Maximally Invasive Teaching

Resident surgical education


Tonight at Surgical Grand Rounds we had an interesting talk by Debra DaRosa. She is a PhD that specializes in resident surgical education and gives a compelling lecture. Her lecture was centered on several concepts. The basic idea was that people don’t learn if you just throw information at them. Like I mentioned in the introductory podcast, my grandfather always said that neurosurgeons could only remember three things at a time. Didactic lectures lose their effectiveness after 15 minutes and people’s attention begins to wander. They need new visual/auditory stimuli and most importantly something to engage them in the learning process. Her basic point was that you learn by being held responsible for the information for which you are being taught.

There are four stages to effective learning

  1. The learning experience
  2. Reflection
  3. Decision making
  4. Testing

Here is an example. You hear a lecture on lumbar disc herniations and think wow that sounds like an easy condition to treat (1. Learning experience). “I’m now an expert in disc herniations” and read several more articles on the condition (2. Reflection). But, tomorrow morning you are asked about the SPORT trial and can’t remember all the specifics (Reflection and Decision Making). Later that same morning you are assisting a lumbar microdisc and the attending has to go next door. They tell you to keep working and all of the sudden you realize that you have no idea what you are doing. You don’t really know where the edge of the lamina is and worry with every bit of ligamentum that you are either going to get a CSF leak or grab the nerve root (Testing). This is the ultimate accountability of learning. Learning is not just about the transfer of information it is about the assuring that the information has been fully assimilated.

The most interesting thing about this lecture was the Q&A. The entire Grand Rounds was centered around making attendings better teachers and every one of their comments (Attending Surgeons don’t ask questions) was aimed at the resident’s inadequacies for learning. Residents now don’t work enough (again the 80 hour work week argument) and don’t want to be taught (i.e. several attendings were upset that they received poor teaching evaluations).

I don’t get upset when I hear older surgeons say “back when I was a resident” because that statement lacks perspective. Every surgical resident thinks they had it harder than everyone else. The residents of Harvey Cushing trained my grandfather and he thought he had it harder than them. I think that my residency was harder than our interns. They have a 16-hour work limit and cannot take overnight call. Does that mean that they don’t want to work? No, that means that we need to more effective teachers to train them in a shorter period of time.

So using the previous example as an illustration of an effective teaching strategy.

  1. In morning report you start with the basics. Show the learner an MRI of the lumbar spine and how to interpret this MRI. Describe the lumbar disc, vertebral body, pedicle, lamina, facet, and spinous process. Describe what a disc herniation is and if it should be treated. Describe how to treat the lumbar disc and provide the learner with a direction for learning more about this condition. “Tomorrow I’m going to ask you about this condition and I want you to summarize”
  2. The motivated resident will reflect on the information, expand their knowledge base, and build to the previous discussion.
  3. The following morning the resident is presented with a decision-making scenario based on the previous instruction. They can draw from their experience and reflection to provide an adequate answer. If the answer is inadequate then fill in their knowledge gaps and motivate them to perform at a higher level.
  4. In clinic or in the operating room, test the residents on what they have learned and use continued positive refinement to really build on their knowledge base.



Joseph MillerMaximally Invasive Teaching

Leave a Reply

Your email address will not be published. Required fields are marked *