surgical learning - it's not just powerpoint anymore
TRANSCRIPT
Surgical Learning – It’s Not Just PowerPoint Anymore
orWhat I did with my Winter Vacation
Michael E. Shapiro, M.D.General Surgery Program Director
Rutgers – New Jersey Medical SchoolHarvard – Macy Scholar
“The ideal college is Mark Hopkins* on one end of a log and a student on the other”**
*Williams College President 1836-72**James A. Garfield, Williams ‘1856
What we (now) need to learn/teach
An Experiment:
At the end of this talk, there will be a quiz.
The Basics - 1
• As an educator, what is our prime role?– To promote learning
• What is learning?– Change (in knowledge, beliefs, behavior) that is
sustained• What is teaching?– The act of promoting/catalyzing change– (ideally, done intentionally and informed by best
practices)
The Basics - 2
• What is assessment/feedback?– Measuring change – • To promote further learning
– Identify strengths and weakness to the learner– Learner centered
• To demonstrate competence– Patient safety– Entrustable professional activities (EPAs)– Certification– System centered
– Need balance of both
The Basics - 3
• Who is the assessment/feedback we do really for (i.e., who are the stakeholders)?– Learner (e.g., student, resident)– Teacher – is our teaching of value?– Regulator
• NJMS– Dean– GMEC
• ACGME• ABS
• How do their interests relate to promoting learning or insuring competence?
The Basics - 4
• Deliberate teaching = defining planned change, the developing appropriate strategy to implement it, and assessment/feedback to promote it and demonstrate it.
• As an educator, asking what do I/we need/want to change, what is the best way to accomplish that, and how would I know if I did?
This case is a work of fiction. Any similarities to any person, living or dead, is purely coincidental and unintentional.
Case Discussion – the “surprised” resident • Bob (not real name) is a PGY-3 surgical resident in
the middle of the year. He graduated from a well-known medical school, and has had excellent evaluations his first two years. The CCC has just met to review the PGY-3’s. The evaluations for Bob this year were very different, and quite negative. They all noted his failure to progress to a stage where he can lead a team, make diagnoses and plans, and make decisions for the patient. All stated they had provided this feedback to Bob.
Case - 2
• You meet with Bob as Program Director. You begin by asking him how he thinks things are going? He responds that he thinks things are going pretty well, in fact, “great.” He is happy in the program, and feels that, although the transition to third year was initially challenging, he now “has everything under control.” At first gently, then more firmly, you raise the concerns of his attendings.
Case - 3• Bob claims to have never heard any of this negative
commentary before. You try to express your concerns to Bob, who refuses to accept those assessments, and states that he “respectfully disagrees” and the faculty concerns are “unfounded and incorrect.”
• Now what do you do?• What do you suspect happened?• How do you reconcile the different perspectives?• Does this suggest anything about the need to track
real-time learning?
Adult Learning Theory
• Adult learning is different from children’s learning.
• Children learn for the joy of learning.– Some of us never grow up
• Adults learn for a purpose– Further educational goals– Gain skills that can be applied– Pass a regulatory exam
ALT - 2
• Prior knowledge is the foundation for new learning
• Adult learners should activate and build upon prior knowledge
• Increasing the links to prior learning is critical• Adult learners should be actively involved in
constructing individual educational goals and meanings – they want to learn.
ALT-3
• Adult learners should own their learning (intrinsic motivation) as opposed to primarily responding to their teachers/evaluators (extrinsic motivation). Intrinsic motivation is associated with deeper learning.
• Teaching adult learners should promote both learner autonomy and growth, ultimately making the teacher unnecessary.
• Our job is, ultimately, to become superfluous.
ALT-4
• So, to maximize learning:– Adult learners need to be actively involved in the
learning process, including:• Initial self-appraisal• Setting goals• Developing mastery• Participating in the assessment/feedback process
– Adult learners need to be active partners, not empty vessels to be filled by the teacher.
A Simple Model of Competence
Prof
essio
nal
Auth
entic
ity
Behaviour Does
Shows howKnows how
Cognition Knows
Miller, 1990 17
Spacing effect
Blocking vs. Interleaving in learning and retention
Judged Performance
Blocked Same Interleaved0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
Proportion of participants
Actual Performance
Blocked Same Interleaved0
0.10.20.30.40.50.60.70.80.9
Proportion of participants
Wood, W.B. and Tanner, K.D., CBE - Life Sciences Education, 2012, 11:3-9
Characteristics and Behaviors of Expert Tutors
• Intelligent– Superior content and pedagogical content knowledge
• Nurturant– Establish and maintain personal rapport and empathy
• Socratic– Provide almost no facts, solutions or explanations, but
elicit these by questioning• Progressive– Move from easier to progressively more challenging
cycles of diagnosis, solutions and new problems
Wood, W.B. and Tanner, K.D., CBE - Life Sciences Education, 2012, 11:3-9
Expert Tutors, cont’d
• Indirect– Provide both negative and positive feedback by
implication. Praise the solution, not the student• Reflective– Ask students to articulate their thinking, explain
their reasoning, generalize to other contexts• Encouraging– Use strategies to motivate students and bolster
their confidence
Translating what effective tutors do to the lecture hall
• Figure out where your students are starting• “Flip” the classroom– Provide the information to the learners to review
before the class – readings, podcasts, handouts• Be Socratic– Replace “telling” with “asking”. Allow learners to work
through problems together.• Avoid direct criticism – Use students to provide feedback to each other– Rather than identifying an answer as wrong, find
someone with the correct answer, and praise that
“Lecture” (2)
• Include “testing” as part of the session– Anonymous audience feedback engages learner
and shows where they fit without embarrassment.– Teaching and testing gives better retention than
teaching and repeating.– Real-time testing provides teacher with immediate
feedback about learning and areas of weakness– Opportunities (digital media) to make testing of
teams, competition generates excitement. Technology also permits re-testing for incorrect answers, reinforcement, etc.
Lecture (3)
• Foster metacognitive awareness– Have learners reflect on their thought processes,
articulate concepts they find difficult or troubling– Allow learners to “know what they know”– Encourage learners to identify which learning
strategies are most adaptive for them• Be supportive – not always a surgical tradition– “Why didn’t you just take out a gun and shoot him?”– “Your patient just died…”
A humble proposal to help “Bob” and all our Surgical learners
• ALT has shown that learners need to be responsible for their own learning.
• Learning occurs at the “Zone of Proximal Development”, i.e., the leading edge of the learners knowledge
• Learners require continuous and immediate assessment and feedback
• Teachers need to communicate with each other to do appropriate learner “hand-offs.”
Educational KanbanTime Frame Traditional Evaluation EK
Beginning of Rotation No formal meetingReview general objectives
Self-appraisalReview EK to date with supervisorReview rotation objectivesSet specific goals with superv. Integrating past experiences
Every month None Interim self-appraisal
During rotation None Update EKMandated performance feedbackReview and set new goals
Summative EvaluationEnd of rotation
Summative supervisor formNo continuity to next rotation
No summative formCollaborative self-appraisal and formative feedbackSet future specific goals
Goldman, SJ, The Educational Kanban: Promoting Effective Self-Directed Adult
Learning in Medical Education. Academic Medicine, 2009, 84:927-934
Goldman, SJ, The Educational Kanban: Promoting Effective Self-Directed Adult Learning in Medical Education. Academic Medicine, 2009, 84:927-934
Educational Kanban-2Time Frame Traditional Evaluation EK
Twice-yearly review Summative supervisor forms Program director review
Informal meetingNot part of formal review
Mentor Meetings None/irregular Review EK quarterly external to rotationContinuity/collaboration
Ownership Training Program FilesPermanent Record
Resident OwnedNot “permanent record”
Humble proposal-2
• Applying Goldman’s EK model to our surgical residency would require:– Milestone-based individual goals for each resident,
each rotation,– Collaborative assessment/feedback at beginning and
end of each rotation between faculty and each resident,
– Communication between faculty from one rotation to the next,
– More frequent interaction between residents and mentors.
Humble proposal-3
• Mostly, it will require:– Interest on the part of the faculty– Dedication of time to teaching and assessment by
faculty on each rotation at each hospital– Clear expectations from faculty to residents– Honest, frequent, real-time feedback
• Last I checked, all three of our (non-VA) hospitals have “University” in their names –
• Time to own up to that!
How many ELEPHANTS were there?
• A – 2• B – 3• C – 4• D – 2 and a Northern White Rhino• E – there were elephants? I thought the
Williams mascot was a purple cow!
Williams College, Class of 2015