Scaffolding during surgical procedures: Guidance with baby steps or giant leaps?

Introduction: Scaffolding refers to the dynamic support teachers provide to help learners complete tasks they cannot yet do independently. This is often done by breaking tasks into smaller, manageable steps and adjusting the support based on the learner's performance. In the operating room (OR), attending surgeons apply scaffolding to guide residents in performing tasks that they are not yet able to do on their own. However, the OR poses a unique challenge: attending surgeons must balance resident learning with patient safety, and procedures consist of multiple tasks for which the learner's expertise varies. Little is known about how surgeons determine and adjust the appropriate level of support during procedures. This study aims to explore how attending surgeons scaffold residents' learning throughout surgical procedures and the strategies they use to adjust their support on a moment-to-moment basis. 

Methods: We conducted a qualitative analysis of 34 instances of step-by-step coaching from transcripts of 16 surgical procedures in which residents performed surgeries under the supervision of an attending surgeon. We used conversation analysis to examine scaffolding in the OR and identify the contexts in which it occurs. 

Results: We found that attending surgeons break down procedures into small steps to guide residents. We identified four components that attendings use, which together form the basic grammar of intraoperative scaffolding. These components are: instructing the resident what the next step is, instructing the resident how to perform the next step, providing an explanation about the step and evaluating the performed step. We described scaffolding as baseline supervision and examined two contexts in which attendings reduce step size: when introducing a new technique and in response to suboptimal task performance. 

Discussion: The findings highlight the underlying structure of scaffolding in the OR, with attending surgeons navigating when to intervene and when to allow greater autonomy. Understanding how attendings adjust their support can improve alignment with residents' learning needs and foster discussions about shared educational goals.