A junior medical studentmeets the operatingtheatrePiers Thomas, Imperial College, London, UK

Iam currently a final-year

student at Imperial Collegemedical school. During the

past eighteen months I haveadopted roles in a number ofsimulation-based studies in theImperial College London Simula-ted Operating Theatre (SOT), aspart of my extracurricular researchinterests. This is a high fidelitysimulated operating theatre thatallows surgical teams to functionin a highly realistic setting, sup-ported by audiovisual review andfeedback.

In light of this and myprevious curricular experiences, Ibecame interested in theproblems that face junior studentsembarking on their journey intothe world of the operating

theatre. In this article I reflect onmy theatre exposure, both as ajunior student and as a partici-pant in SOT simulations, andconsider how my opinions tie inwith the current literature on thetopic. I conclude by describingthe steps I have been taking toprovide a solution to the problemsthat I believe junior students facein the operating theatre, and toenhance the educational value ofthe experience.

BACKGROUND

During their clinical studies, stu-dents on surgical firms are gen-erally given the opportunity toattend theatre sessions, and thismay involve ‘scrubbing up’ andassisting the surgeons, or working

with the anaesthetic staff. This isgenerally seen as an excitingopportunity for the student tobegin to appreciate the practicalaspects of surgery and anaesthe-sia, and is viewed in a positivelight by most.1,2 However, theoperating theatre at first sightcan be an intimidating environ-ment, and this impression can becompounded by ignorance ofbasic theatre protocol, and onoccasion the attitudes of staff. Ithas long been appreciated thatthe presence of such naı̈ve stu-dents in theatre has the potentialto cause problems, and studentscan be viewed as something of asafety hazard and hindrance.3

When asked to scrub up andassist, the novice medical studentis faced with further challenges,

Students can beviewed as

something of asafety hazard

Learner’sperspective

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such as remaining sterile, contri-buting to operation site prepar-ation, and providing helpful andaccurate assistance to the sur-geon. Indeed, a new student inthis position poses a challenge tothe other members of staff too,who must work, supervise andeducate simultaneously.

PERSONAL EXPERIENCES

The National Association ofTheatre Nurses (NATN) has for asome years published guidelines4

that give an overview of thetopics discussed above, and suchmaterial is available to nurses,though not readily so for medicalstudents. I feel that exposure tosimilar material would have faci-litated my inaugural forays intotheatre, and increased my con-fidence at a time when ignorancewas causing my blushes. Forexample, I recall a time when myerrant elbow unwittingly desteri-lised an instrument trolley; andwhile the chastising chorus ofsurgeon and scrub nurse ensuredthat I was aware of the error of myways, I would have preferred notto have learnt the lesson in such amanner.

All these issues tie in well withthe first domain of Lyon’s three-domain model of learning in theoperating theatre (see Table 1),5,6

where such adaptations to thenew environment are highlightedas a key step in the learningprocess. The second domain goeson to describe the manner inwhich students weigh up thepotential benefits of attendingtheatre as against learningthrough other means. For exam-ple, my first surgical firm tied in

well with impending examina-tions, hence my enthusiasm toattend and to learn was high.However, I also felt under anobligation to attend theatre, andto heed my seniors’ wishes. Ithink this can often be thedeterminant of attendance, andmay well often be contrary to thestudent’s own aims. This ties inwith the third domain, as I foundthat mandatory attendance often

led to integration into the team,involvement in the operation andsubsequent teaching.

Another potential problem isthe clinical caseload one canwitness; I saw a lot of vascularsurgery, yet no urology, forexample. While it would belogistically impossible to enableall students to see everything, itis important for course organisers

Table 1. Lyon’s ‘three-domain model’ of learning in theatre5

The first domain Managing the demands of the working environment and the emotional impactof surgery as work

The second domain Managing the educational tasks, learning objectives and relevance

The third domain Managing learning and the social relations of work in the operating theatre

Source: Lyon (2003).

My errant elbowunwittinglydesterilised aninstrumenttrolley

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to try to ensure that studentsget as consistent an experienceas possible. Methods such asusing telemedicine7 have thepotential to assist here, althoughat present there remainsvariability in the experiences astudent might have.

SIMULATED OPERATIONS

The use of simulation in surgicaleducation is becoming increas-ingly popular and is well des-cribed.8 I have been involved ina number of projects usingsimulated theatre sessions as themodel for a variety of researchpurposes. These sessions in-volved the use of a SimulatedOperating Theatre (SOT), anenvironment that allowed theanaesthetic, surgical and nursingteams to be observed whilecarrying out a procedure on aSimMan manikin, followed bydetailed feedback.9 A variety ofclinical situations could besimulated; for example, asapheno-femoral vein ligation ora carotid endarterectomy.

The simulations would gener-ally start with the ‘patient’ awakeand the anaesthetics team carry-ing out pre-operative checks andanaesthetic routines. Generally,there would be problems to beidentified and rectified appropri-ately. Simultaneously, the nursingteam would prepare the instru-ments and ensure that their pre-operative duties had been carriedout. Finally, the surgical teamwould be involved, and the‘operation’ would proceed. Mycontribution during the opera-tions was to act as the surgicalassistant, scrub nurse or circula-ting nurse.

During the sessions I spentas part of the nursing set-up, Irealised that I was embarras-singly unaware of a number ofseemingly simple theatre activ-ities. For example, I stumbledslowly through tasks such assetting up the suction correctly

or locating the correct type ofsuture from the array presentedto me. As time went on though,through repetition, these even-tually became second nature, asdid the protocols followed forsuch activities as instrumentchecks and the correct methodsfor aseptic practice. I also be-came more accustomed to thenames of instruments, somethingthat had eluded me when insurgery previously.

Importantly, by playing thisrole, I witnessed communicationbetween team members from aposition that most medical stu-dents (and indeed surgeons andanaesthetists) never find them-selves in. While the identification

and interpretation of talk patternsand acquisition of a professionalidentity in theatre, and the im-pact of these on the novice, havebeen identified,10,11 I believe therole I played here offered a per-spective and level of understand-ing that is unobtainable in thetraditional role of medical stu-dent, and it was thus an import-ant experience with regard to myunderstanding of inter-profes-sional relations.

My sessions as the surgicalassistant allowed me to practisemy assisting skills, such asfollowing continuous sutures andproviding effective suction. I alsofound that my level of awarenessincreased, so that I became more

I saw a lot ofvascular

surgery, yet nourology

It opened myeyes to the

nature of othertheatre

professions

204 � Blackwell Publishing Ltd 2006. THE CLINICAL TEACHER 2006; 3: 202–205

adept at, for example, providingthe surgeon with effectiveretraction.

Overall, my time in the SOTallowed me to practise and con-solidate skills that I had usedinconsistently in the real world.Moreover, it opened my eyes tothe nature of other theatre pro-fessions. As a result, in my sub-sequent real-life theatre sessionsI have been more aware of, andmore comfortable in, the envi-ronment, and can therefore con-centrate purely on my learningobjectives. Importantly, I thinkover time I have become more of a‘help’ than a ‘hindrance’.

CONCLUSIONS – ANAGENDA FOR CHANGE

I value greatly the experiences Ihave described here, and feel thatthe opportunities I grasped willfacilitate my performance in myfuture work as a medical studentand as a junior surgeon.

I feel that entering theatre forthe first time is analogous tovisiting a gym, where one receivesa brief but comprehensive induc-tion in order to clarify importantsafety and usage issues, and isallowed to ask questions. Ittherefore seems prudent toinvestigate the possibility ofproviding such an induction fornaı̈ve students who are due tobegin their exposure to theatre.While there are steps being takento address the educational prob-lems facing postgraduate train-ees,12 I feel that, currently, theissues facing junior medical stu-dents are underestimated andhave not been addressed suffi-ciently.

A theatre induction programmeI would therefore advocate theestablishment of a theatre induc-tion programme. The initial com-ponent would consist of astraightforward lecture-basedsession with the intention of

briefing the students on theatrelayout, protocol and job descrip-tions. It would also provideguidance regarding what might beexpected of students, not only onwhat to do when asked to assistthe surgeon, but also how to makethemselves generally useful withother members of the theatreteam. Finally, practical advicewould be given regarding ways ofmaximising the students’ learningexperience. This format would bewidely accessible, and thereforebe a high-yield product.

Subsequently, and wherefacilities allow, a programme ofstructured activities in the clin-ical skills laboratory and the SOTcould be used to expand andconsolidate this information. Thiswould incorporate the use ofbench-top models to enable thestudents to practise their assist-ing skills, and visits to the SOT sothat a true appreciation of thetheatre environment can begained. The induction programmewould culminate in the studentsbeing given the opportunity toparticipate in SOT simulations, asI did, in the roles of assistant tothe surgeon or anaesthetist, andas a circulating nurse.

Such a scheme would removeseveral of the current blocks tolearning in theatre. This rings truein particular with regard to ele-ments of the first domain in thescheme suggested by Lyon, as thestudents’ agenda would be prior-itised. It would also allow adegree of standardisation thatreal theatre cannot offer, whilealso ensuring contextualisation ofthe skills learnt. Finally, I hopethat it would also address inter-professional relations in theatre,by giving the new students anunderstanding of the roles playedby the other professionals, andways in which students mighthelp rather than hinder. Thiscould well be the most valuablelesson that students learn.

By the end of such a pro-gramme, I would hope that a largenumber of students would havereceived similar benefits to thoseI was fortunate to gain throughmy extracurricular activities.

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The issuesfacing juniormedicalstudents areunderestimated

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