We set out to review the published literature relating to the educational experiences of medical students in the operating theatre. In particular, we wished to deduce from the current evidence what challenges are posed to student learning in this environment, and how they may be overcome.
National Library of Medicine and Google Scholar databases were searched from 1990-2018, using search terms ‘Operating Theatre,’ OR ‘Operating Theater,’ OR ‘Operating Room’ AND ‘Medical Students.’ Title and abstract review of 679 papers were performed. Full-text English language papers about the learning or satisfaction of medical students in the theatre environment were included. Papers exploring the experiences of residents/trainees rather than medical students were excluded. A total of 36 papers were eligible for inclusion. Thematic analysis was conducted on these papers.
A number of common themes were identified. Throughout the literature, medical students describe a lack of clear learning objectives, fear, anxiety, feelings of humiliation and intimidation, lack of visualisation and lack of opportunity for participation as barriers to their satisfaction with theatre placements and to their subjective learning.
Obstacles identified by students as deleterious to their experiences in the operating theatre are remarkably reproducible across a number of research studies in different populations. Areas to address by both individual educators and curriculum designers include fostering a culture of inclusion in theatre, setting explicit, achievable learning goals for students in this environment and making a concerted effort to prepare students for the theatre setting.
Surgical exposure is incorporated into the curriculum of virtually all medical schools, and widely considered a necessary component of the undergraduate experience. Resultingly, each year thousands of medical students make their first foray into a ‘classroom’ which bears little resemblance to any they have experienced before – the operating theatre. Simultaneously, medical educators adopt the role of the teacher in this unique environment. We were keen to explore the variables influencing learning in this setting, with a view to identifying how education may be optimized.
As a learning environment, operating theatres have many resources to be exploited. Changing the teaching domain (e.g. from classroom to outdoors) is recognised within education as potentially beneficial.
However, there are two sides to any coin. Just as the unique facets of the operating theatre foster a rich and powerful learning experience, so too do the intricacies of theatre present medical students with a number of challenges to contend with. The hierarchical operating theatre can be a stressful environment, with intimidation a common theme reported by medical students and theatre staff alike.
We wished to explore the subjective educational benefit of operating theatre attendance for medical students, and the factors influencing this. We found a lack of integrated research in the current literature in this area. While a variety of heterogeneous studies on a local level had been conducted, we found it was difficult to infer global relevance or generalisability to our own practice from the results. We, therefore, proposed to perform a systematic review, integrating the current evidence and ascertaining which, if any, findings recurred throughout the published literature and appeared to remain applicable outside of the local context.
Our specific objectives were to discover, according to the currently published evidence: i How medical students perceive their time in theatre, ii. What challenges medical students face in the theatre that may influence the educational experience, iii. How such challenges may be overcome and how educators can facilitate this. By becoming more cognisant of the obstacles faced by medical students, we propose that eduators can work at both altering the milieu to make it more inviting, and at equipping students with the skills necessary to navigate the surgical environment.
A critical narrative approach was used in this literature review, with the intent of systematically identifying and synthesizing the published literature related to the learning of medical students in the operating theatre environment.
Literature search strategies were designed for the National Library of Medicine (NLM) and Scopus databases, employing search terms ‘Operating Theater’ OR ‘Operating Room’ AND ‘Medical Students’. A search of the afore-mentioned databases was conducted by the first author (SC) and reviewed by the senior author (WH). Title and abstract review of all papers produced by the search strategy were performed. In addition, the reference list of included papers was reviewed to identify any further papers eligible for inclusion.
Inclusion criteria were research papers published 1990-2018 pertaining to the learning or satisfaction of undergraduate/postgraduate medical students in the theatre environment and written in the English language. Opinion pieces written from the perspective of educators only, papers relating to the experiences of postgraduate surgical trainees/residents and published abstracts without associated full-text articles were excluded. A total of 679 papers were identified from the search results. Following removal of duplicates, screening according to inclusion and exclusion criteria, and additional hand trawl of the reference list, 36 papers were included. The article selection process is outlined in a flow diagram in
Article Selection Process
Papers were reviewed. Data extracted included study characteristics (year of publication, country of origin), participant information (number of participants, year of study, rotation at the time of the study) research methods and findings. Thematic analysis
Author | Year | Country | Population | Research Method | Themes Identified |
---|---|---|---|---|---|
Lyon5 | 2003 | Australia | Medical students and surgeons | Mixed Methods - Group interviews (medical students) - In-depth semi-structured interviews (students, n=15 and surgeons, n=10) - Questionnaire (n=197, response - rate 87%) | Learning goals unclear for medical students |
Fear in strange environment may hamper learning | |||||
Embarrassment / fear of looking foolish experienced by students Time versus educational benefit of theatre | |||||
attendance questioned by students | |||||
Ravindra33 | 2013 | UK | Recently qualified medical school graduates | Questionnaire (n=209, 67% response rate) | Learning goals unclear for medical students |
Victimisation and humiliation experienced by students | |||||
Students desire active participation / to ‘scrub in’ | |||||
Time versus educational benefit of theatre attendance questioned by students | |||||
Zundel11 | 2015 | Germany | Medical students from year three upwards Surgeons | Series of focus groups (medical students, n=17 and surgeons, n=10) | Common themes identified included: Learning goals unclear for medical students Teaching strategy of faculty influences learning Fear in a strange environment may hamper learning |
Fernando13 | 2007 | Scotland | Final year medical students | Questionnaire (medical students, n=54 response rate 90%) | Learning goals unclear for medical students |
Feeling welcome important to students | |||||
Fernando12 | 2007 | Scotland | Final year medical students Consultant trainers | Questionnaire (medical students, n=46 100% response rate; consultants, n=42 46% response rate) | Learning goals unclear / discordant |
Lack of visualisation an issue for students | |||||
Irani14 | 2010 | US | Medical students and faculty | Mixed – field observations and satisfaction ratings. Assessing amount and type of teaching in the operating theatre, relative to curriculum goals. Student n=11. | Learning goals unclear / discordant |
Students may not require active | |||||
participation to have a positive experience | |||||
O’Neill15 | 2017 | US | Third-year medical students, attending surgeons, surgical residents | Questionnaire answered by 57 total participants: Medical students, n= 25 (43.8% response rate) of those who have completed their third-year surgical clerkship, n= 14 (24.6% response rate) of those who have not completed their third-year surgical clerkship, attending surgeons, n=9 (15.8% response rate), surgical residents, n = 9 (15.8% response rate) | Learning goals unclear / discordant |
Feeling burdensome an issue for students | |||||
Hampton4 | 2011 | US | Fourth-year medical students on Obstetrics & Gynecology clerkship and faculty | Focus groups (two focus groups including 13 medical students, one focus group including five faculty members) | Learning goals more aligned students/ faculty in this study |
Practical learning a relevant goal in view of some faculty | |||||
Welcomeness / integration into team recognised as important by faculty | |||||
Flannery16 | 2014 | Northern Ireland | Third-year medical students completing a neurosurgery placement | Questionnaire (n=22, 8% response rate of all students, however not all were eligible as had not attended neurosurgery theatre) | Preparedness of students important |
Learning goals (can be) unclear (or lack a degree of clarity) for students | |||||
Teaching strategy/style of faculty influences learning | |||||
Lee17 | 2005 | Scotland | Fourth-year medical students following ENT placement | Questionnaire (n=152, response rate 100%) | Learning goals sometimes unclear / discordant / not achieved |
Lack of visualisation an issue for students objectives | |||||
Hampton18 | 2014 | US | Medical students on Obstetrics & Gynaecology clerkships | Pre and post intervention questionnaire (n=68 completed post-clerkship and n=27 completed at six months post-clerkship, of a group of 70) | The benefit of clearly stipulated learning objectives |
Positive opinion of faculty teaching correlated with high satisfaction overall | |||||
Hubbell19 | 1996 | US | Medical students | Questionnaire, medical student n=48 (98% response rate) | The benefit of setting clear learning objectives |
Teaching strategies - the role of visual reinforcement | |||||
Callcut21 | 2004 | US | Surgical faculty and medical students | 70+/- 7 student evaluations of 74 academic surgeons | Teaching strategy/style of faculty influences learning |
Bowrey7 | 2014 | UK | Third and fourth-year medical students on a perioperative care placement | Semi-structured interviews (n=9 of 83 invited students) | Fear in a strange environment may hamper learning |
Intimidation experienced by students | |||||
Feeling welcome, team integration important to students | |||||
Morzycki24 | 2016 | Canada | Medical students of all years | Questionnaire (n=180, response rate 40%) | Fear in a strange environment may hamper learning |
Intimidation experienced by students | |||||
Teaching strategies – the benefit of preparatory course | |||||
Chapman25 | 2013 | UK | Medical students of all years | Questionnaire (n=292, response rate 20.8%) | Feeling welcome, team integration important to students |
Active participation important to students | |||||
Stone23 | 2015 | Canada | Final year medical students and recent graduates | Questionnaire (n=72, response rate 21%) | Fear in a strange environment may hamper learning |
Intimidation experienced by students | |||||
Teaching strategies – the benefit of preparatory course anticipated by students | |||||
Miandoab26 | 2016 | Iran | Medical students in semester 4 and semester 8 | Questionnaire (n=62) | Feeling welcome, team integration important to students |
Lyon27 | 2004 | Australia | Final year medical students | Mixed Methods - Group interviews (medical students) - In-depth semi-structured interviews (students, n=15 and surgeons, n=10) - Questionnaire (n = 197, response rate 83%) | Humiliation |
Feeling welcome, team integration important to students | |||||
Active participation important to students | |||||
Teaching strategy/style of faculty influences learning | |||||
Thomas28 | 2006 | UK | Final year medical student | Personal reflection | Humiliation |
Teaching strategies: benefit of a preparatory (simulated operating theatre) course | |||||
Pettitt29 | 2004 | US | Third-year medical students | Questionnaire (n = 84, response rate 83%) | Fear in a strange environment may hamper learning |
Mistreatment experienced by students | |||||
Coveney32 | 2013 | Ireland | Third and fourth-year medical students | Free recall experimental model, assessing recall in two different learning environments | The learning of medical students as assessed by the short-term recall can be preserved in a variety of environments |
Knight34 | 2017 | UK | Penultimate year medical students who had just completed their neurosurgical placement | Questionnaire (n =201, response rate 81.4%) | Feeling welcome, team integration important to students |
Students perceive theatre exposure as useful | |||||
Cloyd35 | 2008 | US | First-year medical students involved in a ‘Surgical Skills Elective.’ | Implementation of Surgical Skills elective followed by questionnaire (n=55 questionnaire responses from 30 students, response rate 88.7%) | Feeling welcome, team integration important to students Feeling burdensome common amongst medical students Teaching strategies – the benefit of a surgical skills workshop |
Active participation important to students | |||||
Hong38 | 1996 | Canada | Fourth-year medical students on surgical clerkship | Implementation of computer-based tutorials on human anatomy before theatre attendance. Evaluated by questionnaire (n= eight medical students and an additional questionnaire completed by faculty also) | The benefit of setting clear learning objectives |
Teaching strategies – the benefit of a preparatory anatomy course | |||||
Patel39 | 2013 | US | First and second-year medical students | Medical students enrolled in an introductory workshop ‘Surgical Saturday’ and completed pre and post-workshop questionnaires (n=33) | Students lack confidence regarding operating theatre etiquette and behaviour |
Teaching strategies – the benefit of a preparatory workshop | |||||
Patel40 | 2012 | UK | First-year medical students | Intervention - students were randomized into four groups for operating theatre preparation: control, didactic lecture, ‘second life,’ and simulated operating suite. Participants completed a pre and post intervention questionnaire. N=60 | Teaching strategies – the benefit of a preparatory workshop |
Martin41 | 2012 | UK | Medical students | A workshop for medical students was designed based on responses of medical students (n=36) and consultant surgeons (n=8) to a questionnaire. A workshop was then delivered to 147 medical students and feedback collected by questionnaire. | Teaching strategies – the benefit of a preparatory workshop |
Students lack confidence in the operating theatre environment | |||||
Drolet42 | 2014 | US | Pre-clinical medical students | Implementation of a preclinical elective in surgery, using a paired resident-mentorship model. Student exposure and confidence with clinical activities evaluated by questionnaire before and after the elective (N = 24, 100% response rate). | Teaching strategies – the benefit of a preparatory course |
Students lack confidence in the operating theatre environment | |||||
Shipper43 | 2018 | US | Pre-clinical medical students | Implementation of a technical and nontechnical skills curriculum, evaluated by semi-structured interviews of students (n=8) and instructors (n=5). | Teaching strategies – the benefit of a preparatory course |
Fear in a strange environment may hamper learning | |||||
Intimidation experienced by students | |||||
Broderick44 | 2002 | US | Variety of theatre staff | The trial of an endoscopic video camera and telescope attached to an operating table, with common objects placed on the operating table in mock surgical fields. Persons (n=11) from a variety of medical backgrounds evaluated the images on the adequacy of visualization. | Lack of visualisation an issue for students |
Berman45 | 2008 | US | Third-year medical students | Questionnaire (n=116, response rate 89%) following a surgical clerkship, during which a structured mentorship programme was in place. | Teaching strategies – the benefit of a preparatory course |
Active participation important to students | |||||
Teaching strategy of faculty influences learning | |||||
Schwind46 | 2004 | US | Medical students | Questionnaire (completed for 114 learning episodes in the operating room) | Active participation – may not be important to students |
Teaching strategy of faculty influences learning | |||||
Time versus educational benefit of theatre attendance questioned by students | |||||
Stark47 | 2003 | UK | Fourth-year medical students and consultant clinical teachers | Focus groups of medical students (n=20 total) and semi-structured interviews of consultants (n=13) | Teaching strategy of faculty influences learning |
Time versus educational benefit of theatre attendance questioned by students | |||||
McIntyre50 | 2008 | US | Third-year medical students on surgical clerkship | The pilot of teleconferencing sessions (live broadcasting of procedures to a classroom setting where students were based along with a faculty member). Observation performed of students (by educators) in operating theatre and the teleconference setting (n=23 observations) and questionnaires completed by students (n=78) | Teaching strategies – the benefit of a novel approach to intra-operative teaching |
Teaching strategy of faculty influences learning | |||||
Time versus educational benefit of theatre attendance questioned by students | |||||
Jensen20 | 2018 | Denmark | 4th-year medical students enrolled in an undergraduate surgical introduction initiative involving assisting in the operating room with a surgical mentor (senior surgeon) | Ethnographic observation (n=7 students, 70 hours of observation) | Learning goals – hidden curriculum exists |
Students may lack confidence in the operating theatre environment | |||||
Teaching strategies – the benefit of a novel approach to intra-operative teaching | |||||
Teaching strategy of faculty influences learning |
Thirty-six papers were included and underwent full-text analysis.
The primary sources identified and discussed in the remainder of this paper are summarized in
One issue reported by medical students is a lack of clarity regarding the purpose of their theatre placement. A study by Lyon and colleagues found less than 50% of students to agree with the statement that “the objectives for attending theatre are clear to me.”
Perhaps unsurprisingly, other studies demonstrate that when medical students are left ‘rudderless,’ without clear guidance as to educational goals, they may formulate learning objectives disharmonious with their seniors’ expectations. Fernando and colleagues found 39% of a student group lacking instruction was “inappropriately overambitious” in aspirations to memorise “skills [and] techniques” “considered postgraduate-level knowledge.”
The emphasis of theatre conversation, however, may not always be congruent with surgical educators’ views of desirable learning goals and outcomes for medical students. One study observing medical students on surgical clerkship/placement noted that 55% of the intraoperative time was “spent teaching technical aspects of the operation.”
Similarly, O’Neill and colleagues, in a questionnaire-based study of medical students, consultant surgeons and residents identified a discrepancy in envisaged learning, with the majority of surgeons surveyed in agreement that medical decision-making, disease processes, and gross pathology were thoroughly taught and emphasized intraoperatively, whilst the majority of medical students disagreed with the same statement.
Specialty-specific studies of students on neurosurgery
Hampton and colleagues trialled a new curriculum for students (n=70) on obstetrics and gynaecology placement, and compared students were experiencing it to a control group on conventional clerkship.
Evidently medical students require formal guidance if they are to understand the aim of theatre sessions and correctly interpret learning priorities. It may be, however, that desirable learning goals are sometimes more abstract than medical students may conceptualize, and here a so-called hidden curriculum may appear. Jensen and colleagues, using ethnographic observation, explore surgical education from the perspective of practice theory.
Several studies show that students draw conclusions on surgeons’ interest in teaching and style of teaching while in the theatre environment, and often correlate this with their learning experience. “Lack of interest” of the surgeon in teaching was cited by several students as a barrier to their learning in the neurosurgical theatre in a study by Flannery and colleagues based on questionnaire and semi-structured interview responses.
Further exploration is needed to uncover the reasons that one cohort emerged as superior teachers in the eyes of the medical students, and the generalisability of this finding is unclear. The study does, however, suggest a certain consistency and reliability in medical student assessment of an operating room educator, implying that teaching style is a significant variable in this context. Whilst students are vulnerable to feeling intimidated in the operating theatre
A myriad of emotions experienced in the theatre setting is reported by students throughout the literature, and their potential effect on the learning experience should be considered.
Fear is an emotion frequently described by students in relation to theatre placements. Fear of syncope or of “violating protocol” is common.
Humiliation is also common. “Experience[ing] embarrassment” in the theatre was reported by 70% of students in a study by Lyon and colleagues.
Perhaps unsurprisingly, anxiety is reported alongside fear, apprehension and humiliation. Pettitt and colleagues surveyed a group of medical students prior to surgical clerkship and enquired about their expectations.
A study published in 2013 (n=209) demonstrated that students who reported being “made to feel welcome” were more likely to attend theatre opportunities than students who refuted this statement.
Students also report feeling like a “burden” or “nuisance.”
Several papers elicit reports of students being unacceptably treated, in a theatre environment made hostile by consultant surgeons, trainees/residents or nursing staff. While some recall bias may exist, and not all experiences may have been specifically theatre-based, Chapman and colleagues’ survey of alumni reflecting on their surgical clerkship experience identified mistreatment as a memory of some respondents.
Whilst there is no evidence to suggest such encounters predominate, the effect of such experiences on the recipient student and others present must be considered.
Some of the emotional aspects, for example the sense of apprehension and fear may be partially attributed to inadequate induction sessions. Champan and colleagues in a questionnare based study of 234 medical students noted ‘lack of preparedness’ to be a chief factor in unsatisfactory theatre experiences,
The concept of preparedness can be addressed in both a specific and a general sense. Locally, on a day-to-day or weekly basis, students may benefit from being advised on which theatre they will be assigned to and what cases will be taking place, to allow them to “read up on expected knowledge.”
In the pursuit of a more global introduction to surgery as a whole or to theatre itself, a number of authors have piloted various induction sessions. Patel et. al designed a Saturday workshop of surgical induction / skills training attended by 33 junior (1st and 2nd year) medical students, primarily with the goal of increasing interest in surgical careers, however noted strong agreement that the session was helpful in making students feel better prepared for the surgical rotation or sub-internship, presumably assuaging some of the fear of the unknown.
An intuitive variable affecting student enjoyment and learning in theatre is the visibility of the procedure. Fernando and colleagues revealed 30% of students felt unable to visualise “much of the operation” and found this “detrimental.”
A further point of consideration is the influence on the student of his/her participation in surgery. There are conflicting reports of the importance of the student being actively involved as an assistant.
Bermen and colleagues in a questionnaire study of 3rd-year medical students (n=116) found that students who had had the opportunity to suture, manage a laparoscopic camera, or otherwise “felt involved in the operating room” were more likely to be interested in surgery as a career (p ≤ 0.01).
Furthermore, surgical teams may be somewhat opposed to the concept of the student assistant. One study that addressed trainer’s perceptions reported 43% of consultants studied felt students acting the second assistant was “not appropriate.”
Regardless, from the available information, it seems the opportunity to ‘scrub in’ is correlated with improved student satisfaction, but that active student participation is less important.
For medical students, time is at a premium. Another factor influencing satisfaction with theatre placements is how worthwhile the student perceives the experience related to time expenditure. Lyon and colleagues confirm students carefully “weigh the cost” of theatre time against other forms of learning which may facilitate the greater acquisition of knowledge “necessary to pass undergraduate exams.”
One novel intervention is proposed by McIntyre and colleagues who trialled intraoperative education via teleconferencing (TC) with a group of third-year medical students (n=29).
The operating theatre possesses many unique factors distinguishing it from standard tutorial rooms, and as such, is a theoretically fascinating environment in which to teach and observe learning. The response of the medical student to this foreign environment is, however, variable, and quite frequently negative. Numerous articles outline the struggles of medical students to assimilate into operating room environments across the globe and across a number of decades. In a 1986 publication, Folse and colleagues identified potential pitfalls of surgical placements, which the authors identified as “frequently unstructured” with “skill acquisition…left largely to chance with little quality control,” “students inadequately monitored” and “feedback seldom given.”
A number of factors emerge in this review as powerful influences on the medical student’s experience in the theatre environment. Almost all are modifiable variables. We propose that initiatives born out of liaison between curriculum designers, surgical teams and non-surgical members of the operating theatre staff could radically improve the student experience. Pre-placement preparation strategies for students, with the establishment of agreed learning goals and some form of an introductory session to operating theatre etiquette and behaviour delivered in a non-threatening environment, appear to be positively embraced by students. Such learning objectives should be set at the curriculum level and discussed with practising surgeons who supervise student placements. Steps taken by educators to put in place specialty-specific measures ensuring adequate student visualisation of the operating field are crucial. Sadly, it appears that medical students frequently perceive the theatre environment as hostile, and mistreatment is not uncommonly encountered. It is quite clear that a concerted global effort to urgently address this situation is essential, in order to both optimise short-term educational benefit and to avoid potentially detrimental effects on the recruitment of students to surgical careers. We feel that action is required by medical school authorities, departmental heads, individual surgeons (both consultant and trainee level) and nursing staff to ensure that the theatre environment is as welcoming as possible to students, whilst established priorities of patient safety and efficiency are maintained. Students’ satisfaction is linked with feelings of welcomeness and team integration, and this can be fostered by all members of the surgical team both inside and outside of the theatre environment. It appears that many of the negative emotional experiences, based on fear, intimidation, embarrassment and anxiety, described by students on a level deleterious to their learning could be ameliorated by greater student and faculty preparation, along with a continued cultural shift towards a more inclusive and welcoming operating theatre ethos across the board. We propose that this would enhance student learning within the operating theatre.
There is a reasonable body of literature addressing medical education within the theatre. This includes a number of published papers highlighting obstacles identified by medical students as detrimental to their learning and enjoyment. Most papers use students’ opinion as their measure. While this may not equate to the most scientifically objective evidence, we feel it is a realistic and appropriate endpoint, as assessing a more distant target such as exam performance is open to such a degree of confounding bias that it is unfeasible. Current papers focus on students in individual universities. This, of course, raises questions regarding generalisability of findings, with each student group a product of a particular curriculum and perhaps each affiliated teaching hospital harbouring a particular ethos. Similarly, some studies are specialty-specific, while others incorporate students who have experienced a variety of different surgical specialties on placement yet evaluate their experience as a whole. These are potential limitations. However, the recurrent themes and remarkably similar opinions of a diverse, international selection of students reported throughout the literature does suggest global relevance.
There are of course areas which merit further research. It would be useful to assess the optimal delivery of introductory sessions and/or the effect of a surgical mentor accompanying the students. The current evidence consists of a variety of local pilot studies demonstrating the efficacy of various forms of induction. However, multicentre trials with randomisation of medical students to different approaches and careful evaluation could provide useful information on effective and cost-friendly strategies to guide curriculum designers. It would also be interesting to observe the outcomes of further research surrounding the application of novel forms of technology to enhance student visualisation. The mini-surgical theatre educational environment measure developed and validated by Nagraj and colleagues may be used in future studies to assess the educational climate of the theatre as perceived by students and to measure change following implementation of an intervention.
A number of factors repeatedly surface in papers published across several continents, over a timespan of more than 20 years. Themes of intimidation, of exclusion, of lack of preparation and confused learning objectives are apparent in multiple studies, and negatively influence the medical students’ experience. They would appear to be powerful enough motivators to influence students’ very attendance in theatre in the first place, as well as their long-term career aspirations. These have been replicated in a number of settings and cited by both undergraduate and postgraduate-entry medical students in their clinical years in medical schools internationally.
There is much to be learnt from the sentiments echoed by students throughout the literature on their experiences in theatre. It is perhaps disheartening that so many of the obstacles they encountered were avoidable. Yet for this very reason, so too can we be inspired. We feel that it is a very achievable feat for educators in the surgical context to modify many of the variables outlined above, and thus we are empowered to improve the theatre experience of our future medical students.
The authors declare that they have no conflict of interest.