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EDUCATION

To the point: teaching the obstetrics and gynecology medical student in the operating room Q3

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Brittany S. Hampton, MD; LaTasha B. Craig, MD; Jodi F. Abbott, MD; Samantha D. Buery-Joyner, MD; John L. Dalrymple, MD; David A. Forstein, DO; Laura Hopkins, MD; Margaret L. McKenzie, MD; Sarah M. Page-Ramsey, MD; Archana Pradhan, MD; Abigail Wolf, MD; Scott C. Graziano, MD

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s obstetrician/gynecologists, we spend a significant portion of time in the operating room (OR). In a study that was aimed to understand reasons for pursuing obstetrics/gynecology as a career, residents rated surgical opportunities to be the highest among many motivating factors.1 Medical students on the obstetrics/gynecology clinical clerkship will participate in and learn from surgical procedures. Teaching and learning in the OR is often directed towards resident needs, with prioritizing technical skills needed for competency rather than focusing on medical student learning needs and experiences. An observational study by Irani et al2 found that an average of 55% of OR educational time in general surgery was spent on technical teaching for the resident; only 10% of each case was spent teaching core clerkship objectives. Such observations may lead both educators and students to question the value of the medical student OR experience in the obstetrics/gynecology clerkship. Investigators have sought to understand student perceptions of the OR experience. Students believe that the OR is a challenging learning environment,

From the Undergraduate Medical Education Committee, Association of Professors of Gynecology and Obstetrics, Crofton, MD. Received Jan. 29, 2015; revised March 27, 2015; accepted April 3, 2015. The authors report no conflict of interest. Corresponding author: Brittany S. Hampton, MD. [email protected]wihri.org 0002-9378/$36.00 ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog.2015.04.002

This article, from the “To the Point” series that is prepared by the Association of Professors of Gynecology and Obstetrics Undergraduate Medical Education Committee, is a review of considerations for teaching the medical student in the operating room during the obstetrics/gynecology clerkship. The importance of the medical student operating room experience and barriers to learning in the operating room are discussed. Specific considerations for the improvement of medical student learning and operating room experience, which include the development of operating room objectives and specific curricula, an increasing awareness regarding role modeling, and faculty development, are reviewed. Key words: curriculum, medical student, obstetrics and gynecology, operating room, teaching

report unfavorable OR experiences, and have mixed beliefs regarding the utility of the OR experience.3-5 They identify apprehension, anxiety, fear, shame, and being overwhelmed as initial emotions and barriers to student learning in the OR.6 Additional barriers include emphasis on patient safety, concerns for surgical efficiency, the presence of multiple learners in the OR, physical constraints with decreased visibility, and the increased use of minimally invasive techniques that may isolate learners. Perceived benefits of the student surgical experiences include improved knowledge of the surgical procedure, anatomy, anesthetics, and sterile technique. Students also express that the OR experience is useful in deciding future specialty choice,7 and studies indicate that positive OR experiences can influence students to consider surgical specialties as a career choice.8 In the emerging era of Entrustable Professional Activities (EPAs) and Milestones, it is also useful to consider how student OR experiences fulfill these requirements. The Accreditation Council

for Graduate Medical Education Obstetrics and Gynecology Milestones state that a graduating medical student who is pursuing an obstetrics/gynecology residency should demonstrate knowledge of basic abdominal and pelvic anatomy; demonstrate basic surgical principles, which include the use of universal precautions and aseptic technique; and position patients appropriately for surgery. In the realm of interpersonal and communication skills, the incoming resident should understand the importance of relationship development, information gathering and sharing, and teamwork.9 The OR is a useful place for students to achieve these milestones. The relevant EPAs for OR learning and experience include EPA 8, which is competency in transitions of care; EPA 9, which is to collaborate as a member of an interprofessional team; EPA 11, which is to obtain informed consent; EPA 12, which is to perform general procedures of a physician, and EPA 13, which is to identify system failures and contribute to a culture of safety and improvement. These EPAs underscore the relevance of

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167 168 TABLE 169 Curriculum initiatives for obstetrics/gynecology medical student operating room learning 170 Initiative Brief description/method of delivery Intended outcome 171 Learning objectives Specific operating room learning objectives to Align educators and learners to goals to focus learning 172 include clinical knowledge and technical skills experiences and maximize time spent in the operating 173 room 174 Distribution to students, faculty members, and 175 operating room staff 176 Logbook/experience cards Checklist approaches to specific operating room Increase student engagement and participation 177 elements intended for students 178 Focus operating room learning, improve knowledge Guided learning modules Written templates or computer-based instruction to 179 guide student learning during specific operating room retention, and satisfaction with operating room 180 experience experiences 181 Skills training Skills laboratories for various technical skills, which Increase student comfort and participation in operating 182 can include faculty-guided learning, peer-assisted room experience 183 learning, video instruction, and mental imagery 184 Increase technical skills 185 186 Increase interest in obstetrics/gynecology as a career 187 Self-reflection/self- awareness Facilitated reflection or self-motivated assignments Increase student awareness of the operating room 188 exercises environment 189 Increase student interest in a surgical career 190 Hampton. Teaching obstetrics/gynecology medical students in the operating room. Am J Obstet Gynecol 2015. 191 192 193 194 the student’s active involvement in the surgical culture and OR functioning.7 educational program, the role of the OR 195 surgical environment.10 The Association of Professors of Gyne- in student education, and the expected 196 cology and Obstetrics (APGO) has ob- learning outcomes.3 197 Considerations for obstetrics/ jectives that are specific to the OR that are The APGO student logbook can be 198 gynecology student OR teaching listed in educational topic 41, “Gyneco- used as an easy, low-cost curricular 199 logic Procedures,” of the tenth edition of addition that allows students to record Learning objectives 200 Outlining goals, setting learning objec- the APGO Medical Student Educational their OR experiences during the obstet201 tives, and clarifying expectations for stu- Objectives, which can be useful with the rics/gynecology core clerkship.19 The 202 dent performance can increase student development of student learning objec- logbook maps entries to educational 203 satisfaction with the learning experi- tives for the OR experience.17 topic 41 (“Gynecologic Procedures”) 204 ence,11 the obstetrics/gynecology clinical and includes items such as observe hys205 terectomy, observe laparoscopy, insert clerkship,12 and the OR13-15 experience in Curriculum in the OR 206 particular. Through a survey study, Fer- Curricula to enhance the student le- Foley catheter, demonstrate knot tying, 207 nando et al16 found that the attending arning experience in the OR can be built gynecology preoperative note, gynecol208 physician and students identified a once objectives are outlined. Curriculum ogy brief operative note, and gynecology 209 knowledge of standard OR etiquette and changes can range from low-cost and postoperative progress note. Hampton 210 protocols; the ability to scrub adequately easily implemented logbooks to time et al18 included a student experience 211 and adhere to sterile technique; the and faculty intensive skills-training ses- card as part of an obstetrics/gynecology 212 awareness of risks to self, staff, and pa- sions (Table). However, the first element OR curriculum that incorporated expe- ½T1 213 tients; and an appreciation for careful of a curriculum should focus on making riences that were suggested by APGO 214 perioperative monitoring to be essential the students and educators aware of and those experiences that were identi215 student skills. In a study with the use of learning objectives. Student handbooks fied as important through student and 216 focus groups, students and faculty or orientation materials can list the key faculty focus groups. Evans and Gus217 members prioritized 4 categories as learning objectives for the OR. Faculty berg20 similarly describe OR assessment 218 important for student learning in the OR: members and residents can be made cards that represent a checklist approach 219 (1) development of a foundation of familiar with objectives through elec- to promote student engagement in the 220 clinical knowledge, (2) surgical technique tronic mail or laminated postings in each OR. Through such cards, students are 221 and skill acquisition, (3) personal insight OR.18 Meetings can be held with OR asked to assess their experience with re222 into career choice, and (4) understanding nursing staff to familiarize them with the gard to (1) introduction to the OR team, 2 American Journal of Obstetrics & Gynecology MONTH 2015 REV 5.2.0 DTD  YMOB10345_proof  23 April 2015  7:23 pm  ce

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(2) the opportunity to review the preoperative imaging, indications for surgery, relevant anatomy, and operative findings, and (3) the opportunity to discuss expected outcomes and participate in some technical capacity. A review of checklists or logbooks can inform students of learning opportunities, and implementation as part of a larger curriculum can increase student engagement in the OR and enhance the student learning experience.18,20 Curriculum strategies to help students remain engaged and learn in the OR have also been described. Written templates that are designed to guide learning during observation in the OR can help the student remain focused and capture the learning event in written record.3 Computer-based instructional content for review by students to aid in the transition from classroom and selfinstruction to learning in the OR environment may be useful. Hampton et al18 developed and implemented three 15minute modules: (1) introduction to OR culture and functioning, (2) How to get the most out of assisting with a hysterectomy, and (3) How to get the most out of assisting with a laparoscopy. The use of these modules in addition to other curricular elements (such as orientation of faculty members and students to objectives, student experience log, and a reflective assignment) improved knowledge retention, increased student satisfaction with student-faculty interactions in the OR, and improved faculty teaching evaluations during the obstetrics/ gynecology clerkship. Skills training during the obstetrics/ gynecology clerkship orientation also increases student satisfaction with the obstetrics/gynecology clerkship experience.21 Researchers have shown that skills training in the obstetrics domain of vaginal delivery boosts student confidence, clinical participation, and examination performance.22-24 Thus, OR skills orientation for students during the obstetrics/gynecology clerkship may enhance student ability to experience the OR as more conducive to learning and increase student participation.3,5,25 With increased knowledge and comfort in skills, students can focus their learning

energy on the opportunities available in the OR instead of on obtaining basic OR skills. Surgical scrubbing and knowledge of instruments have been reported as highly important skills for students entering the OR. Confidence in, comfort with, and knowledge of these introductory skills translated to confidence, comfort, and knowledge for more complex skills, such as surgical instrumentation and knot tying.25 OR orientation sessions can include hand washing, gowning, and gloving; OR protocols; an introduction to common instruments and equipment, and a discussion of what behaviors to avoid in the OR.3 Using this type of orientation has been shown to increase student participation in the operation and inclusion in the surgical team. Gynecology-specific simulation curricula during the obstetrics/gynecology clerkship, which include skills such as intrauterine device insertion and removal, dilation and curettage procedure, and basic laparoscopy skills, have demonstrated improved confidence in performing procedures and have been shown to increase interest in pursuing a surgical field and in women’s health.26 Self-reflection and self-awareness exercises are curricular elements that can help students gain a better understanding of their comfort in the OR, response to the surgical environment, and their interest in surgery as a future career choice. Trained facilitators can be used to guide students through suitable responses to difficult or tense OR situations in teamwork.3 Alternatively, students can complete self-reflective assignments on their own, perhaps focusing on how the surgical experience in the OR during the obstetrics/gynecology clerkship influenced consideration of future plans or career choices.18 Curricular teaching strategies The traditional obstetrics/gynecology clerkship may include disparate experiences in the OR with several different faculty members and residents. More novel Longitudinal Integrated Clerkship models likely allow for more faculty continuity in the OR. Reid et al27 investigated a surgical apprenticeship model in which students apprenticed directly

Review

with faculty members on a 1-on-1 basis. Students who participated in this model had a more positive view of surgeons and were more likely to participate in the OR and patient treatment, compared with students in the usual clerkship model. It may be useful to consider using apprenticeship models during traditional obstetrics/gynecology clerkships to enhance student OR participation and improve student perception of surgical faculty members. The importance of role modeling within the OR has been described by many investigators8,14,28-32; however, surgical faculty members may not understand just how influential they are regarding student surgical experience or career choice.29 Positive behaviors can influence students to consider surgical specialties29; negative behaviors may deter students from considering surgical fields.14 The main themes of calm, teamwork, respect, teaching, patient communication, and providing comfort have been identified as exemplary behaviors modeled to medical students within the OR.28 Some of the most important role-modeling may come from resident physicians with whom the students spend most of their time on the clerkship. Residents demonstrate many qualities that are described in outstanding clinical mentors,31 and several studies show that medical students perceive residents as their main source of OR teaching.33-35 Faculty physicians can use the teaching strategy of to recruit residents as teachers in the OR setting and to create an educational multiplier that allows faculty members to do multilevel teaching, while addressing learners at each level.36 The use of learner-provided objectives in the OR followed by a debriefing or the use of methods to increase student feedback may improve the OR experience. The Briefing e Intraoperative Teaching eDebriefing model focuses both the educator and student on specific learning objectives for the case to guide intraoperative teaching. Briefing is aimed at the assessment of the needs of the learner and the establishment of learning objectives to guide both learner and teacher. Intraoperative teaching

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should focus on the learning objectives that are set during the briefing. Debriefing allows for reflection, reinforcement, correction, and establishment of rules.37,38 The feasibility and success of the incorporation of structured immediate feedback sessions for third-year medical students during their surgery clerkship was investigated by Garner et al39 during a cross-over study. Students who were instructed to seek daily feedback from faculty surgeons reported significantly more feedback and specific instructional guidance; faculty members did not report fatigue with providing feedback to the students, with their perceptions of the students remaining positive. Incorporation of feedback into the OR is another teaching strategy that can be implemented potentially to improve the student surgical experience. There are several ways OR skills programs can be carried out outside of the OR. Faculty availability and time are often an issue for scheduling training laboratories. Peer-assisted learning can be a useful teaching method for OR skills and has been shown by some to be more effective than resident-assisted learning.40 Peer-assisted learning can be more informal and allow learners to raise areas of concern as well as have material placed in meaningful contexts for their level of learning. Shippey et al41 randomly assigned medical students to 1 of th3ree interventions for teaching subcuticular suturing: instructional video, instructor supervision by faculty members, or independent practice. All 3 student groups demonstrated performance gains after each teaching intervention; however, students who used the instructional video were the only group who demonstrated sustained improvement in skills when tested 1 week after the intervention. This reinforces that video instruction and the ability to capitalize on learner-centered and active rather than passive learning can be beneficial to skills retention. Finally, mentally rehearsing OR skills such as suturing may enhance student attainment of OR skills. The impact of mental imagery on student OR skills education was investigated by Sanders et al.42

Medical students were assigned randomly to 1 of 3 instructional groups to learn suturing: (1) 3 sessions of suturing a pig’s foot, 2 sessions of physical practice on a pig’s foot, and 1 session of mental imagery rehearsal or (2) 1 session of physical practice on a pig’s foot and 2 sessions of imagery rehearsal. Groups performed only slightly differently over the time of the study, which indicates that mental imagery rehearsal was as effective as physical practice in learning surgical skills by medical students. It can also be useful to use other medical professionals, such as nursing staff or physician assistants, to teach skills. This, along with peer-assisted learning, videoassisted learning, and mental imagery practice, offers an alternative to timeintensive OR skills teaching and rehearsal with faculty members. Faculty development One of the most cited barriers to effective learning for the medical student in the OR is adverse and unwelcoming surgeons and OR staff attitudes.32 Therefore, enhancing surgical faculty teaching abilities within the OR through faculty development can offer great potential for improving student perceptions of the OR learning environment.32 Confidential, objective, individualized faculty feedback has been shown to improve faculty OR teaching significantly.43 OR assessment cards can be completed and reviewed with specific faculty members to provide directed feedback regarding student experiences in the OR.20 Sharing faculty members’ course evaluations can be another way to facilitate feedback and faculty members awareness of their impact on student learning. In any faculty development effort, the importance of faculty members’ attitudes towards the learner should be emphasized and underscored.

Conclusions The OR serves as an important setting for medical student learning in the obstetrics/gynecology clerkship; however, student learning is often overlooked in this arena. The development of specific learning objectives for the obstetrics/gynecology OR experience along with

integration of specific curricular elements can focus student learning, increase student participation, and improve the OR experience for students and educators. The use of specific teaching strategies in the obstetrics/gynecology OR and during skills laboratories facilitates student engagement and learning. Faculty development can improve faculty teaching abilities and increase awareness to the importance of role-modeling for students. Through examples cited in this review, obstetrics/gynecology educators have a framework to facilitate positive OR learning experiences for all medical students. REFERENCES 1. Blanchard MH, Autry AM, Brown HL, et al. A multicenter study to determine motivating factors for residents pursuing obstetrics and gynecology. Am J Obstet Gynecol 2005;193: 1835-41. 2. Irani JL, Greenberg JA, Blanco MA, et al. Educational value of the operating room experience during a core surgical clerkship. Am J Surg 2010;200:167-72. 3. Lyon PMA. Making the most of learning in the operating theatre: student strategies and curricular initiatives. Med Educ 2003;37:680-8. 4. Stark P. Teaching and learning in the clinical setting: a qualitative study of the perceptions of students and teachers. Med Educ 2003;37: 975-82. 5. Chapman SJ, Hakeem AR, Marangoni G, Raj Prasad K. How can we enhance undergraduate medical training in the operating room? A survey of student attitudes and opinions. J Surg Educ 2013;70:326-33. 6. Bowrey DJ, Kidd JM. How do early emotional experiences in the operating theatre influence medical student learning in this environment? Teach Learn Med 2014;26:113-20. 7. Hampton BS, Magrane D, Sung V. Perceptions of operating room learning experiences during the obstetrics and gynecology clerkship. J Surg Educ 2011;68:377-81. 8. Berman L, Rosenthal MS, Curry LA, Evans LV, Gusberg RJ. Attracting surgical clerks to surgical careers: role models, mentoring, and engagement in the operating room. J Am Coll Surg 2008;207:793-800. 9. The Obstetrics and Gynecology Milestone Project. Accreditation Council for Graduate Medical Education website. Available at: https:// www.acgme.org/acgmeweb/Portals/0/PDFs/ Milestones/ObstetricsandGynecologyMilestones. pdf. Accessed Jan. 5, 2015. 10. Association of American Medical Colleges. Core Entrustable Professional Activities for Entering Residency. Association of American Medical Colleges website. Available at: https:// members.aamc.org/eweb/upload/Core%20EPA

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%20Faculty%20and%20Learner%20Guide.pdf. Accessed Dec. 30, 2014. 11. Harden RM. Ten questions to ask when planning a course or curriculum. Med Educ 1986;20:356-65. 12. Burke WM, Williams JA, Fenner DE, Hammoud MM. The obstetrics and gynecology clerkship: building a better model from past experience. Am J Obstet Gynecol 2004;191: 1772-6. 13. Fenner DE. Avoiding pitfalls: lessons in surgical teaching. Obstet Gynecol Clin North Am 2006;33:333-42. 14. Ravindra P, Fitzgerald JE, Bhangu A, Maxwell-Armstrong CA. Quantifying factors influencing operating theater teaching, participation, and learning opportunities for medical students in surgery. J Surg Educ 2013;70: 495-501. 15. Fernando N, McAdam T, Youngson G, McKenzie H, Cleland J, Yule S. Undergraduate medical students’ perceptions and expectations of theatre-based learning: how can we improve the student learning experience? Surgeon 2007;5:271-4. 16. Fernando N, McAdam T, Cleland J, Yule S, McKenzie H, Youngson G. How can we prepare medical students for theatre based learning? Med Educ 2007;41:968-74. 17. Association of Professors of Gynecology and Obstetrics. APGO Medical Student Educational Objectives. Tenth edition. Association of Professors of Gynecology and Obstetrics website. Available at: https://www.apgo.org/binary/ APGO%20Med%20Student%20Obj%2010% 20Ed.pdf. 2014. Accessed: January 24, 2015. 18. Hampton BS, Raker CA, Sung VW. Implementation and evaluation of a novel operating room curriculum for the obstetrics and gynecology clerkship. J Surg Educ 2014;71:521-9. 19. Association of Professors of Gynecology and Obstetrics, Undergraduate Medical Education Committee. APGO medical student educational objectives logbook. Crofton (MD): Association of Professors of Gynecology and Obstetrics; 2009. 20. Evans LV, Gusberg RJ. Creating a surgery clerkship in a changing environment: reality, simulation, and the rules of engagement. Yale J Biol Med 2012;85:143-52.

21. Stanhope TJ, Myer E, Casey P. Obstetrics and gynecology skills orientation improves student perception of third-year clerkship. Obstet Gynecol 2014;123:118S-9S. 22. Jude DC, Gilbert GG, Magrane D. Simulation training in the obstetrics and gynecology clerkship. Am J Obstet Gynecol 2006;195: 1489-92. 23. Holmstrom S, Downes K, Mayer J, Learman L. Simulation training in an obstetric clerkship: a randomized control trial. Obstet Gynecol 2011;118:649-54. 24. Dayal AK, Fisher N, Magrane D, Goffman D, Bernstein PS, Katz NT. Simulation training improves medical students’ learning experiences when performing vaginal deliveries. Simul Healthc 2009;4:155-9. 25. Graziano S. Clinical medical students’ selfassessed comfort with technical skills. Female Pelvic Med Reconstr Surg 2011;17:125-7. 26. Nitschmann C, Bartz D, Johnson NR. Gynecology simulation training increases medical student confidence and interest in women’s health. Teach Learn Med 2014;26: 160-3. 27. Reid CM, Kim DY, Mandel J, Smith A, Talamini MA, Bansal V. Impact of a third-year surgical apprenticeship model: perceptions and attitudes compared with the traditional medical student clerkship experience. J Am Coll Surg 2014;218:1032-7. 28. Curry SE, Cortland CI, Graham MJ. Rolemodelling in the operating room: medical student observations of exemplary behaviour. Med Educ 2011;45:946-57. 29. Quillin RC 3rd, Pritts TA, Davis BR, et al. Surgeons underestimate their influence on medical students entering surgery. J Surg Res 2012;177:201-6. 30. Chang J, Odrobina M, McIntyre-Seltman K. Residents as role models: the effect of the obstetrics and gynecology clerkship on medical students’ career interest. J Grad Med Educ 2010;2:341-5. 31. Nguyen SQ, Divino CM. Surgical residents as medical student mentors. Am J Surg 2007;193:90-3. 32. Schwind C, Boehler M, Rogers D, et al. Variables influencing medical student learning in the operating room. Am J Surg 2004;187: 198-200.

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To the point: teaching the obstetrics and gynecology medical student in the operating room.

This article, from the "To the Point" series that is prepared by the Association of Professors of Gynecology and Obstetrics Undergraduate Medical Educ...
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