching and (2) how supervisors introduce explicit teaching in real time during surgical procedures. METHODS: An observational qualitative collection study in which all actions of nine supervisor-resident dyads during a total hip replacement procedure were videotaped. Interactions in which supervisors explicitly or implicitly inform residents how to use their expertise now and in future occasions were included for further analysis, using the iterative inductive process of conversation analysis. RESULTS: 1. Supervisors used a basic template of if/then rules for explicit teaching, which they regularly customised by adding metaphors, motivations, and information about preference, prevalence and consequence. 2. If/then rules are introduced by supervisors to solve a (potential) problem in outcome for the present patient in reaction to local circumstances, for example, what residents said, did or were about to do. CONCLUSIONS: If/then rules add the why to the what. Supervisors upgrade residents' insights in surgical procedures (professional vision) and teach the degree of individual freedom and variation of their expert standards for future occasions. These insights can be beneficial in improving supervisors' teaching skills.

[New perspectives on apprenticeship learning]. / Hoe leer je opereren?

Apprenticeships models are the cornerstone of learning in the medical profession for centuries now. Although we know that apprenticeships are effective in medical workplaces, its precise mechanisms remain tacit and implicit. However, decreasing exposure to relevant learning experiences forces us to develop an understanding of teaching and learning in apprenticeships. Central to the learning in apprenticeships are entrustment of autonomy and supply of expertise by the supervisors. Supervisors perform risk-assessments to estimate how much autonomy can be entrusted to their residents continuously. Such assessments are particular challenging to supervisors when the margins for error are narrow, for instance during complex tasks of surgical procedures. In this perspective we present our insights regarding the teaching and learning during surgical procedures. We demonstrate how supervisors and residents can apply insights in teaching and learning to optimize the learning process during complex tasks.

Residents Think in the "Now" and Supervisors Think Ahead in the Operating Room. A Survey Study About Task Perception of Residents and Supervising Surgeons.

OBJECTIVE: Progressive autonomous task performance is the cornerstone of teaching residents in the operating room, where they are entrusted with autonomy when they meet their supervisors' preferences. To optimize the teaching, supervisors need to be aware of how residents experience parts of the procedure. This study provides insight into how supervisors and residents perceive different tasks of a single surgical procedure. DESIGN: In this qualitative survey study a cognitive task analysis (CTA) of supervisors and residents for the 47 tasks of an uncemented total hip arthroplasty was executed. Both groups rated the level of attention they would assign to each task and were asked to explain attention scores of 4 or 5. SETTING: University Medical Centre Groningen (the Netherlands) and its 5 affiliated teaching hospitals. PARTICIPANTS: Seventeen supervising surgeons and 21 residents. RESULTS: Normal attention (median attention score 3) was assigned by supervisors to 34 tasks (72.3%) and by residents to 35 tasks (74.5 %). Supervisors rated 12 tasks (25.6%) and residents 9 tasks (19.1%) with a median attention score of 4. In general, supervisors associated high attention with patient outcome and prevention of complications, while residents associated high attention with "effort." CONCLUSIONS: Supervisors and residents assigned attention to tasks for different reasons. Supervisors think ahead and emphasize patient outcome and prevention of complications when they indicate high attention, while residents think in the "now" and raise attention to execute the tasks themselves. The results of this study allow residents and supervisors to anticipate preferences: residents are able to appreciate why supervisors increase attention to specific tasks, and supervisors obtain information on which tasks require individual guidance of residents. This information can contribute to improve the learning climate in the operating room and task-specific procedural training.

Fingerprints of Teaching Interactions: Capturing and Quantifying How Supervisor Regulate Autonomy of Residents in the Operating Room.

OBJECTIVE: Supervisors and residents agree that entrusted autonomy is central to learning in the Operating Room (OR), but supervisors and residents hold different opinions about entrustment: residents regularly experience that they receive insufficient autonomy while supervisors feel their guiding is not appreciated as teaching. These opinions are commonly grounded on general experiences and perceptions, instead of real-time supervisors' regulatory behaviors as procedures unfold. To close that gap, we captured and analyzed when and to what level supervisors award or restrain autonomy during procedures. Furthermore, we constructed fingerprints, an instrument to visualize entrustment of autonomy by supervisors in the OR that allows us to reflect on regulation of autonomy and discuss teaching interactions. DESIGN: All interactions between supervisors and residents were captured by video and transcribed. Subsequently a multistage analysis was performed: (1) the procedure was broken down into 10 steps, (2) for each step, type and frequency of strategies by supervisors to regulate autonomy were scored, (3) the scores for each step were plotted into fingerprints, and (4) fingerprints were analyzed and compared. SETTING: University Medical Centre Groningen (the Netherlands). PARTICIPANTS: Six different supervisor-resident dyads. RESULTS: No fingerprint was alike: timing, frequency, and type of strategy that supervisors used to regulate autonomy varied within and between procedures. Comparing fingerprints revealed that supervisors B and D displayed more overall control over their program-year 5 residents than supervisors C and E over their program-year 4 residents. Furthermore, each supervisor restrained autonomy during steps 4 to 6 but with different intensities. CONCLUSIONS: Fingerprints show a high definition view on the unique dynamics of real-time autonomy regulation in the OR. One fingerprint functions as a snapshot and serves a purpose in one-off teaching and learning. Multiple snapshots of one resident quantify autonomy development over time, while multiple snapshots of supervisors may capture best teaching practices to feed train-the-trainer programs.

Recruiting expertise: how surgical trainees engage supervisors for learning in the operating room.

CONTEXT: For centuries now, the operating room (OR) has been the environment in which surgical trainees come to master procedures. Restricted working hours and insufficient levels of autonomy at the end of their training necessitate a shift towards alternative effective learning strategies. Self-regulated learning is a promising strategy by which surgical trainees can learn more with fewer exposures. However, the challenge is to understand how surgical trainees regulate their learning in the clinical context of the OR. OBJECTIVES: The purpose of this study is to identify and understand the strategies of surgical trainees in engaging their supervisors for learning purposes and how these strategies contribute to effective learning. METHODS: Total hip replacement procedures performed by four surgical trainees and their supervisors were videotaped. Using the iterative inductive process of conversation analysis, each verbal initiative to engage the supervisor was identified, analysed ('why that now') and categorised. RESULTS: Surgical trainees used a range of practices to engage supervisors and recruit expertise, ranging from explicit recruitment to implicit hints. We identified four major categories. Surgical trainees: (i) invite the supervisor to provide an evaluation of the ongoing task; (ii) express an evaluation of the ongoing task and then explicitly invite the supervisor to provide an evaluation; (iii) express an evaluation of the ongoing task and then invite the supervisor to provide confirmation, and (iv) express an evaluation of the ongoing task without engaging the supervisor. CONCLUSIONS: Surgical trainees recruit expertise from supervisors using practices of four different categories. Trainees' actions are provoked by the moment at which they experience insufficient expertise and are focused on the task at hand in the immediate present. Supervisors can and do elaborate on these requests to provide explicit teaching. Insight into these practices provides tools for reflection on OR learning, proficiency assessment and deliberation to adapt guidance in the real time of the procedure.

[Frail elderly women following traffic accident: a specific approach to the trauma care chain]. / Kwetsbare, hoogbejaarde vrouwen na een ernstig verkeersongeval: specifieke aanpak in de traumaketenzorg.

Three octogenarian women suffered severe blunt trauma because of a car crash. The first patient was 81 years old. She had an instable dens fracture, multiple rib fractures, a haematopneumothorax and multiple extremity fractures. The second patient was 82 years old and was diagnosed with a flail chest because of multiple rib fractures, pelvic fractures, and thoracic spine fractures. Before the crash, she already needed help for her daily functioning. The third patient, 84 years old, developed a bradycardia at the site of the crash. In the hospital she was diagnosed with multiple rib fractures, a sternum fracture and a pneumothorax. After appropriate treatment, the second patient had no prospect of recovery and the care was primarily aimed at comfort, until she died. The other two patients remained in a rehabilitation clinic for months after the accident. The necessary approach to first trauma care, ICU care and rehabilitation differs between young and octogenarian patients. These octogenarian female patients constitute a special group of patients because of their frailty. Due to demographic developments and the changes in trauma care, such patients will be treated more often and further in the care chain. During the ICU stay they will require extensive support because of their frailty. The patient's own efforts will also be tremendous. The balance between quality of life adjusted years won and the toll paid by the patient has to be guarded with great care.

Vertebral fracture assessment in supine position: comparison by using conventional semiquantitative radiography and visual radiography.

PURPOSE: To retrospectively evaluate the accuracy of vertebral fracture assessment (VFA) performed with the patient in the supine position and conventional semiquantitative radiography of the spine by using conventional visual radiography of the spine as the reference standard. MATERIALS AND METHODS: This retrospective study was approved by the institutional ethics review board; informed consent was obtained from the patients. A total of 250 consecutive patients (mean age, 62.0 years; range, 25-89 years) consisting of 190 women (mean age, 64 years; range, 25-89 years) and 60 men (mean age, 57.0 years; range, 27-83 years) who were suspected of having osteoporosis and who underwent VFA in the supine position and radiography of the spine were evaluated. VFA and semiquantitative radiography were analyzed by using a six-marker point method to describe the shape and deformity of each vertebra. Visual radiography of the lateral spine was performed by an experienced radiologist. The agreement between VFA, visual radiography, and semiquantitative radiography of semiquantitative graded fractures was assessed by using weighted kappa statistics. RESULTS: Visual radiography helped identify 92 (36.8%) patients with at least one vertebral fracture (mean, 1.8 per patient). Most fractures were present in T7, T12, and L1. Excellent agreement was found between VFA and visual radiography, with 97.5% concordance and kappa = 0.82; VFA and semiquantitative radiography were in agreement in 97.4% of patients, with kappa = 0.83; and visual radiography and semiquantitative radiography were in agreement in 98.1%, with kappa = 0.87. Sensitivity, specificity, and positive and negative predictive values calculated by lesion level for VFA compared with visual assessment were 83.6%, 99.1%, 84.1%, and 99.1%, respectively. CONCLUSION: VFA performed with patients in the supine position is an accurate method to help detect vertebral fractures when compared with conventional spine radiography. VFA permits combination of fracture assessment with bone mineral density measurement in a single session.