Slides from Prof Dan Pratt presented at the Teaching to Teach Workshop in Boston, MA, May 1-2, 2009; Massachusetts General Hospital, Harvard Medical School.

1. Teaching in the OR
Department of Orthopaedic Surgery
Massachusetts General Hospital
Harvard University
Daniel D. Pratt, PhD
Professor
University of British Columbia

2. A General Model of Teaching
LEARNERS CONTENT
X
VALUES
Y Z
TEACHER
•CONTEXT

3. Typical Orientation
CONTENT
LEARNERS
X
VALUES
Y
Z
TEACHER
CONTEXT

4. Cognitive Apprenticeship
LEARNERS CONTENT
X
VALUES
Y
TEACHER
CONTEXT

5. Critical Educational Strategy
Zone of Proximal Development (ZPD):
 There are things learners can do
by themselves;
--------------------------------
In between, there are a number of things
learners can do with guided discovery
and direct practice.
This is the ZPD … this is where you
-------------------------------
teach
--
 There are things learners cannot
do, even with your assistance;

6. Assessing the Zone
• Have you had the opportunity to do
______? It’s our responsibility, not
Implication:
theirs
• How comfortable do you feel doing
_______?
• Describe the anatomical landmarks
you need to be aware of when
________.
• Describe for me how you would go about
doing a _______.

7. What do they do in the OR?
Learner does this:Teacher does this:
SCAFFOLDING
Observes (with direction) Models (normal practices w/explanation)
Participates (on margins) Models (w/explanation)
Common, uncomplicated cases Point out diagnostically meaningful
information, discriminating
features
Allow for interruptions and questions
Have them give you a ‘cognitive rehears
Practices (w/in zone) Coaches (w/ guidance – hand on shoulder)
More responsibility Debriefing: What went well?
‘Make a commitment’ What would you do differently next time?
Refines & Extends Fades
Learning variations instead of rules Withdraw, but at the ready
This is approximate. It depends on the learner’s ZPD and the case.
e.g., removal of hardware vs. total hip or complex pelvis fracture.

8. Contextual Influences in OR
Time Sensitivity:
• Cold vs. hot action - urgency of situations & press of
time
• Distribution of time - patient care vs. direct teaching
Multiple Levels and Roles of Team Members:
• Number of people and their roles on the team
• Roles that conflict with provision of direct teaching
Patient Census:
• Patient’s condition - learning opportunities
• Acuity of patient’s condition - opportunity to participate
• Total number of patients - examples and non-examples
• Pace of patient movement through OR - time on task

9. Potential ‘Problems’
Putting expertize into words:
• Automatic performance (tacit knowledge)
• Intuitive judgment (hunch vs. judgment)
• Teaching uncommon cases too early in training
Remembering that:
• The ‘rules of engagement’ change dramatically
when students enter clinical sites

10. Rules of engagement: classrooms
Been in school for many years
•
Understand how things work there
•
Things are ordered and predictable
•
Time and sequence is relatively stable
•
With peers at approximately same level
•
They know the rules of the environment
•
Pretty clear idea what is expected of them
•
Have long history of success
•
Know what to do when things aren’t going right
•
Know how to negotiate with authority
•
No serious consequences for ‘getting it wrong’
•
Rules of engagement are clear to

11. Rules of engagement: clinical rotation
What are the ‘rules of engagement’ as seen by
those who come into your service as novices.
For example, describe how a junior resident might
perceive the ‘rules of engagement’ on a clinical
rotation in the OR?

12. Rules of engagement: clinical rotation
Don’t understand the environment
•
Things can seem very chaotic
•
Disoriented -- don’t know the ‘players’
•
Multiple team members (nurses, techs, etc.)
•
With a team of people of many ‘ranks’
•
Language isn’t entirely familiar
•
Don’t know who to ask or what can be asked, e.g., at critical
•
high risk moments of an operation
They are not the centre of attention
•
Often seen as an impediment to getting the case done
•
Unable to sense when mood in room changes
•
When things go wrong, don’t know what to do
•
Not sure what has been done, or why
•
Perceived at risk for ‘getting it wrong’
•
Engagement can be risky!
•

13. Potential ‘Problems’
Putting expertize into words:
• Automatic performance (tacit knowledge)
• Intuitive judgment (hunch vs. judgment)
• Teaching exceptions too early in training

14. Remember …
• Adapt your teaching to the learner’s ZPD
• Learner engagement is key to learning
• If someone’s watching, you’re teaching
• To slow down when you should
• Whatcan be learned outside the OR,
should be learned outside the OR.

15. For teaching
clinical judgment …
Bowen, J. Educational Strategies to Promote
Clinical Diagnostic Reasoning
(NEJM, Nov. 2006)

16. For teaching
in the OR …
Roberts, NK et al. The Briefing, intraoperative Teaching,
Debriefing Model for Teaching in the Operating Room, Journal
of American College of Surgeons, 2009.

17. For teaching
Clinical judgment in the OR
Moulton, et al
Slowing Down When You Should:
A New Model of Expert Judgment
Academic Medicine (2007)