2015, 37: 34–40
TWELVE TIPS
Twelve tips for medical students to maximise learning in theatre DANIEL WEINBERG1,2, MAHDI SALEH1,2 & YASHASHWI SINHA1,2 1
Keele University, UK, 2University Hospital of North Staffordshire, UK
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Abstract Background: Introduction into the clinical environment can be a daunting experience for medical students, especially in the operating theatre. Prior knowledge of how to prepare for theatre and cope with surgical placements is advantageous, as learning opportunities can be maximised from the start. Aim: This article provides medical students with 12 tips devised to help make the most out of their initial theatre placements. Methods: Tips were formulated based on the experiences of three senior medical students and a review of the literature. Results: The 12 tips are (1) Know the patient and procedure, (2) Be familiar with your surgical department, (3) Familiarise yourself with different surgical attire, (4) Revise your clinical skills, (5) Be time-efficient, (6) Learn how to work in a sterile environment, (7) Avoiding syncope, (8) Impress the operating surgeon, (9) Be aware of the professional, ethical, and legal issues in surgery, (10) Use mentors to enhance your learning, (11) Embrace extra-curricular activities to enhance your insight into surgery and (12) Be acquainted with relevant support systems. Conclusions: These 12 tips provide guidance and opportunities to maximise learning for new clinical-phase medical students being introduced to the operating theatre for the first time.
Introduction
Practice points
Attending theatre for the first time as a student can be a stressful experience. As students beginning clinical placements, you will need to quickly become familiar with navigating theatres, often without prerequisite tours or taught knowledge and skills to prepare yourself. Alongside these broader issues, the lack of knowledge on how to dress properly, how to behave in theatre and about infection control measures can limit your experiences of theatres. Tackling these issues could enhance your learning experience (Lyon 2004). As medical students and future doctors, there is a growing pressure for you to make earlier decisions on a career pathway and prepare accordingly. Considering that your undergraduate experiences are key to career selection (Goldacre et al. 2004), it is important for you to enjoy and learn from your early exposure to the surgical environment. Due to the limited time on surgical firms and in theatre as an undergraduate, exemplary theatre-based teaching is essential in promoting interest and later recruitment into the surgical specialties (Fernando et al. 2007a). Without this, you may simply dismiss surgery as a career option because of the nature of your undergraduate experience, rather than the reality of the specialty itself. Core issues faced by many students attending theatre included the feeling that they are not adequately prepared for what the placement entails, they do not feel welcome, and that they are at the bottom of the surgical hierarchy (Fernando et al. 2007a). Fernando et al. (2007a) found that less than half (44%)
Preparing for your time in theatre can lead to enhanced learning opportunities and an overall experience. Organisation, enthusiasm and engagement are key in establishing surgeon-led teaching. Theatre can be a valuable learning experience, and poses as an opportunity to practice skills and consolidate knowledge.
of final-year medical students received instructions before attending theatre. The lack of preparation resulted in medical students feeling limited in their usefulness, and that attending theatre was a waste of time in relation to exams. This, in conjunction with feeling unwelcome, apprehensive and fearful in theatre, may impact negatively on the relationships you will form with surgeons, and consequently your learning experience (Fernando et al. 2007a). As senior medical students having undertaken many surgical placements during clinical years and student-selected components (SSCs), we have acknowledged these difficulties, which pose a barrier to learning in theatre. From our experiences, and a review of the literature, we have devised 12 tips for medical students to enhance your learning in theatre (Table 1). Learning in theatre can be maximised through sufficient preparation and knowing how to behave and engage
Correspondence: Daniel Weinberg, University Hospital of North Staffordshire, 82 Godwin Way, Trent Vale, Stoke-On-Trent, STAFFS, Staffordshire ST4 6JS, UK. Tel: 07503154460; E-mail: [email protected]
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ISSN 0142-159X print/ISSN 1466-187X online/15/010034–7 ß 2015 Informa UK Ltd. DOI: 10.3109/0142159X.2014.932899
Learning in theatre
Table 1. Summary of the 12 tips.
Preparation for theatre is key Know the patient and procedure
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Be familiar with your surgical department Familiarise yourself with different surgical attire Revise your clinical skills Be time-efficient
Maximise learning in theatre Learn how to work in a sterile environment Avoiding syncope Impress the operating surgeon
in learning opportunities while in theatre. Finally, we have proposed general tips regarding broader issues related to learning in surgery, and knowing what to do when confronted with difficulties in theatre. While not all of the tips are directly related to learning tasks, they will help your time in theatre to run more smoothly and increase your confidence and awareness of the learning tasks at hand, consequently enabling you to enhance your overall learning.
Preparation for theatre is key Tip 1 Know the patient and procedure Learning through a patient’s condition, especially within surgery, can be one of the most fruitful and rewarding experiences. Learning about surgical conditions and their management from real-life patient cases is far more rewarding than simply reading such material from books. Further, interacting with surgical patients will enable you to enhance your communication and rapport-building skills, while gaining an understanding of patient-centred care and the bio-psychosocial implications of surgical conditions for patients (Azer et al. 2013). From our experiences, linking surgical conditions to patients you have seen first-hand provides invaluable reinforcement when reading about such disorders and enables you to remember facts more readily in examinations. Lyon (2003) found in a survey that 74% of students agreed, ‘‘Going to theatre gives me a better understanding of surgery than I get from just reading the textbooks’’. We would advise seeing surgical patients pre-operatively, which usually entails an early morning trip to the pre-operative surgical ward. Completing a full history and examination from the patient before they are transported to the anaesthetic room provides an opportunity to learn about the patient’s condition and for comparison of examination findings before and after their operation. Often, based on our experiences, surgeons expect medical students to interview the patients on the morning list so that there is both reinforcement of the patient’s condition and the operation itself. The supervising surgeon truly appreciates this, as it shows you have taken an interest and gone out of your way to prepare for your theatre session. Most operation lists can be viewed in advance, especially if elective. Attending morning ward rounds and checking
Recognising broader issues and relevant schemes to assist learning Be aware of the professional, ethical and legal issues in surgery Use mentors to enhance your learning Embrace extra-curricular activities to broaden your insight into surgery Be acquainted with relevant support systems
operation lists on hospital computers is worthwhile in gaining some background knowledge to the patients and procedures. If unsure, it is well-worth doing some reading about the patient’s condition and planned surgical procedure in advance of their operation. Post-operatively, talking with the patient about their experience and re-examining them (where appropriate) may shed new light onto their clinical course and on their condition. Not only is the learning process enhanced, but also repetition in history taking and examination of the same patient fosters positive reinforcement in remembering that particular case in the long term. Further, paying particular attention to patient notes you see post-operatively and on subsequent ward rounds is worthwhile in gaining understanding of possible post-operative complications.
Tip 2 Be familiar with your surgical department From our experiences, it can take time to become accustomed to the surgical environment. Hence, it is useful to gain familiarity with relevant surgical areas before you are timetabled in for theatre. By knowing your way around the surgical department, you can focus your attention onto your learning needs as well as make yourself more comfortable with planning journeys, not getting lost and the general overwhelming nature of being in theatre for the first time (Lyon 2003; Lydon & Burke 2012). Based on student interviews reported by Lyon (2003) and our experiences, it would be valuable to become familiar with the: Changing room location Pre-operative bay Entrances and exits to and from theatre Correct theatre on the day of the operation Scrubbing area Anaesthetics room Recovery Bay Surgical ward relevant to the operation/specialty It is worthwhile taking a tour around your surgical department before beginning your rotation to become acquainted with such areas. Ideally, a mentor could give you a guided tour and advice to prevent you getting lost during your surgical rotation (see Tip 10).
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Tip 3
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Familiarise yourself with different surgical attire Knowing what to wear when attending theatre will hasten time in the changing room and help diminish surgical site infection. In turn, your supervising surgeon may perceive you as a more competent student, which can result in more teaching (Lyon 2004). We have seen students turned away from theatres by surgeons for not dressing correctly, which stresses the importance of knowing about surgical attire. Five items vital to remember when changing for theatres include: scrub top, scrub bottoms, head cover, suitable shoes and face masks. Scrub suit tops and bottoms are available in various sizes. A good measure to make sure you have the right size is to ensure your top hangs closely to your body. To prevent the shedding of squamous cells within sterile areas, bouffant head covers or surgical hoods should be worn, which should cover the extent of the hairline as much as possible. Shoes with closed ends without holes are recommended to reduce your risk of injury and spillage on underlying socks (AORN Recommended Practices Committee 2005). We recount several experiences where we wore shoes belonging to the surgeon we were about to scrub in with! Avoiding the shoes marked with names or initials should save you this embarrassment. Facemasks are essential to wear if scrubbing up or near the sterile surgical site. If you are assisting, the use of other equipment such as protective eyeglasses may be appropriate if splashing or spraying is likely (AORN Recommended Practices Committee 2005). As surgical staff in scrub suits are fairly indistinguishable, your ID badge should be clearly displayed to avoid confusion with other staff members. Jewellery acts as a well-known growth site for bacteria (Bartlett et al. 2002). It is therefore important that you remove any rings and ensure nose and ear piercings are fully covered to maintain theatre discipline. Upon leaving the theatre area, used scrub suits, face masks and surgical hoods should be appropriately disposed of either for laundering or into the clinical waste bins depending on your facility’s protocols. You can often wear a white coat over scrub suits when temporarily visiting other hospital areas, although there is little evidence to support that this reduces contamination (AORN Recommended Practices Committee 2005). It is essential to realise that the surgeon’s perception of a medical student is an important factor regarding surgeon-led teaching in theatre (see Tip 8). Therefore, dressing appropriately and looking professional will form the immediate impression of a competent medical student.
Tip 4 Revise your clinical skills Time in theatre gives you ample opportunity to practice clinical skills, including basic suturing, wound care, catheterisation, and cannulation. Considering that all patients require intravenous cannulation and usually catheterisation too, there should always be opportunities to practice these in and around theatre. Additionally, skills concerning anaesthesia such as 36
basic airway management can be practiced in the anaesthetics room under close supervision from experienced anaesthetists. We have found that taking the opportunity to suture and dress wounds is a much more realistic and stimulating experience compared to practicing on manikins. Given that patient consent has been attained, you may feel more at ease being able to practice certain skills on patients once they have been anaesthetised, as you can focus purely on the technical aspects as opposed to communication skills too. In order to smoothly translate your clinical skills learnt on manikins to real patients, it is best to practice these skills on patients soon after being taught. Hence, it is well worth revising these your clinical skills before the opportunity arises to practice and consolidate them with real surgical patients. It is highly dependent on the medical school but it has been shown that transfer of skills in urethral catheterisation from simulated training to real patients can be effective for up to six weeks (Todsen et al. 2013). Approaching the end of your studies at medical school, and as the looming prospect of becoming a newly qualified doctor approaches, it is important to be competent as well as confident in performing these clinical procedures. With this in mind, surgical placements provide substantial opportunities to practice and consolidate your clinical skills, which is more useful when those skills are fresh in your mind from recent revision.
Tip 5 Be time-efficient Organising your time efficiently before and during theatre is vital. Putting aside time to prepare for a specific operation list, physically getting to theatre within good time and using your time in theatre wisely can enhance your learning and lead to a more positive experience. Further, it is in your interest as a busy medical student to embrace the learning opportunities at hand in a time-efficient manner, due to the high workload of the course. Do not underestimate the time it may take to change for theatre. It only takes some difficulty finding a pair of shoes to delay your arrival and introduction to the theatre team. Arriving early will allow you to introduce yourself to the other staff as they come, and if there is a briefing before the start of the operating list, it is common etiquette to attend. This will ensure that everyone is aware of your presence, and a punctual arrival will show that you are enthusiastic. Surgeons often arrive early to review patient clinical details or scans. We have found this a great opportunity to introduce yourself, ask questions, ask if you can scrub in and show motivation to learn and participate. Although you may feel towards the bottom end of the hierarchy in theatre, arriving early may lead to a better viewing position, which students find essential towards learning in theatre (Lyon 2003). Initially, time in theatre can be challenging as you have to pick up cues on the run, have reduced patient contact, feel in the way, stand around for long periods, are unable to participate and feel bored (Lydon & Burke 2012). In contrast, understanding to recognise and engage in learning
Learning in theatre
opportunities from the outset will maximise your time efficiency and lead to an enhanced educational experience. If all fails in the learning experience, you can maximise your time in theatre by bringing a medical/surgical textbook to read until an opportunity arises to adopt a more active role.
from the ceiling (Dharan & Pittet 2002). It is important to realise that you should not stand within this square area during an operation, unless appropriately scrubbed in and with a facemask, to reduce contamination of implants. If you are unsure about sterility, always ask a member of the theatre staff.
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Maximise learning in theatre In a study by Woods et al. (2011), one of the approaches to learning during surgical rotations was through creation of learning opportunities using self-initiative. Within this context, learning opportunities can be maximised in a time-efficient manner by deciding what you want out of your time in theatre, and then doing it. Strategically positioning yourself during theatre and between different theatres to be considered part of the team, for example within theatres with less trainees, will enable you to maximise learning at every moment as more learning opportunities will be available.
Tip 6 Learn how to work in a sterile environment One crucial factor especially important in theatre is the preservation of a sterile environment, which is why learning how to work and navigate safely in a sterile surgical area is vital (Creamer et al. 2012). Furthermore, knowledge about sterility can also help avoid unnecessary embarrassment. By maintaining sterile conditions peri-operatively, the risk of post-operative infections is lower and therefore patient recovery is quickened. Importantly, approximately 76% of consultant surgeons and 85% of senior medical students were shown to regard adherence to sterility in the operating theatre as essential (Fernando et al. 2007b). From our experiences, competency in this area can increase the operating surgeon’s trust in you, and result in more opportunities to assist in surgery and be taught. In contrast, students who jeopardise sterility through carelessness are sometimes regarded negatively – potentially limiting your learning opportunities. We have found asking theatre nurses how to properly scrub in theatre is the best and most efficient way to learn this essential skill. You should not be embarrassed to ask for their supervision while learning to scrub up; they will appreciate your sensibility and desire to refine technique and maintain sterility. Sterility not only involves scrubbing in correctly, but also knowing what is sterile and what is not sterile once in theatre. Once staff members in theatre are ‘‘gowned and gloved’’, it is extremely important to keep clear of them unless also scrubbed in and sterile. Further, the sterile drapes used to create a sterile field over the patient and surgical equipment must be avoided unless you are scrubbed in, meaning extra care should be taken while navigating yourself around theatre – especially in confined spaces. When scrubbed in, keeping your hands well above your waist is important to lessen the chance of accidental contamination. Some theatres – notably orthopaedic – contain laminar flow ventilation systems, evident by the box-shaped units arising
Tip 7 Avoiding syncope It is well known that introduction to theatres for the first time is daunting and can be just as much an emotional experience in addition to an educational one (Lyon 2003). This emotion, in addition to poor hydration, low sugar levels and standing for long periods can cause you to feel faint, which is certainly something to avoid while in theatre. Experiencing an episode of syncope as a medical student in theatre is not uncommon, as found by Jamjoom et al. (2009). A total of 12% of students reported an episode of near or actual syncope in theatre, 32% of which lost consciousness. Females are more likely to undergo a syncopal episode in theatre (88% females versus 12% males). The following factors in order of popularity were identified: Warm temperature in theatre (79%) Length of time standing (73%) Surgical mask (47%) Smell of diathermy (23%) Menstruation (17%) There are preventative measures you can take to help avoid syncope in theatre. Keeping well hydrated and having a substantial (but not overindulgent) meal before theatre will help prevent syncope, which is what the majority (61%) of students did to prevent a second recurrence (Jamjoom et al. 2009). If standing in the same spot for extended periods, tensing your calves can help counter orthostatic intolerance. Such leg movements were performed by 18% in the above study. 18% and 12% of students in the study sat down or took a break from assisting respectively, to prevent a second recurrence of syncope. A common misconception is that scrubbing in is associated with increased syncope rates. However, one of the measures taken to help avoid syncope is increased attendance to the operating theatre (Jamjoom et al. 2009), as we too have found with personal experience. The anxiety surrounding theatres as an unfamiliar environment can potentially lead to syncope. With this in mind, mentally preparing yourself by speaking to fellow students about what to expect in theatre can help. Staff occasionally play music that they have brought to theatre, which we have found could be used as a distraction technique if anxious. Prodromal symptoms including a feeling of warmth or nausea, a need to sit down, blurring of vision or black spots in the visual field can be present in vasovagal and orthostatic hypotensive-related syncope (Wieling et al. 2009). If you experience these prodromal symptoms, it is best to notify a staff member in good timing. The staff will appreciate this and direct you to somewhere you can sit.
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Tip 8
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Impress the operating surgeon There is evidence that student motivation is essential in gaining the surgeon’s interest in providing teaching (Lyon 2004). Hence, being competent in areas such as knowing the patient and their condition (Tip 1), knowing what to wear (Tip 3), and maintaining sterility (Tip 6) will impact positively on the operating surgeon, which may encourage the surgeon to teach you and will maximise your learning in theatre. Considering the operating surgeon is responsible for the rest of their team in theatre, being aware of the dynamics of all staff members in theatre affords a huge advantage. Learning how to work as part of a team is an essential part of medicine. Your time in theatre will involve much teamwork to partake in, for example: transferring patients in the operating theatre, liaising between staff and assisting in operations. Engaging in these activities, we have been able to comfortably fit into our own role as medical students within theatres and feel part of the team. We have found that being available to assist in surgery, pass on messages and get involved in teamwork will impress the surgeon and lead to a positive surgeon-student relationship and more teaching opportunities. With the surgeon often regarded as a ‘‘high-profile’’ figure in theatres, it is not uncommon that medical students are worried about embarrassing themselves in theatre and especially in front of the surgeon. One study found that over 70% of medical students interviewed agreed that embarrassment in theatre is common (Lyon 2004). Ways that this could happen include asking questions at the wrong time or at an intricate part of the procedure, getting in the way of theatre staff, wearing the gown the wrong way and even contaminating sterile areas by accident. Therefore, it is important to be aware of the environment while in theatre, and the fact that all medical students experience the same degree of apprehension and hesitancy in undertaking an active role within the team (Lyon 2004). Being a competent and confident team player in theatre will inevitably form a positive impression on other staff members and importantly the operating surgeon, which will lead to an enhanced overall experience. Intra-operatively, students may often not engage as fully after making a judgement that surgeons are less ‘‘studentorientated’’ (Lyon 2004). If this is the case and you feel that the surgeon is unfriendly to students, speaking to and learning from the anaesthetists and scrub nurses can provide some useful learning, as they are often able to lend teaching time between their duties.
Recognising broader issues and relevant schemes to assist learning Tip 9 Be aware of the professional, ethical, and legal issues in surgery Learning about these issues early on will enable you to make informed decisions on the care of surgical patients as a future doctor, and many of these principles are examinable too. 38
Professionalism in theatre and adapting to the surgeon’s environment is partly intuitive and partly learned. Getting a feel for the environment is essential, as for example; some surgeons favour playing music while operating and others may prefer silence. Although the environment is unique and arguably more relaxed in theatre, it is important to maintain professional practice alongside peers, patients and other staff. According to the surgical specialty you experience in theatre, you can relate to relevant ethico-legal issues that form an essential part of the medical curriculum. For example, in paediatric surgery you should be aware of the protocol for suspected child abuse and child protection issues. In transplant surgery, issues with transplant tourism, how organs are retrieved and the selection of patients can be explored (Woodcock & Wheeler 2010). Several learning objectives are highlighted here – for example, what are the prerequisites for liver transplantation and the associated ethical debates with regard to patients with alcohol dependence and these procedures? Patients that refuse the transfusion of blood products on the basis of religious prohibitions has led to the advent of ‘‘bloodless surgery’’, whereby strategies are employed to reduce blood loss during surgery (Gohel et al. 2011). These principles have since become commonplace for many surgical procedures, and you can learn about them in theatre by speaking to surgeons and anaesthetists. Speaking to patients from different religious backgrounds provides invaluable insight into religious opinions on transplant surgery, cosmetic surgery and blood transfusions, and highlights related issues faced by surgeons. In summary, understanding ethico-legal issues in surgery will help to make informed decisions regarding the care of surgical patients, and will guide your professional practice as a future doctor.
Tip 10 Use mentors to enhance your learning You may feel inadequately prepared and unsure of what your learning aims are, and how you will achieve them within such constrained time limits in theatre. Studies show that role models in the form of mentors can influence medical student’s career choices, and that medical students with a positive surgical mentor are more encouraged to pursue careers within surgery (Healy et al. 2012). With this in mind, a senior mentor can lead you to find greater interest in your surgical placements in addition to helping you learn efficiently. As mentoring schemes involving surgical trainees and consultants are often lacking in prevalence, finding a senior medical student willing to mentor you is invaluable and should not be underestimated. Having already been through the same experience, a senior medical student can provide beneficial advice on the best ways to learn, how to get around and what to focus on considering the learning objectives. Considering senior medical students are aware of the position you find yourself in during surgical placements, they can help you to navigate the educational, social and environmental difficulties you may face – something we have found extremely useful
Learning in theatre
during our time on surgery. For example, senior medical students acting as mentors can: Highlight student-friendly surgeons who are most likely to teach Explain tasks to undertake when faced with spare time in theatres Recommend learning resources to enhance your learning specific to the expectations for your year group Give you a guided tour of the surgical department and theatres prior to your placement We have found senior medical students willing to mentor us either through being on the same surgical attachment, the medical school surgical society or other mentoring schemes that the medical school runs.
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Tip 11 Embrace extra-curricular activities to broaden your insight into surgery While on your surgical placement, it is advantageous to be aware of ‘‘extra-curricular’’ opportunities on offer to enhance your Curriculum Vitae (CV) and form a more comprehensive skill set when it comes to academia – especially if you are considering a career in surgery, which is highly competitive. A lot of research in surgery will revolve around patients passing through theatre, which makes it an excellent opportunity to get involved in research from an early stage during surgical placements. Surgeons and senior staff often lack sufficient time for tasks such as data collection and reviewing patient notes for audits etc., so there are usually many opportunities to get involved as a medical student. In addition to providing help to enhance your learning (see Tip 10), mentors can assist in highlighting such opportunities, as you may not necessarily be aware of what is publishable. Additionally, many national and international surgical research collaboratives, covering a range of surgical specialties, exist around the world. Students can often take part in their research, which allows you to work in a team at your local hospital (and be part of a much larger team), gain transferable skills for your future career, and enhance your CV with presentations and publications. Other research opportunities we have become familiar with include case reports/case series, in which interesting surgical patient cases can be written up for publication. Each journal specifies different submission categories, which can include unique surgical presentations, to intriguing anatomical variations or intra/post-operative complications and their management. We have found asking surgical trainees about such research opportunities very worthwhile and rewarding. Besides enhancing your academic portfolio, early surgical placements offer you the chance to learn about a career in surgery. We have found surgical trainees to be most useful for providing career advice as they are at a reasonably early stage of training, and will be familiar with the entry criteria, application process and career path relevant to the country you are in. Importantly, theatre provides an optimal environment to learn about surgery as a career due to the first-hand experience alongside senior staff, as well as the time available
for you to talk with surgeons at opportune moments while they are operating, as generally, they have very busy schedules.
Tip 12 Be acquainted with relevant support systems Finally, it is important to know where to turn if you are having difficulties or if you are concerned in any way, especially considering the importance of your student experience of surgery. Goldacre et al. (2004) showed that 44.9% of students reported that experience of a chosen subject as a medical student influenced their career choice a great deal. As a student, you may become influenced by what you see on your clinical rotations. Your time on surgical placements and in theatres can take a psychological and physical toll on you. Adapting to the lifestyle of a surgeon in the short time you may be on placement can be tough due to early starting times, long and tiresome operation lists and the psychological challenges attached to this and the patients’ conditions. The very nature of surgical placements is unique, and for this reason, you should be aware of relevant support systems in the face of adversity. These include student support services within your medical school, medical defence organisations and fellow colleagues/ senior staff. Depending on the type of support you require, these various support options can be beneficial. For example, if you have had a bad experience with a particular surgeon or have been embarrassed in theatre, you may wish to discuss this with a senior medical student. However, if you have witnessed something concerning, for example regarding patient safety, you may wish to consult higher support systems such as those run by your medical school or medical defence organisations for advice. It is important to address bad experiences early to avoid them impacting on future experiences.
Conclusion As medical students, we often lack optimal knowledge and preparation when facing the unique environment of the operating theatre for the first time. Having to negotiate new social interactions, navigate an unfamiliar environment, while working on our own learning needs in theatre can be disconcerting. There are many ways to enhance the time spent in theatre to make it both an interesting experience as well as a valuable learning process. A positive first experience on surgical placements will form the fundamental groundwork to sparking your interest and potential future career in surgery. Rather than attending theatre apprehensively with little confidence and a negative attitude, an engaging and enthusiastic persona will go further in gaining the surgeon’s trust, resulting in a higher chance of surgeon-led teaching and a more beneficial experience. The key to maximising your time in theatre is truly engaging in tasks within your capabilities, as well as being enthusiastic, professional and well prepared. Attending theatre prepared, while being conscientious about your specific learning desires will lead to an enjoyable and rewarding
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theatre experience. Aspects of being in theatre such as the unusual environment, the emotional provocations and the tendency for syncope may initially seem daunting. These 12 tips outline methods to help you counteract these unfavourable features of being in theatre. We hope that these 12 tips will enable medical students to gain the most out of a limited time in theatre – a time that we, as senior medical students, continue to enjoy and value highly.
Notes on contributors
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DANIEL WEINBERG is a final-year medical student. He is currently investigating the uptake of clinically relevant magnetic nanoparticles in primary neural stem cells during an intercalated MPhil degree. He is passionate about surgery, with a particular interest in evolving therapies, technology, and techniques in surgery. MAHDI SALEH is a final-year medical student. He has an interest in neurosurgery and has undertaken an elective at the Johns Hopkins Hospital. He has been chair of the Keele Neurology Society and an executive committee member of the Keele Surgical Society. YASHASHWI SINHA is a final-year medical student at Keele University Medical School and was chairman of the Keele Surgical Society. He has a keen interest in surgery and has undertaken several months of placements including the following specialties: plastic, trauma & orthopaedic, vascular, general, paediatric and neurosurgery.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.
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Bartlett GE, Pollard TC, Bowker KE, Bannister GC. 2002. Effect of jewellery on surface bacteria counts of operating theatres. J Hosp Infect 52(1):68–70. Creamer J, Davis K, Rice W. 2012. Sterile gloves: Do they make a difference? Am J Surg 204(6):976–979. Dharan S, Pittet D. 2002. Environmental controls in operating theatres. J Hosp Infect 51(2):79–84. Fernando N, McAdam T, Youngson G, McKenzie H, Cleland J, Yule S. 2007a. Undergraduate medical students’ perceptions and expectations of theatre-based learning: How can we improve the student learning experience? Surgeon 5(5):271–274. Fernando N, McAdam T, Cleland J, Yule S, McKenzie H, Youngson G. 2007b. How can we prepare medical students for theatre-based learning? Med Educ 41(10):968–974. Gohel MS, Bulbulia RA, Poskitt KR, Whyman MR. 2011. Avoiding blood transfusion in surgical patients (including Jehovah’s Witnesses). Ann R Coll Surg Engl 93(6):429–431. Goldacre MJ, Turner G, Lambert TW. 2004. Variation by medical school in career choices of UK graduates of 1999 and 2000. Med Educ 38(3):249–258. Healy NA, Glynn RW, Malone C, Cantillon P, Kerin MJ. 2012. Surgical mentors and role models: Prevalence, importance and associated traits. J Surg Educ 69(5):633–637. Jamjoom AA, Nikkar-Esfahani A, Fitzgerald JE. 2009. Operating theatre related syncope in medical students: A cross sectional study. BMC Med Educ 9:14. Lydon C, Burke E. 2012. Students experiences of theatre allocations. J Perioper Pract 22(2):45–49. Lyon PM. 2003. Making the most of learning in the operating theatre: Student strategies and curricular initiatives. Med Educ 37(8):680–688. Lyon P. 2004. A model of teaching and learning in the operating theatre. Med Educ 38(12):1278–1287. Todsen T, Henriksen MV, Kromann CB, Konge L, Eldrup J, Ringsted C. 2013. Short- and long-term transfer of urethral catheterization skills from simulation training to performance on patients. BMC Med Educ 25:13–29. Wieling W, Thijs RD, van Dijk N, Wilde AA, Benditt DG, van Dijk JG. 2009. Symptoms and signs of syncope: A review of the link between physiology and clinical clues. Brain 132(Pt 10):2630–2642. Woodcock T, Wheeler R. 2010. Law and medical ethics in organ transplantation surgery. Ann R Coll Surg Engl 92(4):282–285. Woods NN, Mylopoulos M, Brydges R. 2011. Informal self-regulated learning on a surgical rotation: Uncovering student experiences in context. Adv in Health Sci Educ 16:643–653.
TWELVE TIPS
Twelve tips for medical students to maximise learning in theatre DANIEL WEINBERG1,2, MAHDI SALEH1,2 & YASHASHWI SINHA1,2 1
Keele University, UK, 2University Hospital of North Staffordshire, UK
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Abstract Background: Introduction into the clinical environment can be a daunting experience for medical students, especially in the operating theatre. Prior knowledge of how to prepare for theatre and cope with surgical placements is advantageous, as learning opportunities can be maximised from the start. Aim: This article provides medical students with 12 tips devised to help make the most out of their initial theatre placements. Methods: Tips were formulated based on the experiences of three senior medical students and a review of the literature. Results: The 12 tips are (1) Know the patient and procedure, (2) Be familiar with your surgical department, (3) Familiarise yourself with different surgical attire, (4) Revise your clinical skills, (5) Be time-efficient, (6) Learn how to work in a sterile environment, (7) Avoiding syncope, (8) Impress the operating surgeon, (9) Be aware of the professional, ethical, and legal issues in surgery, (10) Use mentors to enhance your learning, (11) Embrace extra-curricular activities to enhance your insight into surgery and (12) Be acquainted with relevant support systems. Conclusions: These 12 tips provide guidance and opportunities to maximise learning for new clinical-phase medical students being introduced to the operating theatre for the first time.
Introduction
Practice points
Attending theatre for the first time as a student can be a stressful experience. As students beginning clinical placements, you will need to quickly become familiar with navigating theatres, often without prerequisite tours or taught knowledge and skills to prepare yourself. Alongside these broader issues, the lack of knowledge on how to dress properly, how to behave in theatre and about infection control measures can limit your experiences of theatres. Tackling these issues could enhance your learning experience (Lyon 2004). As medical students and future doctors, there is a growing pressure for you to make earlier decisions on a career pathway and prepare accordingly. Considering that your undergraduate experiences are key to career selection (Goldacre et al. 2004), it is important for you to enjoy and learn from your early exposure to the surgical environment. Due to the limited time on surgical firms and in theatre as an undergraduate, exemplary theatre-based teaching is essential in promoting interest and later recruitment into the surgical specialties (Fernando et al. 2007a). Without this, you may simply dismiss surgery as a career option because of the nature of your undergraduate experience, rather than the reality of the specialty itself. Core issues faced by many students attending theatre included the feeling that they are not adequately prepared for what the placement entails, they do not feel welcome, and that they are at the bottom of the surgical hierarchy (Fernando et al. 2007a). Fernando et al. (2007a) found that less than half (44%)
Preparing for your time in theatre can lead to enhanced learning opportunities and an overall experience. Organisation, enthusiasm and engagement are key in establishing surgeon-led teaching. Theatre can be a valuable learning experience, and poses as an opportunity to practice skills and consolidate knowledge.
of final-year medical students received instructions before attending theatre. The lack of preparation resulted in medical students feeling limited in their usefulness, and that attending theatre was a waste of time in relation to exams. This, in conjunction with feeling unwelcome, apprehensive and fearful in theatre, may impact negatively on the relationships you will form with surgeons, and consequently your learning experience (Fernando et al. 2007a). As senior medical students having undertaken many surgical placements during clinical years and student-selected components (SSCs), we have acknowledged these difficulties, which pose a barrier to learning in theatre. From our experiences, and a review of the literature, we have devised 12 tips for medical students to enhance your learning in theatre (Table 1). Learning in theatre can be maximised through sufficient preparation and knowing how to behave and engage
Correspondence: Daniel Weinberg, University Hospital of North Staffordshire, 82 Godwin Way, Trent Vale, Stoke-On-Trent, STAFFS, Staffordshire ST4 6JS, UK. Tel: 07503154460; E-mail: [email protected]
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ISSN 0142-159X print/ISSN 1466-187X online/15/010034–7 ß 2015 Informa UK Ltd. DOI: 10.3109/0142159X.2014.932899
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Table 1. Summary of the 12 tips.
Preparation for theatre is key Know the patient and procedure
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Be familiar with your surgical department Familiarise yourself with different surgical attire Revise your clinical skills Be time-efficient
Maximise learning in theatre Learn how to work in a sterile environment Avoiding syncope Impress the operating surgeon
in learning opportunities while in theatre. Finally, we have proposed general tips regarding broader issues related to learning in surgery, and knowing what to do when confronted with difficulties in theatre. While not all of the tips are directly related to learning tasks, they will help your time in theatre to run more smoothly and increase your confidence and awareness of the learning tasks at hand, consequently enabling you to enhance your overall learning.
Preparation for theatre is key Tip 1 Know the patient and procedure Learning through a patient’s condition, especially within surgery, can be one of the most fruitful and rewarding experiences. Learning about surgical conditions and their management from real-life patient cases is far more rewarding than simply reading such material from books. Further, interacting with surgical patients will enable you to enhance your communication and rapport-building skills, while gaining an understanding of patient-centred care and the bio-psychosocial implications of surgical conditions for patients (Azer et al. 2013). From our experiences, linking surgical conditions to patients you have seen first-hand provides invaluable reinforcement when reading about such disorders and enables you to remember facts more readily in examinations. Lyon (2003) found in a survey that 74% of students agreed, ‘‘Going to theatre gives me a better understanding of surgery than I get from just reading the textbooks’’. We would advise seeing surgical patients pre-operatively, which usually entails an early morning trip to the pre-operative surgical ward. Completing a full history and examination from the patient before they are transported to the anaesthetic room provides an opportunity to learn about the patient’s condition and for comparison of examination findings before and after their operation. Often, based on our experiences, surgeons expect medical students to interview the patients on the morning list so that there is both reinforcement of the patient’s condition and the operation itself. The supervising surgeon truly appreciates this, as it shows you have taken an interest and gone out of your way to prepare for your theatre session. Most operation lists can be viewed in advance, especially if elective. Attending morning ward rounds and checking
Recognising broader issues and relevant schemes to assist learning Be aware of the professional, ethical and legal issues in surgery Use mentors to enhance your learning Embrace extra-curricular activities to broaden your insight into surgery Be acquainted with relevant support systems
operation lists on hospital computers is worthwhile in gaining some background knowledge to the patients and procedures. If unsure, it is well-worth doing some reading about the patient’s condition and planned surgical procedure in advance of their operation. Post-operatively, talking with the patient about their experience and re-examining them (where appropriate) may shed new light onto their clinical course and on their condition. Not only is the learning process enhanced, but also repetition in history taking and examination of the same patient fosters positive reinforcement in remembering that particular case in the long term. Further, paying particular attention to patient notes you see post-operatively and on subsequent ward rounds is worthwhile in gaining understanding of possible post-operative complications.
Tip 2 Be familiar with your surgical department From our experiences, it can take time to become accustomed to the surgical environment. Hence, it is useful to gain familiarity with relevant surgical areas before you are timetabled in for theatre. By knowing your way around the surgical department, you can focus your attention onto your learning needs as well as make yourself more comfortable with planning journeys, not getting lost and the general overwhelming nature of being in theatre for the first time (Lyon 2003; Lydon & Burke 2012). Based on student interviews reported by Lyon (2003) and our experiences, it would be valuable to become familiar with the: Changing room location Pre-operative bay Entrances and exits to and from theatre Correct theatre on the day of the operation Scrubbing area Anaesthetics room Recovery Bay Surgical ward relevant to the operation/specialty It is worthwhile taking a tour around your surgical department before beginning your rotation to become acquainted with such areas. Ideally, a mentor could give you a guided tour and advice to prevent you getting lost during your surgical rotation (see Tip 10).
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Tip 3
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Familiarise yourself with different surgical attire Knowing what to wear when attending theatre will hasten time in the changing room and help diminish surgical site infection. In turn, your supervising surgeon may perceive you as a more competent student, which can result in more teaching (Lyon 2004). We have seen students turned away from theatres by surgeons for not dressing correctly, which stresses the importance of knowing about surgical attire. Five items vital to remember when changing for theatres include: scrub top, scrub bottoms, head cover, suitable shoes and face masks. Scrub suit tops and bottoms are available in various sizes. A good measure to make sure you have the right size is to ensure your top hangs closely to your body. To prevent the shedding of squamous cells within sterile areas, bouffant head covers or surgical hoods should be worn, which should cover the extent of the hairline as much as possible. Shoes with closed ends without holes are recommended to reduce your risk of injury and spillage on underlying socks (AORN Recommended Practices Committee 2005). We recount several experiences where we wore shoes belonging to the surgeon we were about to scrub in with! Avoiding the shoes marked with names or initials should save you this embarrassment. Facemasks are essential to wear if scrubbing up or near the sterile surgical site. If you are assisting, the use of other equipment such as protective eyeglasses may be appropriate if splashing or spraying is likely (AORN Recommended Practices Committee 2005). As surgical staff in scrub suits are fairly indistinguishable, your ID badge should be clearly displayed to avoid confusion with other staff members. Jewellery acts as a well-known growth site for bacteria (Bartlett et al. 2002). It is therefore important that you remove any rings and ensure nose and ear piercings are fully covered to maintain theatre discipline. Upon leaving the theatre area, used scrub suits, face masks and surgical hoods should be appropriately disposed of either for laundering or into the clinical waste bins depending on your facility’s protocols. You can often wear a white coat over scrub suits when temporarily visiting other hospital areas, although there is little evidence to support that this reduces contamination (AORN Recommended Practices Committee 2005). It is essential to realise that the surgeon’s perception of a medical student is an important factor regarding surgeon-led teaching in theatre (see Tip 8). Therefore, dressing appropriately and looking professional will form the immediate impression of a competent medical student.
Tip 4 Revise your clinical skills Time in theatre gives you ample opportunity to practice clinical skills, including basic suturing, wound care, catheterisation, and cannulation. Considering that all patients require intravenous cannulation and usually catheterisation too, there should always be opportunities to practice these in and around theatre. Additionally, skills concerning anaesthesia such as 36
basic airway management can be practiced in the anaesthetics room under close supervision from experienced anaesthetists. We have found that taking the opportunity to suture and dress wounds is a much more realistic and stimulating experience compared to practicing on manikins. Given that patient consent has been attained, you may feel more at ease being able to practice certain skills on patients once they have been anaesthetised, as you can focus purely on the technical aspects as opposed to communication skills too. In order to smoothly translate your clinical skills learnt on manikins to real patients, it is best to practice these skills on patients soon after being taught. Hence, it is well worth revising these your clinical skills before the opportunity arises to practice and consolidate them with real surgical patients. It is highly dependent on the medical school but it has been shown that transfer of skills in urethral catheterisation from simulated training to real patients can be effective for up to six weeks (Todsen et al. 2013). Approaching the end of your studies at medical school, and as the looming prospect of becoming a newly qualified doctor approaches, it is important to be competent as well as confident in performing these clinical procedures. With this in mind, surgical placements provide substantial opportunities to practice and consolidate your clinical skills, which is more useful when those skills are fresh in your mind from recent revision.
Tip 5 Be time-efficient Organising your time efficiently before and during theatre is vital. Putting aside time to prepare for a specific operation list, physically getting to theatre within good time and using your time in theatre wisely can enhance your learning and lead to a more positive experience. Further, it is in your interest as a busy medical student to embrace the learning opportunities at hand in a time-efficient manner, due to the high workload of the course. Do not underestimate the time it may take to change for theatre. It only takes some difficulty finding a pair of shoes to delay your arrival and introduction to the theatre team. Arriving early will allow you to introduce yourself to the other staff as they come, and if there is a briefing before the start of the operating list, it is common etiquette to attend. This will ensure that everyone is aware of your presence, and a punctual arrival will show that you are enthusiastic. Surgeons often arrive early to review patient clinical details or scans. We have found this a great opportunity to introduce yourself, ask questions, ask if you can scrub in and show motivation to learn and participate. Although you may feel towards the bottom end of the hierarchy in theatre, arriving early may lead to a better viewing position, which students find essential towards learning in theatre (Lyon 2003). Initially, time in theatre can be challenging as you have to pick up cues on the run, have reduced patient contact, feel in the way, stand around for long periods, are unable to participate and feel bored (Lydon & Burke 2012). In contrast, understanding to recognise and engage in learning
Learning in theatre
opportunities from the outset will maximise your time efficiency and lead to an enhanced educational experience. If all fails in the learning experience, you can maximise your time in theatre by bringing a medical/surgical textbook to read until an opportunity arises to adopt a more active role.
from the ceiling (Dharan & Pittet 2002). It is important to realise that you should not stand within this square area during an operation, unless appropriately scrubbed in and with a facemask, to reduce contamination of implants. If you are unsure about sterility, always ask a member of the theatre staff.
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Maximise learning in theatre In a study by Woods et al. (2011), one of the approaches to learning during surgical rotations was through creation of learning opportunities using self-initiative. Within this context, learning opportunities can be maximised in a time-efficient manner by deciding what you want out of your time in theatre, and then doing it. Strategically positioning yourself during theatre and between different theatres to be considered part of the team, for example within theatres with less trainees, will enable you to maximise learning at every moment as more learning opportunities will be available.
Tip 6 Learn how to work in a sterile environment One crucial factor especially important in theatre is the preservation of a sterile environment, which is why learning how to work and navigate safely in a sterile surgical area is vital (Creamer et al. 2012). Furthermore, knowledge about sterility can also help avoid unnecessary embarrassment. By maintaining sterile conditions peri-operatively, the risk of post-operative infections is lower and therefore patient recovery is quickened. Importantly, approximately 76% of consultant surgeons and 85% of senior medical students were shown to regard adherence to sterility in the operating theatre as essential (Fernando et al. 2007b). From our experiences, competency in this area can increase the operating surgeon’s trust in you, and result in more opportunities to assist in surgery and be taught. In contrast, students who jeopardise sterility through carelessness are sometimes regarded negatively – potentially limiting your learning opportunities. We have found asking theatre nurses how to properly scrub in theatre is the best and most efficient way to learn this essential skill. You should not be embarrassed to ask for their supervision while learning to scrub up; they will appreciate your sensibility and desire to refine technique and maintain sterility. Sterility not only involves scrubbing in correctly, but also knowing what is sterile and what is not sterile once in theatre. Once staff members in theatre are ‘‘gowned and gloved’’, it is extremely important to keep clear of them unless also scrubbed in and sterile. Further, the sterile drapes used to create a sterile field over the patient and surgical equipment must be avoided unless you are scrubbed in, meaning extra care should be taken while navigating yourself around theatre – especially in confined spaces. When scrubbed in, keeping your hands well above your waist is important to lessen the chance of accidental contamination. Some theatres – notably orthopaedic – contain laminar flow ventilation systems, evident by the box-shaped units arising
Tip 7 Avoiding syncope It is well known that introduction to theatres for the first time is daunting and can be just as much an emotional experience in addition to an educational one (Lyon 2003). This emotion, in addition to poor hydration, low sugar levels and standing for long periods can cause you to feel faint, which is certainly something to avoid while in theatre. Experiencing an episode of syncope as a medical student in theatre is not uncommon, as found by Jamjoom et al. (2009). A total of 12% of students reported an episode of near or actual syncope in theatre, 32% of which lost consciousness. Females are more likely to undergo a syncopal episode in theatre (88% females versus 12% males). The following factors in order of popularity were identified: Warm temperature in theatre (79%) Length of time standing (73%) Surgical mask (47%) Smell of diathermy (23%) Menstruation (17%) There are preventative measures you can take to help avoid syncope in theatre. Keeping well hydrated and having a substantial (but not overindulgent) meal before theatre will help prevent syncope, which is what the majority (61%) of students did to prevent a second recurrence (Jamjoom et al. 2009). If standing in the same spot for extended periods, tensing your calves can help counter orthostatic intolerance. Such leg movements were performed by 18% in the above study. 18% and 12% of students in the study sat down or took a break from assisting respectively, to prevent a second recurrence of syncope. A common misconception is that scrubbing in is associated with increased syncope rates. However, one of the measures taken to help avoid syncope is increased attendance to the operating theatre (Jamjoom et al. 2009), as we too have found with personal experience. The anxiety surrounding theatres as an unfamiliar environment can potentially lead to syncope. With this in mind, mentally preparing yourself by speaking to fellow students about what to expect in theatre can help. Staff occasionally play music that they have brought to theatre, which we have found could be used as a distraction technique if anxious. Prodromal symptoms including a feeling of warmth or nausea, a need to sit down, blurring of vision or black spots in the visual field can be present in vasovagal and orthostatic hypotensive-related syncope (Wieling et al. 2009). If you experience these prodromal symptoms, it is best to notify a staff member in good timing. The staff will appreciate this and direct you to somewhere you can sit.
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Tip 8
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Impress the operating surgeon There is evidence that student motivation is essential in gaining the surgeon’s interest in providing teaching (Lyon 2004). Hence, being competent in areas such as knowing the patient and their condition (Tip 1), knowing what to wear (Tip 3), and maintaining sterility (Tip 6) will impact positively on the operating surgeon, which may encourage the surgeon to teach you and will maximise your learning in theatre. Considering the operating surgeon is responsible for the rest of their team in theatre, being aware of the dynamics of all staff members in theatre affords a huge advantage. Learning how to work as part of a team is an essential part of medicine. Your time in theatre will involve much teamwork to partake in, for example: transferring patients in the operating theatre, liaising between staff and assisting in operations. Engaging in these activities, we have been able to comfortably fit into our own role as medical students within theatres and feel part of the team. We have found that being available to assist in surgery, pass on messages and get involved in teamwork will impress the surgeon and lead to a positive surgeon-student relationship and more teaching opportunities. With the surgeon often regarded as a ‘‘high-profile’’ figure in theatres, it is not uncommon that medical students are worried about embarrassing themselves in theatre and especially in front of the surgeon. One study found that over 70% of medical students interviewed agreed that embarrassment in theatre is common (Lyon 2004). Ways that this could happen include asking questions at the wrong time or at an intricate part of the procedure, getting in the way of theatre staff, wearing the gown the wrong way and even contaminating sterile areas by accident. Therefore, it is important to be aware of the environment while in theatre, and the fact that all medical students experience the same degree of apprehension and hesitancy in undertaking an active role within the team (Lyon 2004). Being a competent and confident team player in theatre will inevitably form a positive impression on other staff members and importantly the operating surgeon, which will lead to an enhanced overall experience. Intra-operatively, students may often not engage as fully after making a judgement that surgeons are less ‘‘studentorientated’’ (Lyon 2004). If this is the case and you feel that the surgeon is unfriendly to students, speaking to and learning from the anaesthetists and scrub nurses can provide some useful learning, as they are often able to lend teaching time between their duties.
Recognising broader issues and relevant schemes to assist learning Tip 9 Be aware of the professional, ethical, and legal issues in surgery Learning about these issues early on will enable you to make informed decisions on the care of surgical patients as a future doctor, and many of these principles are examinable too. 38
Professionalism in theatre and adapting to the surgeon’s environment is partly intuitive and partly learned. Getting a feel for the environment is essential, as for example; some surgeons favour playing music while operating and others may prefer silence. Although the environment is unique and arguably more relaxed in theatre, it is important to maintain professional practice alongside peers, patients and other staff. According to the surgical specialty you experience in theatre, you can relate to relevant ethico-legal issues that form an essential part of the medical curriculum. For example, in paediatric surgery you should be aware of the protocol for suspected child abuse and child protection issues. In transplant surgery, issues with transplant tourism, how organs are retrieved and the selection of patients can be explored (Woodcock & Wheeler 2010). Several learning objectives are highlighted here – for example, what are the prerequisites for liver transplantation and the associated ethical debates with regard to patients with alcohol dependence and these procedures? Patients that refuse the transfusion of blood products on the basis of religious prohibitions has led to the advent of ‘‘bloodless surgery’’, whereby strategies are employed to reduce blood loss during surgery (Gohel et al. 2011). These principles have since become commonplace for many surgical procedures, and you can learn about them in theatre by speaking to surgeons and anaesthetists. Speaking to patients from different religious backgrounds provides invaluable insight into religious opinions on transplant surgery, cosmetic surgery and blood transfusions, and highlights related issues faced by surgeons. In summary, understanding ethico-legal issues in surgery will help to make informed decisions regarding the care of surgical patients, and will guide your professional practice as a future doctor.
Tip 10 Use mentors to enhance your learning You may feel inadequately prepared and unsure of what your learning aims are, and how you will achieve them within such constrained time limits in theatre. Studies show that role models in the form of mentors can influence medical student’s career choices, and that medical students with a positive surgical mentor are more encouraged to pursue careers within surgery (Healy et al. 2012). With this in mind, a senior mentor can lead you to find greater interest in your surgical placements in addition to helping you learn efficiently. As mentoring schemes involving surgical trainees and consultants are often lacking in prevalence, finding a senior medical student willing to mentor you is invaluable and should not be underestimated. Having already been through the same experience, a senior medical student can provide beneficial advice on the best ways to learn, how to get around and what to focus on considering the learning objectives. Considering senior medical students are aware of the position you find yourself in during surgical placements, they can help you to navigate the educational, social and environmental difficulties you may face – something we have found extremely useful
Learning in theatre
during our time on surgery. For example, senior medical students acting as mentors can: Highlight student-friendly surgeons who are most likely to teach Explain tasks to undertake when faced with spare time in theatres Recommend learning resources to enhance your learning specific to the expectations for your year group Give you a guided tour of the surgical department and theatres prior to your placement We have found senior medical students willing to mentor us either through being on the same surgical attachment, the medical school surgical society or other mentoring schemes that the medical school runs.
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Tip 11 Embrace extra-curricular activities to broaden your insight into surgery While on your surgical placement, it is advantageous to be aware of ‘‘extra-curricular’’ opportunities on offer to enhance your Curriculum Vitae (CV) and form a more comprehensive skill set when it comes to academia – especially if you are considering a career in surgery, which is highly competitive. A lot of research in surgery will revolve around patients passing through theatre, which makes it an excellent opportunity to get involved in research from an early stage during surgical placements. Surgeons and senior staff often lack sufficient time for tasks such as data collection and reviewing patient notes for audits etc., so there are usually many opportunities to get involved as a medical student. In addition to providing help to enhance your learning (see Tip 10), mentors can assist in highlighting such opportunities, as you may not necessarily be aware of what is publishable. Additionally, many national and international surgical research collaboratives, covering a range of surgical specialties, exist around the world. Students can often take part in their research, which allows you to work in a team at your local hospital (and be part of a much larger team), gain transferable skills for your future career, and enhance your CV with presentations and publications. Other research opportunities we have become familiar with include case reports/case series, in which interesting surgical patient cases can be written up for publication. Each journal specifies different submission categories, which can include unique surgical presentations, to intriguing anatomical variations or intra/post-operative complications and their management. We have found asking surgical trainees about such research opportunities very worthwhile and rewarding. Besides enhancing your academic portfolio, early surgical placements offer you the chance to learn about a career in surgery. We have found surgical trainees to be most useful for providing career advice as they are at a reasonably early stage of training, and will be familiar with the entry criteria, application process and career path relevant to the country you are in. Importantly, theatre provides an optimal environment to learn about surgery as a career due to the first-hand experience alongside senior staff, as well as the time available
for you to talk with surgeons at opportune moments while they are operating, as generally, they have very busy schedules.
Tip 12 Be acquainted with relevant support systems Finally, it is important to know where to turn if you are having difficulties or if you are concerned in any way, especially considering the importance of your student experience of surgery. Goldacre et al. (2004) showed that 44.9% of students reported that experience of a chosen subject as a medical student influenced their career choice a great deal. As a student, you may become influenced by what you see on your clinical rotations. Your time on surgical placements and in theatres can take a psychological and physical toll on you. Adapting to the lifestyle of a surgeon in the short time you may be on placement can be tough due to early starting times, long and tiresome operation lists and the psychological challenges attached to this and the patients’ conditions. The very nature of surgical placements is unique, and for this reason, you should be aware of relevant support systems in the face of adversity. These include student support services within your medical school, medical defence organisations and fellow colleagues/ senior staff. Depending on the type of support you require, these various support options can be beneficial. For example, if you have had a bad experience with a particular surgeon or have been embarrassed in theatre, you may wish to discuss this with a senior medical student. However, if you have witnessed something concerning, for example regarding patient safety, you may wish to consult higher support systems such as those run by your medical school or medical defence organisations for advice. It is important to address bad experiences early to avoid them impacting on future experiences.
Conclusion As medical students, we often lack optimal knowledge and preparation when facing the unique environment of the operating theatre for the first time. Having to negotiate new social interactions, navigate an unfamiliar environment, while working on our own learning needs in theatre can be disconcerting. There are many ways to enhance the time spent in theatre to make it both an interesting experience as well as a valuable learning process. A positive first experience on surgical placements will form the fundamental groundwork to sparking your interest and potential future career in surgery. Rather than attending theatre apprehensively with little confidence and a negative attitude, an engaging and enthusiastic persona will go further in gaining the surgeon’s trust, resulting in a higher chance of surgeon-led teaching and a more beneficial experience. The key to maximising your time in theatre is truly engaging in tasks within your capabilities, as well as being enthusiastic, professional and well prepared. Attending theatre prepared, while being conscientious about your specific learning desires will lead to an enjoyable and rewarding
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theatre experience. Aspects of being in theatre such as the unusual environment, the emotional provocations and the tendency for syncope may initially seem daunting. These 12 tips outline methods to help you counteract these unfavourable features of being in theatre. We hope that these 12 tips will enable medical students to gain the most out of a limited time in theatre – a time that we, as senior medical students, continue to enjoy and value highly.
Notes on contributors
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DANIEL WEINBERG is a final-year medical student. He is currently investigating the uptake of clinically relevant magnetic nanoparticles in primary neural stem cells during an intercalated MPhil degree. He is passionate about surgery, with a particular interest in evolving therapies, technology, and techniques in surgery. MAHDI SALEH is a final-year medical student. He has an interest in neurosurgery and has undertaken an elective at the Johns Hopkins Hospital. He has been chair of the Keele Neurology Society and an executive committee member of the Keele Surgical Society. YASHASHWI SINHA is a final-year medical student at Keele University Medical School and was chairman of the Keele Surgical Society. He has a keen interest in surgery and has undertaken several months of placements including the following specialties: plastic, trauma & orthopaedic, vascular, general, paediatric and neurosurgery.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.
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