The dynamics of dialogue: Social interaction, language and culture in intraoperative teaching and learning

The operating room (OR) is a complex teaching and learning environment. In this issue, Lambert et al explore how supervising surgeons scaffold support for residents to balance education and patient safety in the OR.1 The authors articulate a structure for intraoperative scaffolding, describing how attending surgeons continuously calibrate intraoperative guidance based on assessments of resident ability and the complexity of each step in a surgical procedure. Their work is grounded in socio-cultural learning theory, which asserts that learning and cognitive development are mediated through social interactions and the culture surrounding them.2 We were particularly struck by Lambert et al's descriptions of the dynamic, co-constructed and dialogic nature of intraoperative scaffolding,1 which allowed us to reflect on other aspects of Vygotsky's work that feature in the intraoperative dialogue between surgeons and trainees. Here, we discuss three of them: social interaction, language and culture. Vygotsky contends learning occurs through internalisation of knowledge that is co-constructed through guided interactions and collaborative dialogue in socially embedded environments.2 In the OR, such interactions involve attending surgeons guiding trainees to perform progressively more complex steps of an operation. While Lambert et al identify the tension between resident learning and patient safety as a constraint to intraoperative social interactions,1 we argue conceptualising this relationship as oppositional may create a blind spot that causes us to miss valuable learning opportunities. Conceptualising this relationship as oppositional may create a blind spot that causes us to miss valuable learning opportunities. Certainly, increased attending surgeon involvement in a case may reduce residents' autonomy, and we acknowledge the disappointment that accompanies having a surgery ‘taken over’. However, there is an educational opportunity in such moments that could be realised by expanding Lambert et al's description of scaffolding to include not only the next step in a procedure and how to perform it1 but also the rationale for the scaffolding being provided. For example, when a consultant identifies a safety threat that compels them to ‘take over’, articulating the reasoning behind this decision would allow the resident to learn about an important safety cue and observe how the surgeon manages this situation. Thus, while potentially leading to reduced autonomy in that moment, such situations can help develop residents' clinical reasoning by helping them to see, think and act like the most responsible surgeon. Such situations can help develop residents' clinical reasoning by helping them to see, think and act like the most responsible surgeon. Language is central to socio-cultural learning, because it serves as a tool not only for communication but also for shaping cognitive development of higher-order skills like perception, planning and problem solving.2 Vygotsky argued learning involves an essential shift, where external dialogue between learners and ‘more knowledgeable others’ is internalised within the learner's inner monologue, shaping their future independent thinking.2 As a mediator of the guidance interactions between learners and educators, language is essential for the transmission of knowledge, skills, values and practices within specialties and across generations of health professionals. Language is essential for the transmission of knowledge, skills, values and practices within specialties and across generations of health professionals. For intraoperative scaffolding to be effective, there must be a common language that facilitates communication and clinical reasoning within surgeon–trainee dyads. In surgery, specialty-specific anatomic terms often serve this purpose, acting as a lingua franca, a shorthand for surgical communication. Such terms can also encapsulate core concepts and knowledge that are critical for effective clinical reasoning. For example, the term ‘frozen abdomen’ is used by abdominal surgeons to indicate dense scar tissue in the abdomen from previous inflammation and surgeries that makes future procedures increasingly challenging. This concise term encapsulates pathophysiologic knowledge, altered and complex patient anatomy, surgical risks and anticipated challenges to those who understand this shorthand. A trainee's fluency in the vernacular of their specialty can impact their access to educational spaces, judgements about their competence and the quality of their learning experiences.3, 4 Therefore, the development of trainees' understanding of specialty-specific surgical language and its relationship to clinical reasoning and surgical communication is an essential aspect of training that may require deliberate instruction. Future research that clarifies how such learning occurs, both in and out of the OR, would advance our understanding of socio-cultural learning in surgery. Fluency in the vernacular of their specialty can impact their access to educational spaces, judgements about their competence and the quality of their learning. For Vygotsky, the values, customs and social norms that make up a community's culture shape what and how we learn. These aspects of surgical culture heavily influence teaching and learning in the OR, including the fading of intraoperative scaffolding that Lambert et al liken to ‘progressive entrustment’.1 However, entrustment itself is a complex cognitive, affective and social judgement that is not just based on resident ability.5-7 For instance, initial entrustment decisions are often governed by residents' reputations and attending surgeons' ‘gut feelings’ (even when unjustified).5, 7 Additionally, mismatches between supervisor characteristics (trust propensity and mood), learner traits (self-confidence, race, and gender) and supervisor–trainee alignment (personality and familiarity) also influence entrustment, creating a distinct set of expectations for each surgeon–trainee dyad.4, 5, 8-11 Residents must navigate this hidden curriculum of entrustment to access educational opportunities. Within such surgeon–trainee dyads, Lambert et al argue that learning objectives must be ‘negotiated between the attending and resident’, encouraging learners to proactively recruit faculty to optimise their learning.1 While this is a laudable goal, this negotiation is constrained by socio-cultural expectations and inherent power dynamics that prevent residents from being fully agentic in this space. Furthermore, while many characteristics of surgical culture (e.g. discipline, assertiveness and indefatigability)12 are not inherently problematic, others (e.g. competition, preference for ‘male’ characteristics and behaviours, self-sacrifice and maintaining the status quo) have been shown to negatively impact autonomy, entrustment, career advancement and well-being for some trainees, particularly those identifying as racialised and female-presenting.11-14 As such, culture represents an important but underexplored aspect of surgical education that may influence learning, well-being and equity. While the surgical literature has begun to contend with these issues, much more work is needed to understand how they influence intraoperative teaching and learning. In summary, Lambert et al's articulation of intraoperative scaffolding as a collaborative and dialogic event encourages us to embrace the socio-cultural dynamics of the OR and its impacts on teaching and learning.1 Further work examining the role of language, opportunities to leverage patient safety moments for learning in surgeon–trainee interactions and the impact of culture on intraoperative education would help identify pedagogical opportunities to enhance intraoperative surgical education. From a practical perspective, explicit dialogue between learners and surgeons that lays bare the rationale for surgical decisions and scaffolding could help learners understand not only what to do, but more importantly, why they should do it. Culture represents an important but underexplored aspect of surgical education that may influence learning, well-being and equity. Lucas Streith: Conceptualisation; writing—original draft. Faizal A. Haji: Conceptualisation; supervision; writing—review and editing. The authors have no conflicts of interest to declare. None. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.