Semantically Ambiguous Language in the Teaching Operating Room

How teaching surgeons communicate: An analysis of intraoperative discourse among male and female surgeons

BACKGROUND

Our objective was to compare the use of agentic ("I") and communal ("we") spoken intraoperative discourse between male and female attending and resident surgeons.

METHODS

We analyzed transcripts involving attending and resident surgeons from 5 specialties at a single Midwestern academic teaching hospital. We adapted and expanded Grebelsky-Lichtman's codes, assessed rater agreement, and systematically coded transcripts for agentic and communal terms. Differences between genders and roles were evaluated using Mann-Whitney U tests.

RESULTS

In the operating room, attendings used significantly more Action Demands, Rationality, Collective Speech, Passive Speech, Nurturing Speech, and Degree Modifiers. Conversely, residents used significantly more Assertive Speech, and Display Solution. Attendings were also more likely to use Action Demands combined with Passive Speech. No significant gender differences were found in any categories.

CONCLUSIONS

Language use in the OR is more closely associated with professional role rather than gender and may reflect underlying power dynamics and the nature of the surgical teaching environment.

Ambiguity in robotic surgical instruction: lessons from remote and in-person simulation

The rise of robotic surgery has been accompanied by numerous educational challenges as surgeons and trainees learn skills unique to the robotic platform. Remote instruction is a solution to provide surgeons ongoing education when in-person teaching is not feasible. However, surgical instruction faces challenges from unclear communication. We aimed to describe, examine, and compare ambiguities in remote and in-person robotic instruction. We designed a simulation scenario in which a standardized learner performed tasks in robotic surgery while making pre-scripted errors. Instructors provided remote or in-person instruction to the standardized learner. We applied tools from discourse analysis to transcribe sessions, identify instructional instances, classify ambiguities, and select passages for further review. We used tests of proportions to compare ambiguities between the settings. We conducted four simulation sessions, including two remote and two in-person sessions, and identified 206 instructional instances. Within these, we found 964 occurrences of three common semantic ambiguities, or ambiguities arising from words alone. Instructors used visual tools - thus employing multimodality - to clarify semantic ambiguities in 32% of instructional instances. We identified a similar degree of referential ambiguity, or ambiguity for which context from multimodality did not provide clarifying information, during remote (60%) and in-person (48%) instructional instances (p = 0.08). We described, examined, and compared ambiguities in remote and in-person instruction for simulated robotic surgery. Based on the high prevalence of ambiguity in both settings, we recommend that robotic instructors decrease referential ambiguity. To do so, instructors can reduce semantic ambiguity, harness multimodality, or both.

Quality and Simulation Professionals Should Collaborate

Simulation is underutilized as a tool to improve healthcare quality and safety despite many examples of its effectiveness to identify and remedy quality and safety problems, improve teamwork, and improve various measures of quality and safety that are important to healthcare organizations, eg, patient safety indicators. We urge quality and safety and simulation professionals to collaborate with their counterparts in their organizations to employ simulation in ways that improve the quality and safety of care of their patients. These collaborations could begin through initiating conversations among the quality and safety and simulation professionals, perhaps using this article as a prompt for discussion, identifying one area in need of quality and safety improvement for which simulation can be helpful, and beginning that work. (Sim Healthcare 19(5):319-325, 2024).

Call to Action: Quality and Simulation Professionals Should Collaborate

SUMMARY STATEMENT

Simulation is underutilized as a tool to improve healthcare quality and safety despite many examples of its effectiveness to identify and remedy quality and safety problems, improve teamwork, and improve various measures of quality and safety that are important to healthcare organizations, eg, patient safety indicators. We urge quality and safety and simulation professionals to collaborate with their counterparts in their organizations to employ simulation in ways that improve the quality and safety of care of their patients. These collaborations could begin through initiating conversations among the quality and safety and simulation professionals, perhaps using this article as a prompt for discussion, identifying one area in need of quality and safety improvement for which simulation can be helpful, and beginning that work.

"Right Into the Center": A Semantic Analysis of Direction in Operating Room Instruction

OBJECTIVE

In our previous work, teaching surgeons used potentially ambiguous language in the OR 12.3 times per minute. Our objectives were to examine ambiguous examples featuring Directional Frame of Reference (DFoR), which involves instructions containing directional terms like "up" or "left," and to uncover what contributes to understanding or misunderstanding of such instruction.

DESIGN

We videorecorded the critical moments of 6 surgeries, as chosen by the surgeons. With a semanticist, we applied constructs from formal semantics to choose potentially ambiguous DFoR terms commonly flagged in our previous work. We separately interviewed attending and resident surgeons, asking each to describe the meaning of those DFoR terms while they viewed case recordings alongside transcripts. We compared their responses, analyzing them for agreement in direction. We performed thematic analysis on case and interview transcripts for themes related to DFoR.

SETTING

Midwestern academic university teaching hospital.

PARTICIPANTS

Six attending and 6 resident surgeons.

RESULTS

Attending and resident surgeons disagreed on direction in 9 of the 26 (34.6%) DFoR examples. Misunderstanding arose from using linear direction to describe three-dimensional space, e.g., "up" for anterior/cephalad/right. It also arose when combining degree modifiers with DfoR, e.g., "we're far enough back" combines the ambiguities of "back" (DfoR) and "far enough" (degree modifier). Use of axial parts (noun-like directional terms), e.g., "bottom," and confusing "left" for "right" also provoked misunderstanding. Misunderstanding was associated with lack of experience and mitigated by pointing with a finger or instrument, concurrent with speech.

CONCLUSIONS

Use of ambiguous language with DFoR incurs a high potential for misunderstanding, especially with novice surgeons. We recommend avoiding linear directions and axial parts, and instead physically pointing to represent complex 3D directions. Degree modifiers can be replaced with exact distances e.g., replace "little more anterior" with "1 centimeter anterior," and semaphores can be used to clarify direction.

Speech Communication Interference in the Operating Room

INTRODUCTION

Operating room communication is frequently disrupted, raising safety concerns. We used a Speech Interference Instrument to measure the frequency, impact, and causes of speech communication interference (SCI) events.

METHODS

In this prospective study, we observed 40 surgeries, primarily general surgery, to measure the frequency of SCI, defined as "group discourse disrupted according to the participants, the goals, or the physical and situational context of the exchange." We performed supplemental observations, focused on conducting postsurgery interviews with SCI event participants to identify contextual factors. We thematically analyzed notes and interviews.

RESULTS

The observed 103 SCI events in 40 surgeries (mean 2.58) mostly involved the attending (50.5%), circulating nurse (44.6%), resident (44.6%), or scrub tech (42.7%). The majority (82.1%) of SCI events occurred during another patient-related task. 17.5% occurred at a critical moment. 27.2% of SCI events were not acknowledged or repeated and the message was lost. Including the supplemental observations, 97.0% of SCI events caused a delay (mean 5 s). Inter-rater reliability, calculated by Gwet's AC1 was 0.87-0.98. Postsurgery interviews confirmed miscommunication and distractions. Attention was most commonly diverted by loud noises (e.g., suction), conversations, or multitasking (e.g., using the electronic health record). Successful strategies included repetition or deferment of the request until competing tasks were complete.

CONCLUSIONS

Communication interference may have patient safety implications that arise from conflicts with other case-related tasks, machine noises, and other conversations. Reorganization of workflow, tasks, and communication behaviors could reduce miscommunication and improve surgical safety and efficiency.

Effects of standardized language on remote ultrasound-guided percutaneous nephrolithotomy training: A mixed-methods explorative pilot study

Background

Remote teaching of procedural skills has demonstrated equivalence in knowledge acquisition compared to in-person teaching. Variations in terminology for probe and needle movements may serve as a barrier in remote training of ultrasound (US)-guided renal access for percutaneous nephrolithotomy (PCNL). This pilot study investigated the utility of standardized terminology in remote training of US-guided renal access for PCNL.

Hypothesis

Standardization of verbal terminology to describe US probe and needle movement instruction improves remote teaching of US-guided renal access.

Methods

Fifteen urology residents (PGY1-6) were stratified by year and randomized into two groups. We provided participants with images illustrating US probe and needle movements labeled with predetermined standardized terminology for the intervention group and images without labels for the control group. Both groups were asked to perform US-guided renal access on a training mannequin with a remote faculty educator with (intervention) or without (control) use of standardized movement instructions. Quantitative outcomes included number of attempts and time to achieve access. All trainees completed pre- and post-session surveys and participated in focus groups; authors conducted thematic analysis of focus group transcripts.

Results

Differences in primary outcomes between groups, including number of attempts and time to achieve access of the renal pole, were not statistically significant. Analysis of focus group interviews revealed that the use of standardized terminology in the setting of remote training can reduce trainee confusion by clarifying ambiguity in educator feedback.

Discussion

Use of standardized terminology during remote surgical skills training allows for more effective feedback to trainees.