How to Walk the Line Between Letting the Residents do the Surgery Versus Doing it Yourself as an Early Career Faculty

Cara Cipriano MD, FAAOS | Daniel Osei, MD, MSc, FAAOS

August 17, 2021


There are many reasons why orthopedic surgery residents choose to pursue an academic career (Figure 1). Often referred to as the “triple threat”, academic surgeons are characterized as those who show excellence in surgery, research and education. In truth, all surgeons vary in aptitude and enthusiasm for the myriad job-related responsibilities. However, there is little doubt that the ability to educate young orthopedic surgeons is universally important to all of us. The ability to inspire, mentor, and nurture our specialty’s future surgeons is both an incredibly fulfilling pursuit and a wonderful way to honor those who did the same for us.

Figure 1

Given the importance of the job, becoming an effective surgeon educator is critical. Nowhere is the weight of the job more palpable than in the operating room, where a patient has placed their outcome and well-being in your hands. For a young academic surgeon, the ability to educate orthopedic residents and fellows is complicated by the need to continue his or her own development as a surgeon. Studies have consistently demonstrated the association between surgical volume or surgeon age and outcomes1–4. Given the evidence, how should a young academic surgeon balance the seemingly oxymoronic imperatives to become an excellent teacher and an excellent surgeon?

As I reflect upon the first 9 years of my career, it is apparent that there is no universal right answer to these questions. There are however, a number of principles that can help guide the young academic surgeon.

  • To become an excellent surgeon educator, become an excellent surgeon first.

It is often said that “those who can’t do, teach”. In surgery, this is patently false. One of the greatest teaching tools I use in the operating room is to allow a resident or fellow to struggle. Iterating, thinking on one’s feet, and even making a few (non-catastrophic) mistakes can make all the difference to the trainee. If you as the young surgeon can’t fix the mistake (or worse still, don’t recognize the mistake), you can’t afford to let the trainee struggle. In our institution, we typically let young surgeons spend the first year operating with Physician Assistants as a first assist. Freed of educational responsibilities in the OR, the young surgeon is afforded time to accelerate their own learning curve and to develop his or her own surgical strategies and approaches to cases. When integrated into the teaching faculty, the young surgeon is more confident, and is ready to contribute meaningfully to the surgical education of trainees.

  • It is okay to pick and choose when to let your trainee operate as “primary surgeon”

Not every procedure should follow the “see one, do one, teach one” mantra often cited as the model for surgical education. A periacetabular osteotomy is not the same as a primary total hip arthroplasty. An anterior interosseous to ulnar motor branch nerve transfer is not the same as a carpal tunnel release. Have the confidence to pick and choose when to take over and teach by demonstration, and when to teach by handing over the scalpel. Remember that teaching a trainee a procedure is not just about getting them from start to finish. It is about all the little details in between. Soft tissue dissection, handling of instruments, when to be deliberate and slow down versus when to pick up the pace, these are the details that take a surgeon from adequate to excellent. Your trainees will all be eager and excited to do as much as possible. In your early career, remember that part of your value as an educator is modeling all the soft skills that residents and fellows have yet to develop. Your ability to teach surgical judgement, perhaps the most important skill at a surgeon’s disposal, cannot be taught without having faced challenges yourself. Conversely, at a time in your career when your schedule is likely less busy than it will be in the future, give your trainees the gift of patience to operate as primary surgeon in cases that are appropriate. They will appreciate your willingness to do so and will be more understanding of the times that you need to take over the case.

  • You don’t need to use a one size fits all approach to surgical education.

All residents and fellows have a different set of strengths and weaknesses. A young academic surgeon needs to develop an ability to tailor their approach to surgical education according to the skills of the trainee with whom he or she is working. A PGY-2 resident is not the same as a fellow, but remember that there is incredible variation within each group. Use simple cases as an assessment tool to figure out where your trainee is on the path to becoming a competent surgeon. Encourage your trainees to be actively engaged in the presurgical planning and decision making. When your resident or fellow feels empowered to contribute meaningfully before surgery, they are likely to perform better during surgery. This will, in turn. allow you to let your trainee operate more.

As a young academic surgeon, the responsibilities and pressure to perform can feel overwhelming. Imposter syndrome is common among young surgeons who compare themselves to their more experienced and accomplished colleagues and are left with a feeling that he or she will never measure up to the impossibly high standard of those around them. Remember that teaching is not a strictly altruistic endeavor. As described by Paul Manske, master surgeon and educator, there is a paradoxical role of teaching and learning shared by those who teach and those who are taught; the two roles are intrinsically intertwined5. A teacher learns from his students what he or she does not know, which motivates the teacher to continue learning. For the young academic orthopedic surgeon, this is an important point to remember and should motivate the surgeon to see the decision to let trainees operate not as a challenge, but as a mutually beneficial opportunity.

References

1.          Farley KX, Schwartz AM, Boden SH, Daly CA, Gottschalk MB, Wagner ER. Defining the Volume-Outcome Relationship in Reverse Shoulder Arthroplasty: A Nationwide Analysis. Journal of Bone and Joint Surgery – American Volume. 2020;102(5):388-396. doi:10.2106/JBJS.19.01012

2.          Kazarian GS, Lawrie CM, Barrack TN, et al. The Impact of Surgeon Volume and Training Status on Implant Alignment in Total Knee Arthroplasty. Journal of Bone and Joint Surgery – American Volume. 2019;101(19):1713-1723. doi:10.2106/JBJS.18.01205

3.          Satkunasivam R, Klaassen Z, Ravi B, et al. Relation between surgeon age and postoperative outcomes: A population-based cohort study. CMAJ. 2020;192(15):E385-E392. doi:10.1503/cmaj.190820

4.          Bridgewater B, Grayson AD, Au J, et al. Improving mortality of coronary surgery over first four years of independent practice: Retrospective examination of prospectively collected data from 15 surgeons. British Medical Journal. 2004;329(7463):421-423. doi:10.1136/bmj.38173.577697.55

5.          Manske PR. Teaching – The second most important thing we do. Journal of Hand Surgery. 2003;28(4):553-554. doi:10.1016/S0363-5023(03)00261-2

Figure 1- Common reasons for choosing a career as an academic orthopedic surgeon


DISCLOSURES: Dr. Cipriano KCI: Paid consultant, Link Orthopaedics: Paid consultant, Musculoskeletal Tumor Society: Board or committee member Dr. Osei has no active consultant relationships, Committees: ASSH Council, Member at Large; ASSH Publications and Products Advisory Committee; ASSH Diversity Committee; Co-Chair ASSH Research Management Committee; Associate Editor, Journal Hand Surgery.

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