Objective: Efforts to implement competency-based medical education require new sources of workplace-based evidence of growth in learning. We used qualitative analysis of operative notes to explore procedural variation in a simple surgical procedure.
Design: We used a grounded theory-based mixed methods approach to depict intersurgeon procedural variation. Our grounded theory approach to analysis included follow up interviews with surgeons and residents to probe their understandings of the reasons for variation in the dictated notes and the current and potential utility of operative notes as a reliable source of data for learning and assessment.
Setting: Publicly funded tertiary care otolaryngology-head & neck surgery residency program in Ontario, Canada PARTICIPANTS: Using maximum variability sampling, all surgeons performing tonsillectomy in the department (n = 6) contributed operative notes from 65 tonsillectomies, 5 intraoperative observations, and 4 semi-structured interviews. An additional 3 residents from various levels of training contributed semistructured interviews.
Results: Intersurgeon procedural variations persist even in simple surgical procedures such as tonsillectomy. Operative notes appear to capture procedural variations in a limited way. Surgeons and resident make informal educational use of the clerical work of writing and assessing operative notes, but optimization will be required to shift such hidden work into the formal educational domain.
Conclusions: The implementation of competency-based medical education requires surgical educators to both eliminate low-yield tasks for learning and to find new opportunities for multiple low-stakes assessment. Analysis of operative notes may become a high-yield strategy for learning and assessment if residents and surgeons are coached to use operative notes more reliably and efficiently.
Keywords: competency-based medical education; mixed-methods; operative notes; procedural variation; qualitative; surgical education; workplace-based assessment.
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