Modern ways to enhance surgical teaching skills

Extrinsic pressures are influencing ways in which medical students and trainees learn, and are taught surgery and surgical principles. As a surgical educator it is useful to understand some of the reasons for these changes and to acquire the skills necessary to provide effective teaching. This short article looks at reasons why one would wish to develop surgical teaching skills, covers basic principles associated with delivery of effective teaching sessions and briefly reviews other avenues that may enhance teaching practice.     

Editorial Commentary: Proficiency-Based Progression Surgical Simulation Training Is an Efficient Adjunct to High-Volume Clinical Experience

The optimal way to train a future surgeon has been debated for years, with strategies ranging from the well-known “see one, do one, teach one” approach to more novel approaches that rely on metrics and proficiency. Recent research shows that surgical training with a proficiency-based progression curriculum is an efficient strategy for teaching arthroscopy procedural skills, and, further, may improve patient safety by reducing the technical errors that might otherwise occur before proficiency is achieved. While every surgical specialty has its nuances that must be mastered to provide safe, effective, and efficient care, for a variety of reasons, the skills needed to perform arthroscopy are incredibly difficult to learn, let alone achieve proficiency or master. “On-the-job” training for orthopaedic residents has become more difficult in today’s fast-paced, work hour–limited, volume-rewarded society. Proficiency-based progression is a piece of the puzzle, but for now, it is not a complete substitute for high-volume, clinical experience and exposure to the countless variables that may affect a "real-life" surgical procedure.     

Surgical skills training restructured for the 21st century

BackgroundFew if any medical schools have a comprehensive surgical skills program taking medical students from learning basic knot tying and surgical skills to performing these skills at a level adequate for function during a primary care, surgical, or subspecialty residency. We have designed and continue to refine a program, which consists of five workshops focused on basic surgical skills, which are applicable to all medical and surgical disciplines.Materials and methodsDuring the first workshop students learn how to tie both one- and two-handed surgical knots. The second workshop involves teaching students differences in suture type and use, instrument handling, and suturing techniques. The third workshop is used to address problems and refine techniques previously learned in the first two sessions. The fourth workshop comprises a final examination to evaluate suture and knot tying skills. The fifth session is a voluntary knot tying and suturing competition with awards for speed, finesse, aesthetics, and the watertightness of a vascular surgical repair. Surgical faculty and house staff are present at each workshop to provide direction and constructive criticism.ResultsFifty-seven third-year medical students have completed the surgical skills curriculum. Statistical analysis demonstrates significant improvement in both knot tying and suturing (P < 0.05) for these students. Forty-four percent of students have successfully sewn a watertight anastomosis.ConclusionWe hypothesize that this curriculum will produce medical students with basic surgical skills, appreciation of surgical technique, and the confidence to perform basic surgical skills at completion of the curriculum.     

How much feedback is necessary for learning to suture?

BACKGROUND: Many laparoscopic simulation training systems exist and have been shown to transfer learning of surgical skills to the operating room. The manner in which the training is structured to maximize learning has not been examined. There are many aspects to the acquisition of laparoscopic skills during training, one of which is the availability of knowledge of results (KR). Knowledge of results is information about the outcome of motor skill execution, usually provided to individuals at the end of the execution. The timing and nature of KR can affect how well people learn new motor skills. In addition, detailed instruction during learning can also affect skill acquisition. We studied the effects of KR and instruction on the learning curve of a suturing and knot-tying task. We hypothesized that KR was necessary for skill acquisition, and that detailed instruction would help trainees to learn to perform the task more correctly and reach a performance plateau earlier. In addition, the overall workload of a trainee during training would decrease as skills improved, especially when KR and coaching were provided. METHODS: Nine medical students with no previous laparoscopic surgical experience were randomly and evenly divided into three groups with different KR conditions: (1) no KR, (2) KR, (3) KR + instruction. Each subject attended a training session for 1 h each day, 6 days a week for 4 consecutive weeks. Performance measures such as task time, smoothness of instrument, and path length were recorded for each trial. Workload was assessed using the NASA-TLX questionnaire. RESULTS: While KR was necessary for learning to suture, continual instruction had limited additional benefits. However, KR + instruction did reduce subjects' perceived overall workload. CONCLUSIONS: Surgical training could be carried out effectively with only knowledge of results. These results have implications for the staffing of surgical skills laboratories.     

Surgical skill acquisition with self-directed practice using computer-based video training

BACKGROUND: Computer-based video training (CBVT) provides flexible opportunities for surgical trainees to learn fundamental technical skills, but may be ineffective in self-directed practice settings because of poor trainee self-assessment. This study examined whether CBVT is effective in a self-directed learning environment among novice trainees. METHODS: Thirty novice trainees used CBVT to learn the 1-handed square knot while self-assessing their proficiency every 3 minutes. On reaching self-assessed skill proficiency, trainees were randomized to either cease practice or to complete additional practice. Performance was evaluated with computer and expert-based measures during practice and on pretests, posttests, and 1-week retention tests. RESULTS: Analyses revealed performance improvements for both groups (all P < .05), but no differences between the 2 groups (all P > .05) on all tests. CONCLUSIONS: CBVT for the 1-handed square knot is effective in a self-directed learning environment among novices. This lends support to the implementation of self-directed digital media-based learning within surgical curricula.     

Improving basic surgical skills for final year medical students: the value of a rural weekend

BACKGROUND: Hospitals employing medical graduates often express concern at the inexperience of new interns in basic surgical skills. In self assessment questionnaires, our senior medical students reported little clinical procedural experience. A practical skills workshop was staged in order to set learning goals for the final study year. This gave the students an opportunity to learn, revise and practice basic surgical techniques. METHOD: The Bruce Rock rural community sponsored a surgical camp at the beginning of the academic year. Ninety-five (80%) of the class registered at the workshop, which rotated them through teaching modules, with private study opportunities and the capacity to cater for varied skill levels. Eight teaching stations with multiple access points were provided, and ten mock trauma scenarios were staged to augment the learning process. RESULTS: The teaching weekend was rated by students on an evaluative entrance and exit questionnaire. Sixty-five (73%) students returned questionnaires. They recorded significant improvement (P < 0.05) in their ability to handle the teaching stations. All students had inserted intravenous lines in practice prior to the camp, so the rating change in intravenous line insertion ability was not statistically significant. CONCLUSIONS: The weekend retreat offers students a chance to focus on surgical skills, free from the pressures of a clinical setting or the classroom. The emphasis was on the value of practice and primary skills learning. Students endorsed the camp as relevant, practical and an enjoyable learning experience for basic surgical skills.     

Training Models in Laparoscopy: a Systematic Review Comparing their Effectiveness in Learning Surgical Skills

Background : Surgery has traditionally been learned on patients in the operating room, which is time-consuming, can have an impact on the patient outcomes, and is of variable effectiveness. As a result, surgical training models have been developed, which are compared in this systematic review.

Methods : We searched Pubmed, CENTRAL, and Science Citation index expanded for randomised clinical trials and randomised cross-over studies comparing laparoscopic training models. Studies comparing one model with no training were also included. The reference list of identified trials was searched for further relevant studies. Results : Fifty-eight trials evaluating several training forms and involving 1591 participants were included (four studies with a low risk of bias). Training (virtual reality (VR) or video trainer (VT)) versus no training improves surgical skills in the majority of trials. Both VR and VT are as effective in most studies. VR training is superior to traditional laparoscopic training in the operating room. Outcome results for VR robotic simulations versus robot training show no clear difference in effectiveness for either model. Only one trial included human cadavers and observed better results versus VR for one out of four scores. Contrasting results are observed when robotic technology is compared with manual laparoscopy. Conclusion : VR training and VT training are valid teaching models. Practicing on these models similarly improves surgical skills. A combination of both methods is recommended in a surgical curriculum. VR training is superior to unstructured traditional training in the operating room. The reciprocal effectiveness of the other models to learn surgical skills has not yet been established.     

The validity of take-home surgical simulators to enhance resident technical skill proficiency

Background

It is unknown whether surgical residents who learn minimal-access surgery skills in an unstructured environment (ie, at home), will develop a technical skill set that rivals that of those trained in the more traditional, structured learning environment.

Methods

Seven surgery residents were provided structured learning through didactic and hands-on skills training sessions and consistent supervision throughout training. A second group of 7 residents participated in an unstructured learning curriculum of training without supervision. End points were determined at the end of training using a standardized simulator based on predetermined performance measures.

Results

Both groups achieved high task scores, with comparable scores on gesture proficiency, hand movement smoothness, instrument movement smoothness, errors, and time elapsed. There was no significant difference between group differences in final skills scores.

Conclusions

Unstructured learning is equally effective in delivering quality skills training when compared with structured training.     

What does leadership in surgery entail?

Background: Leadership is not formally taught at any level in surgical training; there are no mandatory leadership courses or qualifications for trainees or specialists, and leadership performance is rarely evaluated within surgical appraisal or assessment programmes. Methods: Literature obtained from a MEDLINE search was reviewed to determine the characteristics of surgical leaders; outline an analytical framework through which these characteristics can be developed both in surgeons and surgical departments; and reflect on future challenges and recommendations for the central role of leadership in the field of surgery. Results: Leadership in surgery entails professionalism, technical competence, motivation, innovation, teamwork, communication skills, decision‐making, business acumen, emotional competence, resilience and effective teaching. Leadership skills can be developed through experience, observation, and education using a framework including mentoring, coaching, networking, stretch assignments, action learning and feedback. Conclusion: Modern surgery will need leaders with superior leadership skills that are well defined. It is vital that leadership programmes to develop leadership skills are put into practice in medical education curriculum and postgraduate surgical training. This will ensure maintenance and improvement in the quality of patient care.     

Education in postgraduate surgical schools: the role of the surgical tutor as supervisor in the operating room

The Postgraduate Surgical education is in an era of transition, in order to create physicians with skills and attitudes needed by modern health care. Many studies have examined the impact of surgical tutoring in surgical residency programs in USA Medical Schools, while few experiences are reported from European Universities. The new Italian guidelines for post-graduate education require a structured clinical learning with the supervision of a tutor ("attending surgeon" for surgical residency); it is a challenge to describe the role of this teacher and educator, and to implement an effective evaluation of operating room teachers. Confidential survey was administered to 14 surgical residents of the Authors' University. Questions were related to their surgical activity and their perception of educational role of tutors in operating room and tutors' teaching behaviors. Residents pointed out five behaviors they perceive as signs of tutor excellence in clinical and operating room setting. According with studies from other Universities, residents need a tutor with competency but also with good teaching skills and a mature self-perception as educator. Faculty would provide training programs for surgeons in order to improve their teaching skills and behaviors.     

Simulation in surgical education

Simulation is becoming an important tool in surgical education. Surgical faculty have been forced to modify how they teach technical skills. Instead of a complete reliance on teaching in the operating room, a structured curriculum and dedicated time in the simulation center are being used in many centers. Some of the advantages of this approach include the ability to learn and practice new procedures in a safe and nurturing environment. The disadvantages include the significant cost of virtual reality simulators and the competition, between various training programs, to gain access to simulation.     

Editorial Commentary: Resident Education: At What Cost?

Arthroscopic trainees may struggle to learn basic skills, resulting in slower and more expensive surgical procedures. However, the reward of resident involvement includes the satisfaction and benefit to society associated with medical mentorship, and the learning—clinical and otherwise—that is associated with teaching.     

延迟小结追加反馈对基础护理操作技能学习的影响

目的探讨基础护理操作技能教学中延迟小结追加反馈对教学效果的影响。方法随机抽取护理专业2003级2个专科班的125名学生分为控制班（62人）、实验班（63人）。在基础护理操作技能教学中控制班采用同步追加反馈，反馈频率为100％，反馈内容为操作错误的信息；实验班采用延迟小结追加反馈，反馈频率为25％～30％，反馈内容为操作错误以及正确操作的信息。结果控制班在技能获得阶段操作成绩显著高于实验班（P〈0．01），但在随后保持阶段的测试中成绩逐渐下降并显著低于实验班（P〈0．01）。结论练习过程中追加反馈的内容、时机和频率对基础护理操作技能的教学效果有影响。同步追加反馈可以保证技能习得阶段的表现却不利于技能的保持；延迟小结性反馈最有利于基础护理操作技能的学习。     

Development and decay of procedural skills in surgery: A systematic review of the effectiveness of simulation-based medical education interventions

ContextChanges to surgical training programmes in the UK has led to a reduction in theatre time for trainees, and an increasing reliance on simulation to provide procedural experience. Whilst simulation offers opportunity for repetitive practice, the effectiveness of simulation as an educational intervention for developing procedural surgical skills is unclear.MethodsA systematic literature review was undertaken to retrieve all studies describing simulation-based medical education (SBME) interventions for the development of procedural surgical skills using the MEDLINE, PsycINFO, CINAHL, EMBASE and PUBMED databases. Studies measuring skill retention or demonstrating transferability of skills for improving patient outcomes were included in the review.ResultsSBME is superior to no training and can lead to improvement in procedural surgical skills, such that skills transfer from simulated environments into theatre. SBME results in minimal skill degradation after 2 weeks, although more significant decay results after >90 days. Many studies recruited <10 participants, used a variety of methods and were restricted to endoscopic surgical techniques. All studies did not compare interventions with non-SBME teaching methods for developing procedural surgical skills. No studies compared the curriculum design of different surgical training programmes.ConclusionsSBME interventions are effective for developing procedural skills in surgery. SBME interventions are also effective for preventing the decay of procedural surgical skills. Although no studies demonstrate non-inferiority of SBME interventions compared to time in theatre developing skills, SBME interventions do enable the transfer of skills into theatre, and the potential for improving patient outcomes.     

Teaching technical surgery

Surgical educators face many challenges on the path toward ensuring surgical trainee technical-skill acquisition. We present effective intraoperative teaching techniques and discuss the utilization of simulation to improve technical skills outside of the operating room. Adjuncts, including coaching, mental skills, and nontechnical-skill assessments, are also reviewed. Finally, an example of a clinical curriculum that incorporates best practices in teaching technical surgery is presented.     

Computers and virtual reality for surgical education in the 21st century

Surgeons must learn to perform operations. The current system of surgical resident education is facing many challenges in terms of time efficiency, costs, and patient safety. In addition, as new types of operations are developed rapidly, practicing surgeons may find a need for more efficient methods of surgical skill education. An in-depth examination of the current learning environment and the literature of motor skills learning provides insights into ways in which surgical skills education can be improved. Computers will certainly be a part of this process. Computer-based training in technical skills has the potential to solve many of the educational, economic, ethical, and patient safety issues related to learning to perform operations. Although full virtual-reality systems are still in development, there has been early progress that should encourage surgeons to incorporate computer simulation into the surgical curriculum.     

University and practice-based physicians' input on the content of a surgical curriculum.

BACKGROUND: The specific knowledge and skills students learn during surgical rotations are reconsidered in light of recent changes in medical school curricula. The purpose of this study was to determine the priorities of a surgical curriculum based on input from three groups; surgical faculty (SF), primary care faculty (PCF), and community-based , practicing primary care physicians (PCP). METHODS: A questionnaire was developed in which SF (n=54), PCF (n=85), and PCP (n=876) were asked to rank the importance of 145 areas of knowledge and 48 areas of clinical skills on a 5-point Likert-type scale. Responses were rank ordered by the mean of importance ratings for each group. Differences among groups were evaluated using ANOVA. RESULTS: Response rates were best for faculty (100%) SF, 88% PCF, 61% PCP). All three groups were best considered general surgery related topics and general skills very important. Primary care physicians and PCF consistently ranked otolaryngology, ophthalmology, and orthopedic topics and skills higher than did SF. Surgery faculty ranked invasive surgical procedures higher than did PCP while PCP ranked orthopedic procedural skills more highly. CONCLUSIONS: There is significant overlap among physicians about what medical students should learn during surgical rotation. Differences between groups centered on surgical subspecialty knowledge and clinical skills. These results provide a broad perspective about required subjects for a core surgical clerkship curriculum, which should include surgical subspecialty training.     

The theoretical base of e-learning and its role in surgical education

INTRODUCTION: The advances in Internet and computer technology offer many solutions that can enhance surgical education and increase the effectiveness of surgical teaching. E-learning plays an important role in surgical education today, with many e-learning projects already available on the Internet. EDUCATIONAL THEORY: E-learning is based on a mixture of educational theories that derive from behaviorist, cognitivist, and constructivist educational theoretical frameworks. CAN EDUCATIONAL THEORY IMPROVE E-LEARNING?: Conventional educational theory can be applied to improve the quality and effectiveness of e-learning. The theory of "threshold concepts" and educational theories on reflection, motivation, and communities of practice can be applied when designing e-learning material. E-LEARNING IN SURGICAL EDUCATION: E-learning has many advantages but also has weaknesses. Studies have shown that e-learning is an effective teaching method that offers high levels of learner satisfaction. Instead of trying to compare e-learning with traditional methods of teaching, it is better to integrate in e-learning elements of traditional teaching that have been proven to be effective. CONCLUSIONS: E-learning can play an important role in surgical education as a blended approach, combined with more traditional methods of teaching, which offer better face-to-interaction with patients and colleagues in different circumstances and hands on practice of practical skills. National provision of e-learning can make evaluation easier. The correct utilization of Internet and computer resources combined with the application of valid conventional educational theory to design e-learning relevant to the various levels of surgical training can be effective in the training of future surgeons.     

Qualit?t und Objektivierbarkeit der Aus- und Weiterbildung in der Urologie

The attraction to study medicine has not changed, however we are facing a lack of trainees especially in surgical subspecialties like urology. Possible explanations are a 70% proportion of female students and different views on the work-life balance in the future. A high burden of theory and unrealistic multiple choice examinations support those who can learn but there are no objective and reproducible criteria to recognize the competence of a good physician early in the career. This problem continues during residency, especially in surgical subspecialities. The different medical boards in Germany responsible for the training programs have no concepts. Many attempts in other countries to objectively measure surgical skills have so far been ignored. If we do not want to lose our traditionally high competence in medicine we should join those who attempt to improve teaching and to use methods for selecting suitable candidates for surgery as soon and as objectively as possible.