What’s New in Surgical Education?

1. What’s New in Surgical Education?

4. ASE – San Antonio – April, 1988 • A twenty session course in clinical anatomy for surgical residents. • J Osuch et al. • “One of the greatest obstacles encountered during the first year offering of the course was motivating already stressed surgical residents to learn. In addition, overextended clinical faculty were unable to meet all of the teaching expectations outlined in the course plan.”

5. ASE – San Antonio – April, 1988 • The Surgeon Simulator • RK Reznick, MD • “The surgeon simulator technique refers to a teaching method where the surgeon takes on the active role of a patient with a particular disease. …The surgeon can alter the case scenarios instantaneously, and in so doing, challenge the student with the nuances of surgical decision making and patient management.”

6. ASE – San Antonio – April, 1988 • Medical students’ attitudes toward use of microcomputers as instructional tools. N. Lang, MD et al: • “While only 25% of the students considered themselves computer literate ….. they are interested in using this technology as a learning tool”

7. What’s New in Surgical Education? The more things change … … the more they stay the same

8. OSCE for PGY I residents • 10-station exam • Focused on patient safety • Relatively common problems faced by PGY-I residents • Defines desirable and “critical” skills for safe patient care • Assesses diagnostic and patient management skills in addition to history-taking, physical exam and communication skills. • Provides extensive quantitative and qualitative feedback to individual residents and program directors

9. SERF Program • Mentoring • Reflection • Networking • Faculty Development

10. ASE Strategic Planning • International focus/global mission • New products and services • Streamline executive functions • New partnerships/development of existing partnerships

11. APDS/ACS Portfolio Project • Promote self-directed learning and reflection • Document and share Continual Professional Development efforts

12. Patient Safety Curriculum • The culture of surgery • Physician behavior • Skill sets for promoting safe environment • System approach • Multi-layered longitudinal approach

13. What have I observed and learned as these projects have progressed? • Are there any important common themes?

14. Reflective Thought “…active, persistent and careful consideration of any belief or supposed form of knowledge in the light of the grounds that support it and the further conclusions to which it tends.” John Dewey, 1933

15. ……usually provoked by an event in one’s life that arouses a state of doubt, perplexity or uncertainty, and that leads an individual to search for possible explanations or solutions.

16. The process of Reflective Thought • State of doubt, perplexity or uncertainty due to an emerging difficulty in understanding an event or solving a problem • Intellectualization of a difficulty or complexity that has been experienced into a problem to be solved • Generation of suggested explanations or possible solutions through inductive reasoning • Elaboration of ideas derived from abstract deductive reasoning and consideration of their implications • Testing hypotheses by overt or imaginative action.

17. Reflective Practice (Schön, 1983) • Practice is largely based upon tacit knowledge (knowing-in-action) • Practitioners tend to be selectively inattentive to phenomena that do not fit the categories of their knowing-in-action and often miss opportunities to think about what they’re doing

18. Reflective practitioner • Able to identify when a phenomenon or unexpected outcome eludes his or her ordinary categories of knowing-in-action • Engages in a process of reflection in-action • Defines problems within the dynamics of the situation and identifies decisions to be made, and the means by which to achieve desired results. • Facilitates cognitive restructuring (e.g. basic science knowledge is integrated or encapsulated into clinical knowledge • Deepens feelings of competence

19. Deliberate Practice • Primary mechanism by which expertise is acquired • Effortful activity conducted with the goal of improving performance (not part of routine work) • Requires: • Critical reflection upon one’s practices • Focusing on weaknesses in one’s performance, in particular when encountering difficult or unexpected problems • Goal to improve performance • An attitude of openness towards reflection • Meta-reasoning (thinking about one’s own thought prcocesses and critically reviewing one’s own assumptions and beliefs) (Mamede & Schmidt, 2004)

20. Obstacles • It doesn’t always come naturally • It is often unspoken • Tend to view it as an “airy-fairy” process; absolute pragmatism and concrete thinking prevail • Can be difficult and time-consuming • Facilitation requires specific skills (faculty discomfort) • Rarely practiced “in action” in clinical settings (not in a reflective frame of mind, particularly while teaching in the OR or the trauma bay)

21. Types of Learning in Practice • Explicit: • Courses, classes, discussion on rounds, advice, teaching overtly intended to instill professional values • Tacit: • The Hidden Curriculum • Continuous, day-to-day learning • More powerful because it is reinforced more frequently and relates to doing rather than saying

22. The Dilemma • Explicit: • Stresses empathy, listening, responding, relief of suffering, trust, fidelity, patient’s best interest • Tacit: • Stresses objectivity, detachment, wariness, distrust of emotions, patients, insurance companies, administrators, the state…. • Promotes 3 traits: • Detachment (survival) • Entitlement • Nonreflective professionalism (shift toward technician) (Coulehan & Williams, 2001)

23. Professional vs Technician • Professional knows the larger context and uses this knowledge for lifelong learning • Technician’s knowledge is limited to performing a specific task

24. “There is no happiness if the things we believe in are different than the things we do” Albert Camus

25. The Big Picture • Evidence suggests a stunting or leveling off of personal, moral and emotional growth during clinical training, possibly due to the lack of adequate opportunities to reflect on practice in a systematic way. • The trend toward large group practices and service delivery networks demands the ability to function competently as a team member and to adapt and contribute to the professional values of the institutions in which practice takes place.

26. Solutions • Role modeling • Enthusiasm for learning • Demonstrate high degree of skills and knowledge • Emphasize the psychological and social aspects of medical care • Gaining the trust of learners • Clinical excellence • Interest and concern for learners and patients • Recognize and capitalize on teachable moments

28. Expert panel Recommended PBLI Objectives by level of training • MS-3-4: • Be able to recommend changes in clinical processes for a group of patients • Junior resident: • Identify places in the resident’s own practice that can be changed to affect the processes and outcomes of care • Senior resident: • Demonstrate how to use several cycles of change to improve the care delivery system (Ogrinc et al, 2003)

29. The role of Reflection in Problem-Based Learning & Improvement • PBLI is like “holding up a mirror to ourselves to document, assess and improve our practice” (Ziegelstein & Fiebach, 2004). • The mirror (our tools) are: • Portfolios • Chart self audits (3/year by each resident to identify learning needs) • M&M (Planned, safe environment) • The tools reflect practice and allow comparison to practice guidelines and scientific evidence

30. The Village • Based on Hilary Clinton’s book, It takes a Village • PBLI requires work as part of a community and team of health providers • Multidisciplinary patient care rounds • Nurse evaluations of residents • Quality assessment/improvement exercises (Ziegelstein & Fiebach, 2004)

31. Portfolios • Counteract the limitations of a reductionist approaches to assessment • Personalize the assessment process • Support the principle of “Learning through Assessment” (Friedman Ben David et al, 2005)

32. Portfolios • Currently being used by the Royal College of Physicians and Surgeons of Canada (Maintenance of Competence; MOCOMP) • Creates databases for establishing standards of performance for continuing ed programs (Friedman Ben David et al, 2005)

33. Elements: List of patients and diagnoses Written Learning Plan Goals for improvement Evaluations Conference Attendance Scholarly activity Procedure logs Presentations Teaching activities Awards Meaningful patient experiences Criteria: Clear and specific learning objectives Consistency between objectives and activities Documented evidence of application to learning Discusses the extent to which objectives were met Inclusion of critical incidents New learning plans based on critical incidents Understanding/reflection on the learning process Portfolios: Suggested Elements and Evaluative Criteria (Ziegelstein & Fiebach, 2004; Mathers, 1999)

34. Portfolios Can also include: • Videos of interactions with patients and/or peers • Annotated patient records • Letters of recommendation • CV • Written reflections (Friedman Ben David et al, 2005)

35. Simple Steps • Ask reflective questions: • What actually occurred with this patient? • What did we accomplish with this interaction? • What did you mean by that? • Say more about that… • Acknowledge emotion in individuals not participating in conversation, e.g. by providing opportunities for participation for learners who seem eager to add to discussion • Encourage discussion that elaborates on a topic, rather than raising different topics on a surface level. • Focus on higher levels of meaning – moral, ethical, social, professional issues

36. Simple Steps • Conduct writing sessions • Meet with residents to plan for M&M • Assign residents to complete chart self-audits • Require and facilitate portfolio development

37. “Your hearts know in silence the secrets of the days and the nights. But your ears thirst for the sound of your heart’s knowledge” Kahlil Gibran, 1923