The use of an educational time-out in thyroid and parathyroid surgery to move the needle in periprocedural education

Published:October 07, 2022DOI:



      As surgical training shifts toward a competency-based paradigm, deliberate practice for procedures must be a point of focus. The purpose of this study was to assess the impact of an educational time-out intervention on educational experience and operative performance in endocrine surgery.


      For 12 months, third-year general surgery residents used the educational time-out to establish an operative step of focus for thyroidectomy and parathyroidectomy procedures. Data were collected using the System for Improving and Measuring Procedural Learning application and post-rotation surveys. The Zwisch scale was used to classify supervision, with meaningful autonomy defined as passive help or supervision only.


      Eight residents and 3 attending surgeons performed the educational time-out for a total of 211 operations (93% completion rate). At the end of each rotation, there was improvement in the frequency of goal setting. There was strong agreement (90%) that the intervention strengthened the educational experience. For most cases (52%), the residents were rated at active help. Residents performed a median of 3/6 thyroidectomy steps at meaningful autonomy and a median of 2/5 parathyroidectomy steps at meaningful autonomy. Review of the qualitative data revealed that optimal feedback was provided in 46% of cases.


      The educational time-out strengthened educational experiences. Stepwise procedural data revealed the varying levels of supervision that exist within an operation. Broader implementation of this intervention could facilitate competency-based procedural education.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Stride H.P.
        • George B.C.
        • Williams R.G.
        • et al.
        Relationship of procedural numbers with meaningful procedural autonomy in general surgery residents.
        Surgery. 2018; 163: 488-494
        • George B.C.
        • Bohnen J.D.
        • Williams R.G.
        • et al.
        Readiness of US general surgery residents for independent practice.
        Ann Surg. 2017; 266: 582-594
        • Hashimoto D.A.
        • Bynum WEt
        • Lillemoe K.D.
        • Sachdeva A.K.
        See more, do more, teach more: surgical resident autonomy and the transition to independent practice.
        Acad Med. 2016; 91: 757-760
        • Bucholz E.M.
        • Sue G.R.
        • Yeo H.
        • Roman S.A.
        • Bell Jr., R.H.
        • Sosa J.A.
        Our trainees’ confidence: results from a national survey of 4136 US general surgery residents.
        Arch Surg. 2011; 146: 907-914
        • George B.C.
        • Dunnington G.L.
        • DaRosa D.A.
        Trainee autonomy and patient safety.
        Ann Surg. 2018; 267: 820-822
        • Lindeman B.
        • Brasel K.
        • Minter R.M.
        • Buyske J.
        • Grambau M.
        • Sarosi G.
        A phased approach: the general surgery experience adopting entrustable professional activities in the United States.
        Acad Med. 2021; 96: S9-S13
        • Wojcik B.M.
        • Fong Z.V.
        • Patel M.S.
        • et al.
        Structured operative autonomy: an institutional approach to enhancing surgical resident education without impacting patient outcomes.
        J Am Coll Surg. 2017; 225: 713-724 e712
        • Bohnen J.D.
        • George B.C.
        • Williams R.G.
        • et al.
        The feasibility of real-time intraoperative performance assessment with SIMPL (System for Improving and Measuring Procedural Learning): early experience from a multi-institutional trial.
        J Surg Educ. 2016; 73: e118-e130
        • Lillemoe H.A.
        • Stonko D.P.
        • George B.C.
        • et al.
        A preoperative educational time-out is associated with improved resident goal setting and strengthens educational experiences.
        J Surg Educ. 2020; 77: 18-26
        • Lillemoe H.A.
        • Stonko D.P.
        • Sullivan M.E.
        • Geevarghese S.K.
        • Terhune K.P.
        Preoperative goal setting and perioperative communication in an academic training institution: where do we stand?.
        Am J Surg. 2019; 217: 318-322
        • Snyder R.A.
        • Tarpley M.J.
        • Tarpley J.L.
        • Davidson M.
        • Brophy C.
        • Dattilo J.B.
        Teaching in the operating room: results of a national survey.
        J Surg Educ. 2012; 69: 643-649
        • George B.C.
        • Teitelbaum E.N.
        • Meyerson S.L.
        • et al.
        Reliability, validity, and feasibility of the Zwisch scale for the assessment of intraoperative performance.
        J Surg Educ. 2014; 71: e90-e96
      1. About SIMPL OR. Accessed February 10, 2022.

        • Williams R.G.
        • Chen X.
        • Sanfey H.
        • Markwell S.J.
        • Mellinger J.D.
        • Dunnington G.L.
        The measured effect of delay in completing operative performance ratings on clarity and detail of ratings assigned.
        J Surg Educ. 2014; 71: e132-e138
        • Karim A.S.
        • Sternbach J.M.
        • Bender E.M.
        • Zwischenberger J.B.
        • Meyerson S.L.
        Quality of operative performance feedback given to thoracic surgery residents using an app-based system.
        J Surg Educ. 2017; 74: e81-e87
        • Williams R.G.
        • George B.C.
        • Bohnen J.D.
        • et al.
        A proposed blueprint for operative performance training, assessment, and certification.
        Ann Surg. 2021; : 273
        • Roberts N.K.
        • Williams R.G.
        • Kim M.J.
        • Dunnington G.L.
        The briefing, intraoperative teaching, debriefing model for teaching in the operating room.
        J Am Coll Surg. 2009; 208: 299-303
        • Ericsson K.A.
        Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains.
        Acad Med. 2004; 79: S70-S81
        • Lillemoe H.A.
        • Lynch Jr., K.A.
        • Schuller M.C.
        • et al.
        Beyond the surgical time-out: a national needs assessment of preoperative communication in US general surgery residency programs.
        J Surg Educ. 2020; 77: e172-e182
        • Mullins C.H.
        • MacLennan P.
        • Wagle A.
        • Chen H.
        • Lindeman B.
        Repeat attending exposure influences operative autonomy in endocrine surgical procedures.
        J Surg Educ. 2020; 77: e71-e77
        • Sandhu G.
        • Thompson J.
        • Matusko N.
        • et al.
        Greater faculty familiarity with residents improves intraoperative entrustment.
        Am J Surg. 2020; 219: 608-612
        • Rose J.S.
        • Waibel B.H.
        • Schenarts P.J.
        Disparity between resident and faculty surgeons’ perceptions of preoperative preparation, intraoperative teaching, and postoperative feedback.
        J Surg Educ. 2011; 68: 459-464
        • Levinson K.L.
        • Barlin J.N.
        • Altman K.
        • Satin A.J.
        Disparity between resident and attending physician perceptions of intraoperative supervision and education.
        J Grad Med Educ. 2010; 2: 31-36
        • Anderson C.I.
        • Gupta R.N.
        • Larson J.R.
        • et al.
        Impact of objectively assessing surgeons’ teaching on effective perioperative instructional behaviors.
        JAMA Surg. 2013; 148: 915-922
        • Ahmed M.
        • Sevdalis N.
        • Vincent C.
        • Arora S.
        Actual vs perceived performance debriefing in surgery: practice far from perfect.
        Am J Surg. 2013; 205: 434-440