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The surgical clerkship provides medical students with valuable hands-on experience. This study examined why medical students speak or remain silent in the OR to improve progression from novice to engaged surgical team member. Using Constructivist Grounded Theory 37 interviews were conducted concerning expectations and behaviors that encourage or discourage students from speaking during their clerkship. Transcripts were coded, analyzed, and triangulated to develop a conceptual model. Students’ decision to speak or remain silent was based on their perception of the OR as a safe learning space. Our findings suggest that better preparation, awareness of critical moments, and informal communication with team members encouraged student speech. Medical students remain conflicted about their speaking in the OR and their evaluation. Key to improving students’ psychological safety is establishment of interpersonal relationships, awareness of OR mood, and assignment of case-related tasks to assist with OR assimilation and improved learning. [Display omitted] •The surgical clerkship provides medical students with valuable hands-on experience.•Barriers to the team dynamics of the OR may dissuade students from speaking.•Intentional silence is expressed two ways to avoid risk: acquiescence or quiescence.•Surgical clerkships carry expectation and trepidation that manifest student fear.•A student's decision to disengage in the OR may be setting them up for failure.

Background Preventable intraoperative errors have the potential to lead to adverse events. Our objective was to build a conceptual model of the relationship between minute technical errors performed by the surgeon and adverse patient outcomes. Materials and Methods We used constructivist grounded theory methodology to build a model for the avoidance of technical errors. We used the Observational Clinical Human Reliability Assessment system, which categorizes granular, technical intraoperative errors, as our conceptual framework. We iteratively interviewed surgeons from multiple adult and pediatric surgical specialties, refined our semi-structured interview, and developed a conceptual model. Our model remained stable after interviewing 11 surgeons, and we reviewed it with earlier interviewed surgeons. Results Our conceptual model helps us understand how technical errors can be associated with adverse outcomes and is applicable to a broad range of surgical steps. Each technical error is defined by a unique improper technical motion that without a compensatory response, it may lead to 1 or more discreet adverse outcomes. Our model includes 5 primary defenses against an adverse outcome, including perfect technique, recognizing imperfect technique, adequately correcting imperfect technique, recognizing an adverse event, and adequately compensating for an adverse event. It includes multiple examples of compensating for a technical error, resulting in a near miss. Discussion Our conceptual model suggests that adverse patient outcomes can be related to minute technical deviations in surgical technique and provides a basis to study these preventable errors. Our model can also be used to develop intraoperative strategies to prevent these technical surgical errors.

Background Patient safety in the Operating Room (OR) depends on unobstructed team communication. Yet the typical OR is loud, containing numerous sounds from surgical machinery overlayed with human-caused sounds. Our objective was to compare machine vs human-caused sounds for their loudness and distraction, and potential impact on team communication. Methods After surveying OR staff about sounds that interfere with job performance and team communication, we recorded 19 machine and 48 human-caused sounds measuring their acoustical intensity. We compared peak measures of machine vs human-caused sound loudness, using Student’s t -test. We observed the effect of these sounds on OR staff in 59 live surgeries, rating level of interference with team function. We visually depicted competing sounds through a spectral analysis. Results The survey response rate was 62.8%. 93% of respondents indicated that OR noise, especially human-caused sounds such as irrelevant conversations, interfere with team communication, hearing, and focus. OR peak decibel levels ranged from 56.8 dB (surgical packaging) to 105.0 dB (kicked metal stepstool). Human-caused sounds were comparable to machine-caused sounds in terms of mean peak dB levels (77.0 versus 73.8 dB, p  = 0.32), yet were rated as more interfering with surgical team function. The spectral analysis illustrated both machine and human-caused sound sources obscuring the surgeon’s instructions. Conclusions Avoidable human-caused sounds are a major source of disruption in the OR and interfere with communication and job performance. We recommend surgical team training to minimize these distractions.

The objective of this study was to identify intraoperative instructional strategies that embody the ways that learning occurs in the social contexts of surgery. We performed a qualitative review of examples of intraoperative teaching from transcripts of ten videotaped surgeries, coupled with interviews with surgical attendings and residents. We coded the examples according to the key tenets of sociocultural learning theories and used these codes to develop instructional strategies aimed at improving resident surgical autonomy. The sociocultural learning theories prompted six intraoperative teaching strategies (Assess Learner Needs, Inquire, Coach, Permit, Entrust, and Debrief) to address residents' learning needs in specific surgical tasks. The six strategies involve identifying procedure-specific learning needs; discussing interventions based on strategies successful with other learners; providing in-the-moment, interactive coaching; allowing the resident to struggle; increasing the resident's graduated responsibility; debriefing about successes and struggles. We argue that these six strategies should improve the quality of intraoperative teaching, and therefore, enhance progression to autonomous practice. •We propose novel intraoperative teaching strategies: Assess Learner Needs, Inquire, Coach, Permit, Entrust, and Debrief.•These strategies address residents' learning needs in specific surgical tasks.•They are derived from sociocultural learning theories.•Hallmarks include cooperative problem-solving, permitting residents to struggle safely, and goal-directed debriefing.

Our objective was to compare the use of agentic (“I”) and communal (“we”) spoken intraoperative discourse between male and female attending and resident surgeons. We analyzed transcripts involving attending and resident surgeons from 5 specialties at a single Midwestern academic teaching hospital. We adapted and expanded Grebelsky-Lichtman's codes, assessed rater agreement, and systematically coded transcripts for agentic and communal terms. Differences between genders and roles were evaluated using Mann-Whitney U tests. In the operating room, attendings used significantly more Action Demands, Rationality, Collective Speech, Passive Speech, Nurturing Speech, and Degree Modifiers. Conversely, residents used significantly more Assertive Speech, and Display Solution. Attendings were also more likely to use Action Demands combined with Passive Speech. No significant gender differences were found in any categories. Language use in the OR is more closely associated with professional role rather than gender and may reflect underlying power dynamics and the nature of the surgical teaching environment. [Display omitted] •We analyzed spoken language between male and female attending and resident surgeons.•Role, not gender, impacted the use of gendered language.•These communication patterns likely reflect underlying power dynamics in the OR.•They also reflect the nature of the learning environment.

Our objective was to examine the influence of silence on team action in the operating room. We conducted a constructed grounded theory study with semi-structured interviews with 25 interprofessional surgical team members. Using a framework of silence as communication and performance, transcripts were iteratively team-coded to develop themes and a conceptual model. OR silence is expressed verbally and nonverbally. Two contexts of silence were identified: homogenous as collective action, and disparate, as disengagement. Complex and dynamic, two primary themes emerged, Power that often shuts down communication, and Focus during critical moments. Five additional sub-themes included critical moments, respect, self-reflection, personal preference, and, bad mood. OR silence is not an absence of communication and requires a response. Whether homogenous through cohesiveness, or desperate as a solitary act, OR silence is a call to action. Examining silence as a part discourse has important implications on surgical team function. •Silence is an important part of communication.•In the operating room silence is complex and contains meaning.•During surgery silence can alter team perceptions of time and space.•Operating room silences require a response and inform team member action.•Silence as discourse during surgery has multiple purposes and interpretations.

Placental dysfunction is a leading cause of numerous pregnancy complications, including preeclampsia, preterm birth, fetal growth restrictions, placental abruption, and late spontaneous abortion [...]

Surgeons who work with trainees must address their learning needs without compromising patient safety. We used a constructivist grounded theory approach to examine videos of five teaching surgeries. Attending surgeons were interviewed afterward while watching cued videos of their cases. Codes were iteratively refined into major themes, and then constructed into a larger framework. We present a novel framework, Intelligent Cooperation, which accounts for the highly adaptive, iterative features of surgical teaching in the operating room. Specifically, we define Intelligent Cooperation as a sequence of coordinated exchanges between attending and trainee that accomplishes small surgical steps while simultaneously uncovering the trainee's learning needs. Intelligent Cooperation requires the attending to accurately determine learning needs, perform real-time needs assessment, provide critical scaffolding, and work with the learner to accomplish the next step in the surgery. This is achieved through intense, coordinated verbal and physical cooperation.

Surgical residents desire independent operating experience but recognize that attendings have a responsibility to keep cases as short as possible. We analyzed video and interviews of attending surgeons related to more than 400 moments in which the resident was the primary operator. We examined these moments for themes related to timing and pace. Our surgeons encouraged the residents to speed up when patient safety could be jeopardized by the case moving too slowly. In contrast, they encouraged the residents to slow down when performing a crucial step or granting independence. Attending surgeons encouraged speed through economical language, by substituting physical actions for words, and through the use of Intelligent Cooperation. Conversely, they encouraged slowing down via just-in-time mini-lectures and by questioning the trainee. We present recommendations for safe teaching in the operating room while simultaneously maintaining overall surgical flow. Teaching residents to operate quickly can save time and is likely based on an automaticity in teaching. Slowing a resident down is vital for trainee skill development and patient safety. •When teaching, maintain tight control over the pace of the case and safety of the patient.•Encourage residents to slow down when performing a crucial step or granting independence.•Encourage speed with economical language, substituting physical actions, and Intelligent Cooperation.•Slow down via just-in-time mini-lectures and by questioning the trainee.•We present an overall strategy for efficient, safe surgical teaching.

BackgroundInstructions form a vital part of OR communication, yet ambiguous language is common. This study compares attending and resident understanding of ambiguous intraoperative instructions using concepts from formal semantics.MethodsWe filmed attending and resident surgeons during intraoperative critical moments, the portion most crucial for safe, effective surgery. We transcribed all communication and with a semanticist, analyzed transcripts for instructions that could be interpreted ambiguously, while simultaneously viewing case video for context. We distinguished explicit instruction from implicit instruction as delivered only by implicature. Afterward, we interviewed the surgeons independently about their interpretation of each implicit instruction. We compared their answers, noted misunderstanding, and conducted thematic analysis to explore what makes instruction semantically clear versus misunderstood.ResultsThe team recorded 169 min of critical moments from 6 cases, involving 6 attending and 8 resident surgeons, and interviewed 12 surgeons. We identified 334 instructions, 79.9% from the attendings and 20.1% from residents: 113 (33.8%) were explicit and 267 (66.2%) implicit. 7% of potential ambiguities provoked misunderstanding, including one not recovered. Attending and resident understanding of implicit instruction was context-dependent, involving high degrees of tacit knowledge. Some instructions allowed the resident to practice decision-making. Many implicit instructions involved highly varied ways to instruct someone to begin a motion, prepare to stop, or stop. Many were constructed with polite formulas.ConclusionThe majority of instruction to residents is implicitly stated or contains lexical ambiguities, yet is well-understood. Future research should examine the impact of misunderstood instruction on resident educational and patient safety.