Educating Orthopaedic Surgery Residents in the Dictation of Operative Notes

Purpose The purpose of this study was to analyze the existing literature to determine if and how surgical residents are taught to dictate operative notes. The secondary aim was to compile perceptions regarding the teaching and quality of resident operative dictation (OD) and ways in which teaching might be improved. # Method A systematic review was performed following PRISMA guidelines. PubMed, CINAHL, Web of Science, and EMBASE were searched for studies related to operative note dictation in U.S. surgical residency programs from 2010-2023. Results The initial search yielded 782 results, which were screened by two independent reviewers (MVL and BCG), resulting in 9 studies that met the inclusion criteria. These studies, covering various surgical subspecialties, revealed that while 44%-67% of surveyed surgical residency program directors (PDs) prioritize teaching OD, only 17% currently provide formal education in this area. Notably, synoptic reports, which employ templates with discrete data fields, demonstrated significantly greater completeness (94.7%) compared to traditional dictated operative reports (66%). Completeness of resident OD did not correlate with level of training, and pertinent information was lacking at all resident PGY-levels. Educational interventions in the form of lectures and video instruction improved the completeness of OD by up to 22%. Conclusions Despite the crucial role of OD in patient care, medicolegal aspects, and billing, this review underscores a lack of routine and formal instruction of this skill in U.S. surgical residency programs. Limited studies suggest potential improvement through formal educational interventions. Future research should delve into the costs and barriers hindering the integration of formal dictation training, shedding light on why PDs have not universally adopted such initiatives.