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Operative dictations in surgical trainees: an underutilized educational resource?
Britta Han1, Julie Clanahan2, Cameron Casson2
1Division of Minimally Invasive Surgery, Department of Surgery, Washington University School of Medicine, 660 S. Euclid Avenue, Campus Box 8109, Saint Louis, MO, 63110, USA. bhan@wustl.edu.
Surgical Endoscopy
|August 28, 2023
Summary
Surgical residents often lack comprehensive operative notes due to insufficient training. A formal curriculum is needed to improve dictation skills and ensure quality patient care documentation.
Area of Science:
- Medical Education
- Surgical Training
- Healthcare Quality
Background:
- Accurate operative notes are crucial for patient care, communication, billing, and legal purposes.
- Current operative note quality is variable, often lacking critical details.
- Standardized training for operative dictations is absent for surgical trainees.
Purpose of the Study:
- To assess surgical residents' ability to dictate comprehensive operative notes.
- To identify the need for a formal operative dictation curriculum.
Main Methods:
- Pilot study involving 38 surgical residents (post-graduate years 1-4) using a ventral hernia repair simulation.
- Residents completed a needs assessment and dictated an operative note post-simulation.
- Notes were evaluated using a modified, validated rubric.
Main Results:
- 82% of residents had completed ≤25 dictations, and 77% received minimal feedback.
- Overall mean score was 18.9/33, with no significant difference between junior and senior residents.
- Senior residents scored higher on patient history and note headers, but procedural details were similar.
Conclusions:
- Standard surgical training may inadequately prepare residents for operative dictation.
- A formal residency curriculum could enhance residents' ability to create effective operative notes.
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