D. Joanna Kim, MD | Liana J. Tedesco, MD
March 15, 2023
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Improving surgical skill is critical to becoming a successful orthopedic surgeon. The reality is that not all residents begin at the same place in terms of technical ability. However, with appropriate motivation and practice, there are opportunities to improve both in and out of the operating room. We hope these tips will help anyone who is looking to improve.
The best piece of advice I received as a junior resident was, “treat every consult procedure as if it were a surgery.” Think through every step before (think “skin to skin”) and get the supplies ready for each step. If necessary, write it down! For a laceration repair, for example, make sure you have all the equipment you need including the appropriate suture options and the right light. Ensure you have the right table and a chair or stool if you want to sit. Preparing for these small procedures in the emergency room as if they were a surgical procedure will help to develop not only your technical surgical skill as a resident, but also your ability to efficiently flow through a case.
Learning and knowing the criteria for operative vs non-operative treatment is a critical skill that must be learned as junior residents. If you are the consult resident, think through each consult, make appropriate measurements on each radiograph, and know the exact indications of the correct treatment pathway – nonoperative vs operative. For example, measure the radial height, radial inclination, volar tilt, and articular step-off for distal radius fractures on all pre- and post-reduction radiographs. Are your measurements satisfactory? If it is operative, why does it meet the criteria? What other tests or imaging should be performed? Thinking through various treatment options and knowing operative indications is one skill to master as a junior resident.
Whether you are in the emergency room or operating room, think anatomy, anatomy, and more anatomy. The foundation of surgery is mastering anatomy and knowing what structures to avoid. One of my attendings told me that being a great surgeon is knowing when to slow down and knowing when you are safe; this all comes with understanding the anatomy. Beyond this, when you are scrubbed as first or second assist, watch how your seniors or attendings hold the knife or instruments. Practice holding these instruments and making them familiar in your hands. Whether you are doing the approach or helping retract, always be there to learn – memorize each step of the approach as if you are doing the next case. Try to anticipate what the next two steps of the surgery would be, and if appropriate, ask for the correct instruments at the right time. Mental rehearsal has been shown to dramatically improve performance.
Lastly, don’t be afraid to ask questions. Ask your senior resident or attending their thought process for selecting the specific pathway. Take voluminous notes and start a living document and constantly add to it as you progress throughout your training.
As you progress through training, the key is reps, reps, reps. Scrub in as many cases as you can. There is truly nothing that can replace technical practice. However, it is not only the act of doing surgery that allows you to improve your skill. It is also the post-case reflection. Whether you have a notebook you carry or use a living document on your computer, at the end of each case it is crucial to debrief. Ask yourself, “what went well and what could have gone better?” And don’t forget to analyze the critical “why?” For example, if you had difficulty while exposing the glenoid in a shoulder arthroplasty, was it because of the retractor placement or positioning of the arm?
In surgical training, residents may not personally be performing EVERY step of the case. For the portions of the case where you are assisting, make sure you aren’t just observing what is happening in the surgical field, but also the way the attending positions him/herself in relation to the surgical field. These observations can help you more efficiently perform surgery and help to reduce steps. Be sure to ask questions in real time (if the situation allows), such as the reasoning behind a particular suture use or a retractor placement. Being able to synthesize this information at the time of the surgical step will help to remember and, in turn, document.
Beyond repetition, self-reflection and documentation, there are other opportunities to build your technical skill outside of the operating room throughout residency. Attending courses with cadaveric surgery is an invaluable experience (these counts as reps!) Speak with the educational leadership at your residency to coordinate a cadaver lab at your institution. Investigate society- and industry-sponsored multi-day courses. These opportunities are everywhere, you just have to look! Attend these courses as much as allows. The hands-on experience can also be a great opportunity to improve surgical teaching skill for senior to junior residents in a more controlled, stress-free environment.
Outside of the surgical realm, there are home-based hobbies you can pursue to improve dexterity. Whether it is knitting a sweater or building a bench in your garage, the skills we as orthopedic surgeons use in the operating room are ever present. Use any opportunity you can to improve your technical skill during residency to maximize your potential!
DISCLOSURES: Dr. Kim This individual reported nothing to disclose. Dr. Tedesco This individual reported nothing to disclose.
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