Effective Teaching in the Operating Room



Changes in work hours pose major challenges to surgical education and training in residency programs (1). In the midst of these changes, resident physicians are still expected to perform more cases in the operating room, take care of more complex patients, and learn about rapidly evolving minimally invasive surgical techniques (1,2). Even with the increasing number of skills laboratories being built around the world, the operating room (OR) remains a critical site for honing intraoperative skills (2). Yet, the OR remains the least structured and studied format for teaching surgery (2).

Surgical mentors, therefore, play an important role in the educational development of medical students, resident physicians and fellows (3-5). However, educational opportunities between surgical mentors and resident physicians are often brief, spontaneous and opportunistic events (6). In addition, very few surgical mentors possess any formal background in cognition and learning; their teaching setting is within a busy, complex hospital environment; and unlike other professional education teachers, surgical mentors have to tandem their teaching responsibilities with patient care (3-5). This article, therefore, summarizes the current literature pertaining to effective teaching the OR, as well as other important determinants of effective educational encounters, and makes suggestions on how to implement these in practical settings.

Learning Surgical Skills

Developing into a competent surgeon requires acquisition of both cognitive and motor skills, and many aspects of these skills can be achieved outside the OR (4). Surgical anatomy can be mastered using surgical atlases and cadaveric dissections (4). Similarly, steps of the procedure and instrumentation can be memorized and simulated by the resident physician alone and in preoperative conferences (4). Motor skills can be practiced in surgical skill laboratories, and models and simulators can be used for more complex skills (4). Certain essential components such as the way tissues feel when the surgeon is in the correct surgical plane, however, must be mastered in the OR. Only by seeing visual and spatial relationships, exploring tissue planes and textures, and observing surgeons in real cases can the resident physician fully develop a solid mental image of the skills to be learned (4). The final step in surgical competency involves automatization, and requires real OR experience and repetition (4). The ability to perform a surgical case from start to finish, adapt to the particulars of that case and the patient’s anatomy, and direct surgical assistants and other OR personal requires OR experience (4).

Tips to Promote Effective Teaching in the OR

Pre-OR (6)

  1. Create a constructive learning environment
    Learning occurs the most when resident physicians are legitimate participants in clinical activities. This means giving them meaningful tasks to involve them in every activity that they will eventually perform independently.

  2. Individualize each educational encounter
    Resident physicians learn effectively when material is related to their previous experiences and is relevant to real-life problems they expect to encounter. New learning that is integrated with existing knowledge is more likely to remain stable over time.

  3. Actively engage
    Durable learning involves a cycle of action or experience, reflection on the experience, formation of abstract concepts, and further action.

In the OR (4,6)

  1. Make expectations clear
    Expectations are set before starting each surgical case. All teams in the OR function better when everyone clearly understands his or her role.

  2. Teach basic principles
    Invoking principles and general concepts can encourage higher-order thinking. One approach is to teach the principle and then, in collaboration with the resident physician, highlight the intraoperative application of the principle.

  3. Provide Inspiration
    Motivation improves learning. An enthusiastic surgical mentor who conveys his or her passion for the subject is one of the best motivating factors for a resident physician.

Post-OR (6)

  1. Feedback
    Giving feedback is a particularly important function of a surgical mentor because it is very difficult for resident physicians to assess their own progress accurately. If it is to be useful, feedback must be given in a non-threatening and constructive way. It is important to emphasize the resident physician’s strengths and reinforce these behaviors. In practice, this can be achieved by asking the resident physician to identify what they did well, followed by positive comments from the surgical mentor. The resident physician is then asked to identify what could be improved and how, followed by the mentor’s suggestions

  2. Stimulate self-directed learning
    An important role of a surgical mentor is to help the resident physician identify appropriate directions and resources for continued growth of knowledge. In practice, this means helping resident physicians construct answerable clinical questions and suggesting resources where the answers might be found.


Much surgical education continues in an informal setting, during brief, impromptu educational encounters in the OR (4). Although the OR remains the most widely used format for teaching surgical skills, the number of hours that resident physicians spend in the OR continues to decrease (6). In addition to developing other formats for honing cognitive and technical surgical skills, surgical mentors must seek every opportunity to direct, critique and actively teach resident physicians in the OR (4,5). Although this article reviews several teaching techniques, high-quality prospective educational research is still needed to assess strategies to teach effectively in the OR.


  1. Pugh CM, DaRosa DA, Glenn D, Bell RH Jr. A comparison of faculty and resident perception of resident learning needs in the operating room. J Surg Educ. 2007 Sep-Oct;64(5):250-5.
  2. Pugh CM, DaRosa DA, Glenn D, Bell RH Jr. A comparison of faculty and resident perception of resident learning needs in the operating room. J Surg Educ. 2007 Sep-Oct;64(5):250-5.
  3. Cox SS, Swanson MS. Identification of teaching excellence in operating room and clinic settings. Am J Surg. 2002 Mar;183(3):251-5.
  4. Kenton K. How to teach and evaluate learners in the operating room. Obstet Gynecol Clin North Am. 2006 Jun;33(2):325-32.
  5. Fenner DE. Avoiding pitfalls: lessons in surgical teaching. Obstet Gynecol Clin North Am. 2006 Jun;33(2):333-42.
  6. Jeffree RL1, Clarke RM. Ten tips for teaching in the theatre tearoom: shifting the focus from teaching to learning. World J Surg. 2010 Nov;34(11):2518-23.

Reviewed for March 2014 by
Nigel Pereira, MD
Department of Obstetrics and Gynecology,
Drexel University College of Medicine,
Philadelphia, PA