Reducing the stress of teaching surgical residents

When I graduated from my residency, far from my current professional home, I wanted to write a book called How Not to Get Yelled At in the Operating Room. Or How to Clear the Fear from Your OR.

I had these titles in mind because I struggled so much during my intern year. It was a tough year, full of intense patient care and sleep deprivation, but the challenge that I most wanted help with during that time was learning to perform procedures. And by the time I graduated, I had an idea about how to make that process easier.

Surgical training is stressful from the trainee’s side, especially during that first year of residency. We all learned the anatomy during year one of medical school, and we all spent thankless hours retracting during the third year. But when you’re an intern, you’re going to start holding the scalpel. That’s a big step.

I didn’t think about it then, but now that I’m the one who is guiding the residents, I realize that surgical training is stressful from the teaching side as well. No matter how experienced the surgeon, guiding trainees through all the variations of any particular surgery or teaching them how to assist — while maintaining safety and control in the operating room — can be exhausting.

It’s a basic tenet of all pedagogy that people can’t learn in a room full of fear. How can your teacher teach when there’s so much to worry about? How can you learn if your teacher won’t let you try?

Here is my answer to the surgical teaching dilemma, or at least part of it. Like many solutions, it’s pretty obvious, and perhaps not particularly exciting, but I think it works. The answer is (as it often is): communication. Or more precisely, narration.

No attending surgeon will let a trainee operate if the surgeon doesn’t know what the trainee is about to do. So you, the trainee, have to tell the surgeon. Actually, you have to tell him or her, then perform the action, then tell the surgeon about the next action. This means that before you pick up the scalpel you say, “I’m going to pick up the scalpel. I’m going to incise the skin, down through the dermal layer.” Then you do that. Then you say, “Now I’m going to use the Bovie cautery, to stop bleeding from any small vessels.” And then you do that. Repeat until you’re done.

The most important (and of course, most difficult) part of this technique is the delivery: As much as possible, the narration should project imperturbability, confidence and the idea that everything is going just fine. Your speaking voice should be low, smooth and slow. If you sound as if you’re narrating a PBS special on marine life, you’re doing it right. If you sound as calm as a jazz DJ after a relaxing cup of chamomile tea, then you’re doing it right.

From the attending surgeon’s side, this type of narration lets me know that you, the resident, know what’s supposed to come next; I know that you have a surgical plan. And more than that, I can start to trust that you’re not going to make any sudden moves, and that I can jump in while you’re narrating to make an adjustment (or veto your plan).

Clearly, this technique is not useful the first or second time you assist with a particular surgery. It requires knowledge of the relevant anatomy, and of the steps of the surgery. But by the time you are ready to wield surgical tools, it can be extremely helpful.

Now that I’m the one in charge in the OR, I try to teach this technique to every intern I work with; I also try to mention it to the medical students I work with, because I think it can help with all sorts of procedural learning, whatever field they might choose.

No matter what high-stakes skill you’re learning, if you tell your teacher what you’re about to do, and if you sound calm and confident, then the odds are higher that the teacher will actually let you do it. You can help keep that OR free of fear and maintain the chamomile-tea-level calm. That helps everyone in the room: the surgeon, the trainee and the patient.

Eve Karkowsky is an assistant professor of obstetrics and gynecology, Albert Einstein College of Medicine, Bronx, NY. She blogs at The Doctor’s Tablet.

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