Assessing the Utility of Intraoperative Educational Time-Outs in the Promotion of Medical Student Knowledge

Use of systematic checklists within the inpatient setting has gained particular traction as a means by which to codify interventions, minimize ambiguity, and enhance the overall reliability of care processes. In a similar fashion, the advent of systematic time-outs within the operative setting has come about with the chief goal of maximizing safety. Recently, Yang et al ¹ proposed the implementation of an “educational time-out” model as a mechanism by which the training of surgical residents could be maximized prior to cases through assessment of indications for surgery, surgical plans, and technical considerations. We hypothesized that implementation of a similar practice for use in the education of medical students within the operative setting would be a natural extension of the model, promoting preoperative case preparation and enhancing the intraoperative experience. Herein, we present preliminary results based on a pilot study and assessment of the implementation of such a model at our institution.

Fourteen medical students were recruited and randomly assigned to 20 surgical cases in a blinded fashion as a part of their routine clinical training. Cases spanned across several disciplines, including general (n = 8), gynecologic (n = 4), neurological (n = 4), plastics (n = 2), and orthopedic surgery (n = 2). All students were informed of the intention to assess general understanding of observed surgical procedures postoperatively. In 10 procedures, in addition to traditional surgical time-outs, educational time-outs were employed prior to incision, with a review of factors such as including initial clinical presentation, risk factors, physical examination findings, presumed diagnoses, anticipated intraoperative and postoperative concerns, and postoperative treatment plans by either the attending physician or senior resident. No such review was prioritized within the other 10 cases. Following completion of cases, students were provided with 10-question, written procedure–specific examinations to assess general understanding of patient presentation, procedural indications, and common intraoperative techniques. Statistical analysis was conducted using Prism 6.0 software (GraphPad Software Inc., La Jolla, California).

Overall, participants randomized to cases with educational time-outs outperformed their counterparts on written assessment (median = 9.0 vs 7.5; P < .001 by 2-tailed Wilcoxon match-pairs signed rank test). Controlled by procedure-specific assessment, scores within the time-out group surpassed, tied, and fell below controls in 14/20 (70%), 5/20 (25%), and 1/20 (5%) instances, respectively. Aside from objective assessment, students within the treatment group also noted increased confidence in their understanding of surgical anatomy, procedural steps, and possible postoperative complications in several instances.

Preliminary results suggest a significant improvement in medical student understanding and retention of factors specific to common surgical procedures and patient-specific knowledge with the institution of educational time-outs within the intraoperative setting. Given the inherent limitations of this small pilot study, further studies are merited. However, initial evidence suggests a benefit of such debriefings in the enhancement of not only resident and student education but also that of the overall surgical team, including scrub technicians, circulating nurses, and other critical team members. Separately, extension and modification of such practices to settings such as intensive care unit handoffs may translate into further advances in patient safety and medical quality.