Thinking Out Loud by Residents in the OR: A Multipurpose Tool to Micromanage Teamwork and Navigate the Balance Between Competence and Seeking Guidance

OBJECTIVE: To explore how surgical residents use thinking out loud (ToL) during procedures to navigate supervisory relationships, coordinate care, and take ownership of their learning. BACKGROUND: Surgical training unfolds in a high-stakes environment where residents must prove readiness while being closely supervised to protect patient safety. One often-overlooked strategy in this balancing act is ToL: verbalizing thoughts during action. While ToL is common in team-based communication, its use as a learning and supervisory negotiation tool in the operating room remains underexplored. Understanding this function may unlock new perspectives on how learning is co-regulated during live surgery. METHODS: In an observational study, three total hip replacement procedures performed by surgical residents were video-recorded. Using the iterative, inductive method of conversation analysis, 199 instances of ToL were identified and examined to determine how residents used speech to manage the flow of the procedure and supervision. RESULTS: All ToL behaviors could be categorized into three forms and corresponding functions: (1) Announcing: stating planned actions or intentions to structure workflow and invite assessment; (2) Noticing: verbalizing visual or tactile findings to manage unequal access to the surgical field; and (3) Evaluating: assessing one's own actions, either to demonstrate competence or elicit help. Each form shaped the dynamic of co-regulated learning (CRL), enabling real-time calibration of autonomy and supervision. CONCLUSIONS: This study reveals ToL as a powerful tool residents use to assert agency, enhance transparency, and engage supervisors in shaping intraoperative learning. Recognizing and supporting ToL may help surgical educators fine-tune supervision to maximize learning without compromising safety.