The next portion is intraoperative teaching. And intraoperative teaching is focused on mutual objectives, and it's also focused on observed performance. So you've set the objectives in the briefing. Now you're going to focus your teaching on those objectives. Of course this happens during the operation, but one thing I want to let you know is that I don't think that this precludes any other natural guiding that you would do or any other teaching that's going to come up. So, in other words, when you're in the middle of an operation there's almost always some sort of teachable moment. And I'm not saying that you have to get rid of those teachable moments at all. What I am saying, though, is that you need to be focused. You need to expect that your learner is going to walk out of the room with having learned about the objectives that you and your learners set at the beginning of the operation. So, kinds of things that you might ask your learner as you're going through the operation is, what are you thinking as you do this part? Or you might dispense what we call pearls. So here's a trick of the trade, or here's how experts think about that problem. So this is, again focused on your objectives, but not precluding you from dispensing pearls, and not precluding you from making use of teachable moments. And you want to be emphasizing good performance, so you want to make sure that your learner is doing what you want them to do as they perform the operation. So let's think about how we might apply this to other settings. >> So this is a little bit tougher. because I think when we think about intraoperative teaching the patient is asleep and the physician can kind of speak freely. And so when I think about intraoperative teaching in other settings, I really think of it as the entire case. So it's from the time the patient walks in to the whatever setting to the time that the patient goes home. And during that time there's times when you're not going to be in the room with the learner, and that you may be able to do that teaching outside of the room. Specifically with procedures it becomes kind of difficult. >> Mm-hm. Yeah, I mean you have to assess your patient as well as assessing your learner. And what's your patient's tolerance going to be for teaching in the moment? And are there ways that you can teach in the moment that aren't necessarily quite so alarming, like don't do that? But I think if you set a clear objective and the objective is well focused, it may be that you're able to do that intra-procederal or intra-case teaching in a way that does honor the patient and also honors the learner. >> I think that works, and I think if you take, for example, doing a spinal tap, if the learners objective is to make sure that they understand the anatomy so that they place the needle in the right place. I think the way that I usually manage that is by pretending to teach the patient, or tell the patient what we're doing. And so it would be something like we're going to put Betadine here and then we're going to landmark what this finest processes are and you do it by telling the patient in terms of. And sometimes we do higher landmarks or lower landmarks and you do it by kind of surreptitiously guiding the learner with either hand signals or by instructing the patient. I think that generally works for procedures. But I think you're right, it's trying to figure out how is this patient with this? But I've usually found that patients are open to the learner being there with the understanding that I'm there. >> Yeah, and I think that's the critical piece, is that nothing bad is going to happen to you. I am here always overseeing this process. And my learner is learning. And I'm teaching. And so I think that that works brilliantly. >> Yeah. And I think patients usually, for the most part, they appreciate it, and they feel like they're, kind of, helping the learner along the way. And then, in the more clinical setting, moving away from procedural things, I think it is important to think about kind of different ways to teach in that way. So, not necessarily at the bedside, but maybe out of the room or other things like that. I think there are different methods of doing that teaching. One of them is kind of the think out loud process. >> Mm-hm, sure. >> And I think in think out loud, it's my chance as an expert to say, this is the way that I think about something, so that the learner can kind of model it. >> Yeah, and I think that that's especially effective when it's in response to something that's clearly puzzling the learner. >> Mm-hm. >> So if the learner is going through something and you can tell that they don't understand what it is they're doing, you can take the reins and say, I'm an expert in this and here's how I think about that kind of problem. >> And then you might ask the learner to do the same for you. How are you thinking about this problem? That gives you a needs assessment and it also gives you an opportunity to maybe set a sort of a micro objective, or here's how I want you to think about that next. >> Mm-hm and I think the way that you framed it in the slides before is that to actually do the first part, the learner part first, to get a sense of do they know where they are. >> Right. >> Then if they don't really know what they're supposed to be thinking, then to do a role modeling or a think out loud. And during those times, I think it is important to say, I'm going to tell you about my thought process so that you might understand it. I think the other thing that you talked about was kind of pearls, is coming up with pearls for things. >> Yeah, and I think that pearls come from two places. So you're going to have pearls as an expert, obviously. But by the end of the session the learner should have a pearl of his or her own that they've generated that they can say, the next time I practice in this environment, the next time I do this kind of thing, here's what I want to keep in mind. Here's what I want to remember about how I do this. >> Yeah, I think that's good. And then I think in the teaching during the case, just being aware of what are they doing well, what are they doing not so well, that you can kind of improve? And I think this works in all settings, whether or not it's communicating with patients, or intensive care unit or we'll often do this in resuscitations in the emergency department to kind of set the goal before they go in. And their goal might be that I'm want to make sure that we get things done quickly and efficiently. We'll talk more specifically about what that means. And then you can kind of guide as you go through to help them understand it better. I think that works and I think it does apply to other settings as well as the operating room, I understand how it works. >> Yeah, I think so too. >> Great, thank you. >> Thanks. >> Good. Here we go. Okay, so now Amir we're going to move to the bowel and anastomosis portion. I know we kind of talked about at the beginning that this was one of your goals or a couple of your goals. Will you tell me again what your two goals related to this are? Goal number one is to get familiar with that instrument, with the stapler. Goal number two was to get a better orientation in the bowel. >> Okay, and my goal is to be able to do the anastomosis, line up the antimesenteric borders, I don't want any mesentery involved, so good. Let me first show you the stapler. The stapler comes apart. It's got two pieces. Each end goes in each end of the bowel. You then push the stapler together. >> Okay. >> To fire the stapler, you pull this black tab, you advance it until it doesn't go anymore, and then you pull it back, okay? >> Okay. >> Only after that can you release the stapler by pressing this back button. >> Okay. >> Okay? It takes a little bit of force, so I want to make sure you stabilize with one hand. Okay we want to line this up nicely and don't want to slip. >> All right. >> Sound good? >> Yeah. >> So I'm going to hold the bowel, and I'm going to have you advance the staplers. Good, one on each end. Very good, good, very nice. Now, I think you did a nice job there, again, it takes a little more force, I think, than you're probably used to. >> Okay. >> But again, as you get more used to the instruments they'll be more comfortable, but make sure you really stabilize with one hand and don't let it slip around too much. Okay? >> Thank you. >> [INAUDIBLE]
