How to approach teaching as a surgical skill

Kimberly S. Ephgrave, MD, FACS
Professor of Surgery
Department of Surgery
University of Iowa
Iowa City, IA

Prologue

Twenty-eight years ago, when I was a 23-year-old medical school graduate and eager to start surgical residency, my sister, who had graduated from medical school two years earlier, gave me a copy of Cope’s Surgical Diagnosis of the Acute Abdomen. It was the pre-CPT era and inside the book she inscribed, “Never let the skin stand between you and a diagnosis!”

As an intern, I was sure that the surgery students I encountered would be as thrilled as I had been to see small intestines peristalsing, lungs expanding, or hearts beating, and to be part of surgical teams that would rid patients of their perforated appendices, inflamed gallbladders, or colon cancers. My first surgical students were indeed enthusiastic, and at the end of their rotation presented me with a fictious newspaper headlined, “Ephgrave Named Best Surgical Intern.”

Surgical teachers are developed, not born

Three years later, my situation had changed drastically. I had switched programs after following my husband to Texas . My copy of Surgical Diagnosis had long since disappeared after being lent to some careless student. I was sleep deprived by working over 100 hours each week in a setting where women were not always viewed as "welcome" in the program, and where even some patients felt we were there to experiment on, rather than help them. One day, the clerkship director called me into his office to discuss a legitimate student complaint made about me. As we talked, he spotted the summary of Selected Readings in Surgery folded in my pocket used for studying during those "extra" moments when patients were being anesthetized prior to an operation or just waking up following one. "You know, Kim," he said, "if you took a small fraction of the time you’re putting into patient care and studying into thinking about teaching our students, you would have fun with teaching. Plus, the students would love you." "The HELL they would," I thought, but I was grateful enough that he was letting me stay in the program that I gave his suggestion a try.

"The thinking about teaching" suggestion transformed what I had seen as a burden into an interesting challenge. Junior residents as well as medical students responded to my attitude change, and my career goals expanded to include surgical education.

There are several reasons why it is impossible to be an outstanding surgeon without achieving basic competence as a teacher. However, fitting the additional responsibility of teaching skills into a surgical residency curriculum poses a challenge to surgical program directors. Our surgical residents display a wide range of teaching skills, and those with the least educational knowledge or skills are often the least enthusiastic about learning more teaching skills.

Fortunately, the evidence base for what makes a good educator¹and a good coach for practical skills² has grown enormously in the past two decades. Outstanding teachers of adults share a passion for their subject matter, deep knowledge of their subject--and some thoughts on how the subject connects to the learners’ world--and a strong belief that others can learn the subject.

P. Jeff Fabri MD, PhD, FACS, promotes two key advances in educational research that surgical educators find provocative as well as useful.³The first is the description of the developmental stages in acquisition of expertise, from novice through competence and proficiency, promulgated by David Leach of the Accreditation Council for Graduate Medical Education.⁴The second advance in the research base of our training programs is the compelling database compiled by K. Anders Ericsson and colleagues showing that becoming an expert takes about 10,000 hours of deliberate and distributed practice, whether in performing surgery, playing chess or the saxophone, or snowboarding. In other words, time spent practicing a new skill is most useful if you reflect on or receive feedback on your performance, and have numerous sessions distributed over time rather than the same number of hours compressed into one day’s session.⁵

These components are suggested to facilitate the expansion of the use of teaching skills in residency programs:

familiarize program directors with the many ways in which surgeons use their teaching skills in clinical as well as academic settings.
utilize patients who are in favor of assisting in the development of surgery residents’ teaching skills.
motivate surgical chairs or deans to support a "residents as teachers" program to improve medical student ratings of the surgery clerkship.

Residents obviously want to become outstanding surgeons. However, they also have to work on cohesive, mutually supportive clinical teams as part of their duties. Thus, surgery residents’ top reasons to invest in acquiring teaching skills are:

To strengthen the residents’ own understanding of important aspects of their life’s work by explaining concepts to students who come from their different backgrounds and by responding to their various questions.
To gain fulfillment in recognizing that teaching is what students need, and to understand that the effort residents invest in students’ education is usually rewarded back with the students’ loyalty and clinical work.

Practicing surgeons benefit from skills addressed in residents as teachers programs in additional ways that may not yet be apparent to our trainees. These benefits include:

Surgeons’ patient outcomes may be affected as much by the patients’ ability to understand their medical condition and care for themselves as they are affected by our operative techniques. Teaching experience garnered from educating medical students will help surgeons assess and deliver what patients and their caregivers need to learn.
Practicing surgeons’ livelihoods are dependent on good relationships with physicians and surgeons practicing in other specialties. Taking an interest in medical students and educating them well, regardless of whether the students want to pursue careers in surgery, will help produce physicians that consult surgeons appropriately.

Surgical chairs need to have residents who are supported in developing their roles as medical student educators, and in reflecting "deliberate practice" on their educational skills. Some key points to remember are:

Surgical residents tend not to be naturally patient people. In the absence of educational training, this lack of patience can result in complaints about the student teaching program in the surgical department.
In general, medical students are bright, motivated people who are easy to teach. The sense of accomplishment educationally skilled residents derive from their teaching experience carries over to the way they feel about themselves and their training program. Residents trained to be effective, learner-centered educators are more effective at recruiting new residents, more likely to have positive feelings regarding participating in research projects in conjunction with their faculty, and less likely to generate clinical complaints.

Does resident-as-teacher’ curricula make any difference? A 2004 meta-analysis on the subject, based on all 14 studies that had been published up to that point, found that with interventions ranging from only a one hour session to a 13-hour, once monthly curriculum, both residents’ self-ratings as teachers, as well as student evaluations of their work, tend to improve. Furthermore, three out of the four randomized, controlled studies demonstrated statistically significant improvements in at least one learning outcome.⁶

Since that time, an additional 2007 study of 24 Obstetrics-Gynecology residents⁷ confirmed the effectiveness of a "residents as teachers" program in a more surgical setting. The authors found that a monthly series of workshops affected both participants’ scores on Objective Structured Teaching Examination modules and their residents’ self-assessments as teachers.

Faculty development programs for physician teachers have a longer track record than "residents-as-teachers" programs, and thus can give us insight into the long-term effects of programs created to enhance physician teaching skills. Since 1987, hundreds of new faculty and fellows at Johns Hopkins University School of Medicine, Baltimore, MD, have participated in a nine-month program with weekly sessions covering modules such as giving and receiving feedback; conducting one-on-one clinical teaching sessions; giving formal teaching sessions and presentations to large groups; and participating in team leadership sessions. In this setting, the program participants differed from non-participants in self-ratings of teaching effectiveness and learner-centeredness, and satisfaction with teaching, as well as having higher rates of academic faculty retention from seven to 15 years following the teaching skills program.⁸

Epilogue

The American College of Surgeons (ACS) Division of Education offers valuable resources to help program directors develop, evaluate, or improve their surgical training with regard to residents’ teaching skills. The ACS "Surgeons as Educators" course is a good starting point. Closer to home, program directors, at academic medical centers, may find a division of medical education in the center with faculty and staff who can provide workshops. Within all surgery programs, there may be program directors in other departments who would like to collaborate, or who have developed materials that you can adapt for surgical needs. Finally, you may find colleagues in the Association for Surgical Education and/or Association of Program Directors in Surgery affiliated with other centers who are interested in consulting or collaborating on programs to train your residents as educators.

Select Residents-as-Teachers Resources

Gaba N, Blatt B, et al. Improving teaching skills in obstetrics and gynecology residents: Evaluation of a residents-as-teachers program. Am J Obstet Gynecol, 2007;196:e1-7.
Musunuru S, Lewis B, et al. Effective surgical residents strongly influence medical students to pursue surgical careers. J Am Coll Surg, 2007;203:164-7.
Morrison EH, Ricker L, et al. The effect of a 13 hour curriculum to improve residents’ teaching skills: a randomized trial. Ann Intern Med, 2004;141:257-63.
Dunnington GL, DaRosa D. A prospective randomized trial of a residents-as-teachers training program. Acad Med, 1998;73:696-700.
Morrison E, Friedland J. Selected bibliography on residents as teachers. Residents as Teachers’ Web site/University of California at Irvine. Available at: http://www.ucimc.netouch.com/bibliography.shtml.

Article References

Bain K. What Outstanding College Professors Do, Harvard University Press, 2004.
Carnahan H. Feedback for learning clinical motor skills: Good or bad? American College of Surgeons Web site. Available here.
Fabri J. Is there a difference between education and training? American College of Surgeons Web site. Available here.
Batalden P, Leach D, et al. General competencies and accreditation in graduate medical education Health Affairs Web site. Available here.
Ericsson K, Krampe R, et al. The role of deliberate practice in the acquisition of expert performance. Psych Rev, 1993:100:363-406. Available here.
Wamsley M, Julian K, Wipf J. A literature review of “resident-as-teacher” curricula: do teaching courses make a difference? J Gen Intern Med, 2004:574-81. Available here.
Gaba N, Blatt B, et al. Improving teaching skills in obstetrics and gynecology residents: Evaluation of a residents-as-teachers program. Am J Ostet Gynecol, 2007;196:el-7.
Knight A, Cole K, et al. Long-Term Follow-Up of a Longitudinal Faculty Development Program in Teaching Skills. J Gen Intern Med, 2005:721-5. Available here.

Online October 28, 2008