It's worth the wait: optimizing questioning methods for effective intraoperative teaching

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The structure of surgical residency education has seen a significant shift in the last two decades. Heightened regulations for resident duty hours in the setting of increased surgical complexity – in part from rising patient acuity, comorbidities and technological innovations – requires residents learn more knowledge and skills in less time.1 Serendipitous learning, a tenant of the past, is no longer sufficient and strategic efforts at improving resident education have been undertaken nationally.3 Despite efforts aimed at improving residency education, many surgery graduates do not feel confident in their ability to perform operations independently.5 In a 2009 nationwide study, 27.5% of residents did not feel confident in their ability to operate autonomously and we contend that this number is likely an underestimation as increased work hour restrictions have been implemented in the interim.6 Furthermore, attending surgeons deem 21% of surgery graduates unprepared for fellowship.7 Concerns for educational outcomes are a call to action for optimizing teaching and learning during residency training.7
The operative suite is a learning environment unique to surgery residency; a signature pedagogy of the profession that is ripe for focused educational enhancements by both faculty and trainee.8 Although consisting of only 6–12% of duty hours, intraoperative learning time is a crucial period for education and endowing residents with the tools necessary for autonomous practice.10 Given the high stakes environment in which trainee error can result in significant patient harm, developing the optimal teaching environment and interactions has become the focus of many surgical educators across the nation.1 In particular, injecting pedagogical best practices, methodologies and theories into intraoperative teaching has the potential to improve resident learning, confidence and achievement of the overarching goal of effective, autonomous, attending surgeons.5
An aspect of education that has been extensively studied is that of questioning.13 Famously utilized by the philosopher Socrates, the power of questioning to induce learning and development has provided a scaffolding for teaching for centuries.14 More recently, education specialists have further investigated the art of questioning to better understand how to strategically utilize different types of questions to increase learner involvement and retention.15 Two components of interest with regard to question investigation are that of question complexity and learner wait time.16 We sought to investigate both these outcomes in the intraoperative environment.
Not all questions are of the same complexity; therefore, the thinking that is required for question response varies. Harnessing the variability in questions to engage the learner to think beyond basic facts has led to the development of questioning frameworks. Although many different taxonomies for cognitive learning exist, one of the most prominent is the revised Bloom's Taxonomy.16 This classification was first introduced by educational psychologist Benjamin Bloom in 1956 as a way to organize cognitive domain of learning and propel learners into higher and more complex thinking.16 Updated in 2000, the revised Bloom's Taxonomy divides learning objectives into six categories – each with successive complexity – remembering, understanding, applying, analyzing, evaluating, and creating.19 The first level, remembering, asks the learner to recall and remember basic knowledge facts. Understanding reaches further, requiring the learner to not just memorize the information but have a comprehension of its meaning. Application refers to understanding and knowledge in a certain scenario – the learner must understand the concepts at hand and be able to use them in concrete situations. Next, analyzing, asks of the learner to break down information and into pieces and relate those pieces to another for answer formulation.
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