Briefing and debriefing are common methods used to carry out teaching sessions in medical education. The pedagogical importance of this method has also been demonstrated in simulation and for surgery in the context of healthcare quality and patient safety [1-3]. The purpose of the briefing is to prepare the students before a scenario and to help the participants achieve the objectives of the scenario ^[4]. The value of debriefing is that it is a form of “reflective practice” and provides a means of reflecting on the action in the process of continuous learning [5,6]. This reflection-on-action is a crucial tenet of Kolb’s experiential learning theory, which describes how experience is a primary source of learning and development [7,8]. Central to the ideas of reflective practice and experiential learning is the belief that experience alone does not lead to learning but rather to deliberate reflection on that experience ^[8]. The role of debriefing in simulation is to help learners understand, analyze and synthesize their reasoning, emotions, and actions during practice to improve their future performance in similar situations ^[9]. A briefing-debriefing process in the operating room can promote patient safety by adding continuous improvement through reflective learning and immediate feedback ^[1]. It can also strengthen team collaboration, communication, and team dynamics ^[10]. In addition, medical pedagogy has shifted from classical teaching based on traditional lectures to approaches that promote reflection and active learning ^[11]. The flipped classroom (FC) approach is gaining popularity in higher education, especially medical education [12,13]. FC promotes higher levels of cognitive processing as defined by Bloom’s taxonomy ^[14]. Despite advancements in medical education, briefing-debriefing is mainly used for simulation, and the FC for theoretical courses. These methods are rarely assessed in the operating room context. Orthopedic residents typically learn theory through weekly lectures and conferences and gain practical experience by attending surgeries, on-call duties, and workshops, often sponsored by medical labs, raising potential conflicts of interest [15, 16]. These last practical courses, “where residents learn the most,” include theoretical parts and “briefing and reflective practice” discussions. Nevertheless, Practical learning in residency often occurs in the operating room during surgeries. Residents assist the surgeon, ask questions, and take notes. However, some, especially junior residents, fail to prepare due to unclear objectives and lack of motivation. Fear of disturbing the surgeon often prevents them from asking questions, leading to confusion and frustration. This stems from unclear learning goals, absence of briefing and debriefing, and lack of intraoperative discussion, all critical for reflective practice and motivation, as described in Kolb’s learning cycle ^[7]. This work aims to evaluate a new teaching model to enhance learning for orthopedic surgery residents, using the BID model (briefing, intraoperative teaching, debriefing) described by Roberts et al. in 2009 ^[17]. We have modified the technique by adding a reverse teaching technique to the operating room that was inspired from the FC method, giving residents more explicit objectives to better prepare for the intervention.

The study was approved by our institutional review board (project N° 2023 049). Sixteen residents participated in this evaluation study for 6 months (February 2023 to August 2023), within the Department of Orthopedic Surgery and Traumatology of the University Hospital of Tours. Among them were 8 junior residents (1^st/2^nd year) and 8 senior residents (≥3^rd year) (Table 1). Two teaching methods were applied: The so-called traditional one that is usually practiced, and the so-called “new” one, evaluated specifically for the study with its 3 phases: The briefing, the reverse operative teaching, and the debriefing.

In the “traditional” method, the residents typically divide the days of scheduled operations equally a week in advance. They prepare the cases and review the surgical technique the day before surgery, attend the operation with the senior surgeon on the day of surgery, and write the post-operative instructions notes at the end of the operation. However, there is no briefing between the senior surgeon and the resident regarding the objectives to be prepared before and during surgery. The senior surgeon does not know whether the residents have prepared the intervention, and there is no post-operative debriefing on what was done during the intervention. Regarding the “new” method (Fig. 1), in practice, the following steps were taken. The day before a scheduled intervention, a resident and an enrolled senior surgeon were specifically notified of the implementation of the new teaching method: briefing-inverted surgical class debriefing. The first step of the briefing was carried out the day before the intervention where the pedagogical alliance was established ^[18]. It consisted of a brief discussion-presentation of the case between the resident and the senior surgeon: history of the disease, clinical presentation, radiographs, indications, planned surgical technique, and alternatives. The senior surgeon answered any additional questions from the resident. This was followed by the second step of the reverse operative teaching, during which the senior surgeon presented to the resident, in a manner adapted to their level, the objectives to be prepared for the intervention, by providing educational materials or recommending certain references (videos on the surgical technique, surgical anatomy or specific approach, general or specialized articles) to meet the objectives. The resident was then tasked with preparing the educational materials advised by the senior surgeon the day before the intervention. On the day of the surgery, the senior surgeon discussed each stage of the intervention with the resident and verified that the knowledge provided aligned with the learning objectives that had been set and prepared by the resident. The resident asked questions related to their readings during the intervention. The discussion then continued upon request during the third and final step of the teaching: The “debriefing” during the surgical closure or after the intervention in the “reporting room” or break room. This step included three phases, according to the description proposed by Rudolph et al. ^[9]: Reaction, analysis, and summary. It lasted about 5–10 min.

Upon completion of the learning experience, the questionnaire was distributed to all participants through an online questionnaire (Google Docs; Google Inc., Mountain View, California, USA). The first part of the questionnaire, titled  “evaluation” comprised 16 general questions that sought to gauge their impressions of the applied teaching methodology, irrespective of its nature. The questions encompassed their perception of well-defined pedagogical objectives both before and after the intervention, the extent to which they felt supported and guided, the challenges encountered in sourcing pedagogical resources, their preparatory approach, their satisfaction with the teaching, and their ease in approaching the seniors with queries. The second part of the questionnaire titled “New method” was exclusively devoted to the novel teaching method probed, comprising 19 questions pertaining to its efficacy, the respondents’ subjective reactions, and overall satisfaction levels. The responses to the questionnaire were collected and participants provided their opinions using a Likert scale. All data collected were anonymized and the results were compiled in an Excel spreadsheet for analysis (Microsoft Corporation, Richmond, Virginia, USA). The median values, minimum and maximum values, and percentages for each question were calculated for all enrolled residents and for each subgroup: Junior residents (8) and senior residents (8). To establish the face validity of the questionnaire, a group of three experts with expertise in medical education was convened. These experts were provided with the questionnaire and instructed to assess its content, structure, and language to ensure its clarity, relevance, and comprehensibility for the intended respondents. The feedback and suggestions provided by these experts were carefully considered and integrated into the final version of the questionnaire, thereby enhancing its face validity.

The results of the residents’ questionnaire are presented in Table 2 (Part 1) and Table 3 (Part 2).

Regarding the first part of the questionnaire, 50% of the residents (including 75% of junior residents) indicated that they lacked well-defined objectives regarding what they should know or excel at their level for the surgical intervention they were assisting. In addition, between forty and sixty percent of junior residents also noted an absence of distinct objectives during the post-operative phase, either on an occasional or frequent basis.

More than 60% of the residents rarely reviewed the generalities of the pathology or read articles about the planned surgical intervention. However, 81% of the residents tried to review the operative technique as often as possible on the day before the intervention. Residents answered occasional or frequent difficulties in finding pedagogic material to read the day before surgeries, which was also associated with a perceived loss of time, reported in 50% and 31.5% of cases, respectively. Junior residents (>50%) had more difficulty asking questions to the seniors during or after the intervention than senior residents (12.5%). The residents rarely (50%) or occasionally (37.5%) met with the senior surgeons to discuss the cases on the eve of the planned surgery. Similarly, they reported that the surgeon never (37.5%) or rarely (50%) met with them to discuss the cases and tell them what they needed to prepare for the surgical intervention (Table 2). In the second part of the questionnaire, the responses of the residents indicated their satisfaction with the newly tested teaching method, which was found to be associated with an increase in their level of trust and improved quality of their relationship with the senior surgeons. The residents reported feeling better supported, with clearly defined learning objectives, leading to better retention and mastery of the subject matter related to the intervention. They also felt that asking questions was more comfortable and found assisting surgical interventions to be more motivating and finding teaching materials to be easier. The majority of residents favored this method as a teaching approach, and a large proportion of them wanted to use it when they become senior surgeons. To implement this method effectively, 70% of the residents believed it should be offered by senior surgeons the day before surgery, while 30% thought that it should be offered by residents. In addition, the majority of residents (81.25%) did not consider the method as time-consuming or uninteresting (Table 3).

To empower residents to take ownership of their learning, an active and proactive approach to education is required. The traditional teaching model in which learners are passive recipients of information is evolving, enabling them to engage, participate, collaborate, exchange ideas, and enhance their knowledge through reflective practice, in accordance with Kolb’s experiential learning theory ^[7]. This theory involves a four-part experiential learning cycle, consisting of concrete experience, reflective observation, abstract conceptualization, and active experimentation ^[7]. Similarly, Gibbs proposed a model of experiential learning that comprises four phases, including action planning, action implementation, reflection, and integration with theoretical knowledge ^[19]. During the briefing phase, it is crucial for the surgeon to establish a trustworthy environment. This phase serves as an opportunity for the resident to give consent for the use of the proposed teaching method, and for the surgeon to outline the educational approach’s purpose. This includes providing a clear explanation of the learning objectives, what is expected of the resident, and what materials should be studied. The surgeon should also provide resources to aid in preparing for the intervention and a clear plan for what will be discussed during the surgery and debriefing process. It is imperative to provide a transparent description of the learning objectives while avoiding any potential ambiguities for the residents. By promoting an open and trusting relationship between the senior surgeon and residents, communication channels are strengthened. To facilitate an effective debriefing process and promote optimal learning outcomes, it is crucial for the surgeon to establish a supportive and conducive climate in which residents feel valued, respected, and able to learn in an environment that upholds their dignity [20, 21]. It is essential that the residents are given the opportunity to share their experiences with a candid, transparent, and truthful approach. Furthermore, it is essential to be mindful of the participants’ vulnerability and ensure that it is consistently respected throughout the debriefing process. A similar strategy, known as the BID model, was previously introduced by Roberts et al. in 2009 at the University of Illinois. BID stands for “Briefing, Interoperative teaching, and Debriefing” ^[17]. In this strategy, before the surgical intervention, the surgeon and the resident discuss the resident’s expectations regarding the procedure. This may include the parts of the procedure that the resident will perform, or even whether the resident will carry out all the stages of the operation. It should also involve a discussion on the specific area the resident hopes to focus on to improve their techniques and performance. Then, during the intervention, the surgeon provides immediate formative feedback regarding the resident’s performance, helping them understand what they are doing well and what needs improvement. Similarly, during the debriefing, the resident and the surgeon review what went well and what could be improved, making a comparison with previous performances. Residents also expressed satisfaction with this approach and expressed a desire for its continued implementation in their residency training. Notably, they expressed their intention to employ this method themselves in their future roles as educators. The primary significance of this study lies in its ability to identify the pedagogical deficiencies in previously employed methods and propose an alternative approach that appears to have garnered support from various actors in the resident-surgeon relationship. The pre-operative briefing and establishment of clear objectives contribute to better psychological preparation of residents, guiding and motivating them to study and prepare for surgical interventions in comparison with traditional method where residents have no clear objectives. It also fosters a climate of trust between residents and senior surgeons through mutual listening and pedagogic alliance (Fig. 2).

The theoretical benefits of this method can be summarized as follows for each stakeholder (Table 4). These benefits highlight the significance of implementing this approach, along with a clear objective setting, as an effective educational strategy in surgical training programs.

This study has several limitations. The questionnaire was developed by the author and underwent only face validity assessment. There is a possibility that various biases, including question formulation bias or leading questions, could have influenced the quality of responses, leading to increased subjectivity. However, to mitigate these biases, respondents were ensured anonymity during data collection.

Another limitation is that this method can be evaluated differently by residents depending on the senior surgeon overseeing their training. Residents may have either a positive or negative experience based on their senior’s approach. In addition, it can be challenging to accurately assess the skill level and expectations of each resident. A final limitation is that many surgeons are not used to conducting debriefing sessions, which require expertise and are crucial during learning. However, this method aims to support and motivate residents, improve the surgeon-resident relationship, and deepen residents’ knowledge through reflection, enhancing learning per Kolb and Bloom’s taxonomy [7, 14]. This means that the debriefing aspect of the method does not necessarily require a high level of expertise, but rather it is a structured mentoring approach to assist residents in memorization, reflection, and providing them with guidance and objectives to acquire, rather than wasting time using inadequate or inappropriate educational tools. To address the issue of subjectivity, the discussion during the briefing phase between the resident and surgeons is crucial. However, there is no concrete “formative or summative” evaluation at the end of this method in this study, which limits the analysis of its beneficial effect on improving residents’ knowledge level. Nonetheless, these limitations can be somewhat disregarded given that the study’s primary focus was on residents’ perceptions of the learning experience with this new teaching method, a technique that has not been previously explored, and the majority of responses were positive in nature. Further studies could be conducted to evaluate the reliability of this method and potentially compare residents’ performance between the beginning and end of the semester. A larger number of participants, along with a validated questionnaire, would also be beneficial.

This new pedagogical approach could be worth considering in the field of surgery. This method effectively prepares and guides orthopedic residents with clear objectives for the surgical interventions. It creates a safe environment and eliminates barriers by strengthening the surgeon-resident relationship and fostering a pedagogical alliance while preserving their motivation and commitment to their training. It also enables more in-depth discussions during the surgical procedure due to the prior preparation. Reflective practice and constructive feedback during the debriefing process would enhance the learning process and promote higher levels of cognitive processing.

A structured teaching method incorporating briefing and debriefing, along with reverse teaching, can optimize the learning experience for orthopedic residents. It promotes better preparation, intraoperative discussions, and post-surgical reflection, ultimately improving surgical education and patient care.