How to watch: a guide to structured operative observation and cognitive simulation for trainees

Every surgical trainee is expected to assist surgical operations. The experience of assisting a planned list, a last- minute request to ‘hold the camera’ for a laparoscopic case, or ‘bedside assist’ for a robotic operation is common during training. Trainees, junior doctors and medical students find observing and assisting in the operating theatre often to be of low educational value1 and report that assisting cases can be frustrating and disheartening.2 While increasing operative hands-on opportunities is essential there is also an opportunity to activate the learning opportunities at the bedside to transform perspectives in surgical learning. Learning through observing is an essential component for developing core knowledge and skills that promote operative autonomy which is required for progression through training.3 Dilution of surgical exposure and experience is a frequently cited challenge in the modern era of surgical training. In recent years this has been compounded by the disruptions to usual practice as a result of the COVID-19 pandemic.4 As we look to the future of surgical training, incorporation of novel minimally invasive technology including surgical robotics has raised further concern that these modalities will limit the hands-on opportunities for trainees.5 Surgical training programs highlight the importance of assisting, and in robotic surgery it is well recognized that bedside-assist skills are essential, however most trainees feel the educational value of assisting rapidly diminishes after a few cases.6 It is essential to look to encourage educational opportunities in the setting of assisting operative cases. While learning in the operating theatre is essential7 and assisting is an integral part of this, orientation to surgical training does not routinely include guidance on how to optimize the value of these educational opportunities. Australian data highlights that trainees are largely unaware of how to learn in the operating theatre.8 Barriers exist to learning including trainees ‘waiting to be taught’8 and a lack of effective teaching methods9 further highlighting the often-passive nature of intraoperative learning. While there is evidence for the efficacy of observational learning for developing sensorimotor skills10 many trainees do not have the requisite skills to interpret visual cues, despite this being noted as a core competency for success in surgical training.11 Learning by observation in the absence of explicit teaching activity is noted to be particularly challenging for the very junior learner as they are often unaware of what they should be paying attention to.12 There is a demonstrated need to provide better guidance to trainees as to how to gain value from observational learning.13 Development of an approach to structured operative observation can assist in activating learning opportunities in non- primary operator settings. An example framework for guiding trainees in how to watch an operation for maximal educational gain is proposed (Table 1). This framework assists in the identification of components of the operation that a trainee can focus on. This has the potential to bridge the gap for learners where it is difficult to identify the key learning points for an operative case. This is a graduated approach with increasing complexity of components. As a trainee becomes more knowledgeable and comfortable with a particular operation they will progress from orientation led observation, largely observing the procedural and technical aspects of a case, to focussing on the nuances of the procedure such as the tips and tricks and the efficiency component. From a learning perspective this framework can also be used to also structure briefing and debriefing with surgical supervisors. This approach to structured operative observation has been developed through review of strategies in surgical education for interacting with visual inputs for learning collated from investigations in observational learning.14-22 Noting anatomical landmarks Critical operative steps Decision making nodes Surgeon specific variation Patient positioning Placement of retractors Strategies for use of the surgical assistant To engage in active operative observation can be challenging for trainees who are often engaged in operative assisting tasks and not prioritizing learning.23 Mental operating by internally reflecting on operative decision making is a strategy that can assist in engaging in developing operative skills through observation. This reflects back to the components of structured operative observation by mentally addressing the aspects of the framework during the operation. These in turn also provide a scaffold to ask questions intraoperatively to enhance learning when the surgeon deviates from what was anticipated. Cognitive simulation is the process of utilizing a range of inputs including visual, verbal, tactile and kinaesthetic cues, to build a procedural mental map encompassing the technical and non-technical skills required to safely complete an operative task. Cognitive simulation uses structured operative observation to develop mental imagery that is then used for rehearsal, consolidating procedural learning (Fig. 1). Cognitive simulation is designed to utilize the full range of conscious intellectual skills – thinking, perception, remembering, judgement, reasoning through experience, and incorporation of the senses. This concept is derived from high performance disciplines such as sport and the arts and has been demonstrated to have efficacy in surgical learning.24-26 For example, an athlete or artist will often utilize a mental run through of their performance as preparation, including not only visualizing the technical aspects of what they need to achieve, but other key cues that influence performance such as how their body is feeling, the presence of the crowd and their emotional response to the situation. This can be replicated in surgery using structured observation and cognitive simulation. Structured operative observation and integration of this in cognitive simulation is an approach that is accessible to all trainees adding educational value to training without requiring additional resources or time. Given the simplicity of this training methodology, structured observation and cognitive simulation can be employed in a time and cost- effective manner across a range of contexts. For example, this approach can be used in other settings of observational surgical learning such as watching surgical videos. Empowering surgical residents as independent learners has been identified as a key focus of modern training27 and self- motivation of trainees has been associated with superior performance outcomes.28 Incorporation of orientation to observational learning, and concepts of cognitive simulation when commencing surgical training could assist in guiding the next generation of trainees to take ownership of their learning and get the most out of their time observing operative cases. Kirsten Larkins: Conceptualization; writing – original draft. Emma Downie: Writing – original draft; writing – review and editing. Satish Warrier: Supervision; writing – review and editing. Helen Mohan: Conceptualization; writing – review and editing. Alexander Heriot: Supervision; writing – review and editing. Open access publishing facilitated by The University of Melbourne, as part of the Wiley - The University of Melbourne agreement via the Council of Australian University Librarians. Kirsten Larkins is a graduate research student and would like to acknowledge the financial support of the Australian Government through the professional practice research training program scholarship. The material presented in this manuscript is the original work of the authors and has not been submitted or presented elsewhere prior to this submission.