How surgical skills training can lead to residency program improvement
Linnea S. Hauge, PhD
Department of General Surgery
Rush University Medical Center, Chicago, IL
As the end of another academic year nears, the season for reflection and planning is upon us. It is this season that brings to mind the arrival of the resident class of 2004, and the extent of their growth from newly anointed physicians to competent, confident surgeons. Perhaps the most rewarding aspect of academic surgery is the role that you, as faculty, play in cultivating that growth. As you look back on the past year and begin to plan ahead for the coming academic year, consider your opportunities for making tangible and feasible improvements to your surgical skill training programs. While evaluating options for enhancing your program, consider the following tips, based on motor learning and psychology research, for enhancing the surgical skill training experiences for your new interns and seasoned residents. Ultimately, their success and confidence exemplify some of your program's greatest academic accomplishments.
1. Clarify your expectations for resident performance.
Keeping in mind that what may seem second-nature to you may be new to new residents, consider these questions:
- What skills should residents have before they perform in the OR?
- What and how often should a resident practice independently outside the OR?
- How should residents prepare for a case?
These expectations will be most effectively clarified from a programmatic perspective. Gather faculty consensus and support in reinforcing these expectations.
2. Know your residents' performance level.
Ask your residents about their past performances (e.g. asking, "how many times have you done this procedure in the lab? In the OR?" Then determine how they did in those instances.) Ask them about how they have prepared for the case they are working on with you. What did they read or review? Ask them how they view their skills as needed for the procedure.
3. Conduct a briefing with your resident before you get to the OR.
This briefing can be done at the scrub sink. Ask the resident to verbally rehearse the key steps of the procedure. Accurate mental rehearsal is important for skill development, and verbal rehearsal allows an expert to "observe" one's mental rehearsal. Verbal rehearsal will provide an opportunity for you to identify resident conceptions, misconceptions, or concerns, and prepare for receiving constructive teaching throughout the case. Furthermore, professional communication with your resident team and your entire OR team may reduce the potential for miscommunication, resulting in improved patient safety and a more efficient operation.
4. Provide residents with correct examples of surgical skills and procedures.
The development of surgical skill and judgment is dependent upon observational learning, or modeling. It is important for residents to be able to visualize the correct steps and details of a procedure, prior to performing the steps. Observing you, another resident or attending, or a video is an important aspect of learning a procedure. But watching will lose its effectiveness if the observations are not accompanied by performance opportunities, in the lab or the OR.
5. Give residents insight into your surgical judgment and decision-making.
Let residents know why you do what you do. Explain the science and the art of surgery by describing your decisions, and comparing and contrasting your practices to the practices of others. Your descriptions may be most effective if they are explained as you are making decisions in actual cases. Give residents insight into the crucial timing aspects of surgical decision-making by thinking aloud during key features of a procedure.
6. Provide residents with decision-making opportunities in the OR.
Conducting a briefing with verbal rehearsal and giving insight into your surgical judgment sets you up well for handing over decision-making as a teaching technique. Of course, it is expected that you will give your residents direction when appropriate. Direction is a type of instruction where the learner is assumed to have no choice but to execute the instructor's directive. Giving direction is a requisite teaching technique for the OR, and is akin to training wheels on a bicycle. The resident is "doing" the hands-on work, but the attending is deciding what needs to be done and how it should be done. When you have ascertained, through briefing and past experiences, that a resident is ready to decide what and how, using guidance is an effective teaching technique. Guidance is a type of instruction where the resident makes decisions and the faculty responds to them, shaping performance as necessary. Guiding helps to foster resident independence under appropriate supervision. While there are similarities between the two methods, guidance and direction are subtly different techniques. Direction is generally easier and more convenient, especially for instructors, and is necessary during most of a resident's training. Guidance requires a bit more patience on the part of the instructor and with a little practice can easily be incorporated into your normal OR interactions, resulting in long-term training benefit, such as independent practice.
7. Debrief with your residents after a case.
Asking residents two quick questions following completion on a case will yield worthwhile results for all of you:
- Did the case go as the residents expected, and if not, why not?
- What can residents do to enhance their next OR performance? Lab practice, reading or reviewing textbooks or video, additional mental rehearsal?
8. Design deliberate practice opportunities for your residents.
Deliberate practice is activity designed for the purpose of improving performance.* Such activities are separate from work activities, which include "public performance, competitions, services rendered for pay, and other activities directly motivated by external rewards."* The cited definition explains the differences between the work of the operating room and deliberate practice activities. Deliberate practice is highly structured, includes feedback about performance and results, provides for frequent, repeated experiences for a learner to systematically correct performance weaknesses, and requires learner dedication. It also requires structured experiences designed to include learner access to materials and equipment, accurate models or demonstrations, and feedback. Deliberate practice for surgical residents include drill and practice, which is repetitive and can be boring. It is important to provide residents with protected time for scheduled sessions, and easy access to the materials, equipment, and models needed for such sessions. (For more on deliberate practice strategies for surgical training, see the Winter 2004 edition of the Association for Surgical Education's Focus publication.)
* Ericsson, K.A., Krampe, R.T., & Tesch-Romer, C. (1993). The role of deliberate practice in the acquisition of expert performance. Psychological Review, 100 (3), 363-406.
Revised January 18, 2005
