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Procedures and the Operating Room

The operating room is a profoundly rich learning environment for students when faculty and staff take simple steps to help students navigate through their initial sense of intimidation and disorientation, while setting some basic expectations for learning and preparation.
To participate in clinical teaching of FIU HWCOM  students, you must have a clinical faculty appointment and undergo an initial orientation with the clerkship or course director, or their designee.  The following information is designed to supplement and reinforce what you gain from orientation.

  • Orienting the Learner to the Site and Preceptor

    Orienting students and setting expectations are the foundations of a good clinical learning experience. Skilled clinical teaching will be lost on a student who is preoccupied with trying to figure out what they should do, what they are supposed to learn and know, what and how much they are supposed to do with a patient, or even how they will find the bathroom.

    In some sites, ancillary providers or staff may quickly provide this on the student’s first day. If you would like to write any specific and consistent expectations of your site for students to review prior to the first day, the clerkship director or clinical faculty director can provide this before the rotation begins. Some clinical sites may provide an "Orientation PowerPoint" the students can watch prior to arrival at the site. If you would like to do this with narration, FIU has very easy-to-use PowerPoint narration software provide by the IT support staff.

    The One Minute Learner is a tool adapted from Boston University that you can use when you first meet the student to orient them to your teaching and site:

    ONE MINUTE LEARNER, adapted from Boston University

    1. GOALS: Learner’s level of experience; Learner’s and Your Goals
    2. GETTING GOING:  When, how and who should the learner see? 
    3. HOW MUCH and HOW LONG  Focused or Full History and Physical?
    4. PRESENTING:  Where and how?
    5. CHARTING:  When and how?
    6. QUESTIONS: When is a good time to ask questions that come up?
    7. USE OF TECHNOLOGY*  When can learners use phones/ipads to look up the answers to clinical questions? At the moment of care or later?
    8. UNSTABLE PATIENTS*  How would you describe an unstable patient? When should the learner immediately get you to assess a patient?
    9. LOGISTICS* who’s on the team/reporting/residents, the logistics of rounds, lunch, bathroom, entry codes, daily schedule/activities/roles for student (even if faculty not on floor)

    *added by S.Minor at FIU

    For further information about the One Minute Learner, visit one of these resources:
    You can also ask your staff to orient the students to:
    • How to contact the hospital team in case of personal emergency
    • How the student may contribute to patient care
    • Where to put personal belongings and any possible independent workspace
    • Patient education materials
    • EMR Access
    • Retrieving test results
    • Pre- and post-op work they can complete
    • Writing post-op orders
    • Ordering tests and consultations
    • Dining options and locations
  • Teaching Procedures and Teaching in the OR

    The operating room is a profoundly rich learning environment for students when faculty and staff take simple steps to help students navigate through their initial sense of intimidation and disorientation, while setting some basic expectations for learning and preparation.

    Preparing for the Case

    While a surgical resident can be directed to "read about the case" or "review the procedure" the night before, a medical student will benefit from more specific direction, such as "read about the muscles and vasculature of the anterior abdominal wall" or "review the course of the ureter in the pelvis." When possible, they should read or review a video prior to the case, which at least begins at their level. FIU students are given links to several websites with surgical videos. Let them know of any you strongly recommend for early learners - ones that break cases into the major steps with reference to the most relevant aspects of anatomy for that case.

    Students should of course know the patient when possible, and if not, know the key details of the case. Especially since the emphasis for third-year learning is diagnosis, it is important for them to understand how the patient’s surgical disease presented, the differential diagnosis for that presentation and the work-up for that presentation.

    Regarding informed consent, you can help the student understand:
    • What is it that the patient needs to make the right decision?
    • How do you know if someone really understands the risks and indications?
    • Here is what I do to understand the situation from the patient’s point of view . . .
    • Here is how I deal with my biases . . .
    • Here is what I do to mediate when the family disagrees over care . . .

     

    In the Operating Room

    Especially the first few times in the operating room, and the first time with a new attending, students need communication and cues. Let them know:
    • If they will scrub or just observe
    • Where they should stand
    • What they will/might do (i.e., place a foley, close skin, put on a tenaculum)
    • When they might get to see the operative field on open cases

    Use anatomical terms to describe location.

    It is also important to remember that when instructing students in instrument, retractor, and suture placement and movement, terms like "up" and "down", or "here" or "there", can be very confusing. They are usually better replaced with anatomical terms (e.g., anterior abdominal wall, caudad, the patient’s right side).

    Use ancillary staff

    Students can learn from others in the OR as well. Spending a portion of the case with a scrub nurse who names the instruments as they are passed, while offering a basic description of how that instrument will be used, may be a better learning experience than simply retracting in a field that they cannot see.

    Remember the power of narration.

    Explaining both what you are doing and why you are doing it, will turn for many students a bewildering and passive experience into a goldmine of learning by observation.

    Let the students know.

    Students need to hear both what they are doing well ("You cut the structure the correct length") and what they need to correct ("You need to close the instrument completely").

    Resources

    This diagram on teaching medical procedures is from an article from the New England Journal of Medicine geared towards residents who teach and applicable to any medical educator. Click here to read the whole article.

    This article from the American College of Surgeons describes "Employ a Structured Approach to Teaching Psychomotor Skills to Enhance Learner Performance"

    This 2 ½ page article is from the Association of Professors of Gynecology and Obstetrics and describes "Effective Operating Room Teaching"

    The University of Western Australia crafted the Teaching on the Run Tips Series.  Each Tip is less than two pages.
    • Tips
    • Teaching a Skill
    • The Doctor as Teacher
    • Teaching With Patients
    • Effective Use of Questions

  • Ways Students Can Contribute to Patient Care While Learning
    Students can contribute to patient care!  Consider these opportunities for students to practice their skills while enhancing patient care:
    • Complete initial intake of patients; this helps patients feel they are waiting less.
    • Complete pre-op history and physical examinations.  Then, present these history and physical examinations along with the pre-op labs. 
    • Review the EMR on the patient and present to the attending.
    • Track down or follow up on missing lab results/studies.
    • Write patient notes.  This may include daily care notes for the chart which you co-sign or discharge summaries which you use for dictating. 
    • Present information from evidence-based resources such as Uptodate or a review article from Pubmed.
    • Call consults or act as connection with other health providers.
    • Call the patient with their lab results, further patient education (such as titrating insulin up), and for follow up on behavior changes (such as smoking cessation).
    • Document patient calls. 
    • Provide patient education about diet, exercise, family planning and advance directives. 
    • Perform injections, blood draws, EKG’s and urine dipsticks.
  • Giving Feedback
    Giving feedback is an integral skill for medical educators. Characteristics of quality feedback include:
    • Frequent
    • Timely – don’t wait too long!
    • Named – "I’m giving you feedback…."
    • Limited – in bite size chunks, just as we provide patient education
    • Requires a credible source and a culture of respect and support - It’s all about the relationship! Learners need to know you are looking out for their learning and well-being.
    • Based on direct observation
    • Uses questions, thus promoting self-reflection. Some great questions include:
      • "What did you do well?"
      • "What can you improve?" 
      • "What’s your SMART plan for improvement?" SMART=Specific, Measurable, Achievable, Relevant, Time-limited
    • Focuses on the process not the person – giving feedback about the process of learning or development of a skill creates a growth mindset whereas feedback about the person creates a fixed mindset in which growth does not occur.  This is an example of feedback on the process: "You took in the feedback I gave you about avoiding medical jargon and used layperson's language when explaining the patient’s diagnosis. Well done!"  This is an example of feedback on the person, which is not helpful to the student: "You are such a smart student."

    "Giving Feedback": The University of Western Australia crafted the Teaching on the Run Tips Series. Each Tip is less than two pages

    Free CME: Go to the FIU COM Online Teaching Modules on Giving Feedback for free CME!

  • FIU COM Online Teaching Modules for Free CME!
    Go to the FIU COM Online Teaching Modules on Giving Feedback, Narrative Comments, Orientation to Clerkship Teaching, the EPA's (Entrustable Professional Activities) and the Patient Role in Teaching: