The process of learning a new surgical procedure has been described as ”See one, do one, and teach one.”
However, in reality the acquisition of specific motor skill’s is more about cognitive, integrative and autonomous stages for the learner. I have taught pediatric orthopedic surgery for many years, probably in the same way as it has been done for centuries. In this situation I see myself as a coach helping the orthopedic resident (student), during their three months rotation at my department, through the different stages in a process that is the opposite of collaborative learning. However, maybe the use of online technologies can create a community for learning and enable collaboration.
The earlier stages of traditional surgical training take place outside the operating room. First we intellectualize the task by discussing indications for surgery, relevant anatomical structures and potential errors, which helps to create a theoretical framework.
In this stage, the student gathers information from the teacher, textbooks and online resources but the student is not sharing this knowledge with the community. I believe that the use of computer supported collaborative learning systems built around different surgical procedures could enhance learning and teaching. I am not aware of any hospital that have developed this type of novel system and this blog post are just my speculations regarding a possible design and advantages.
This type of new learning tool, an e-learning platform, has the potential to provide greater access of standardized information regarding a specific surgical procedure using instructional design and learning object principles.
The content should mainly be created by subgroups of residents responsible for the 10-15 different surgical procedures they need to learn how to perform independently or under supervision. The content should include information to help the students to understand the mechanics of the surgical procedure. Other types of content could be flashcards and a quiz mode created by the students to let them self-assess their knowledge. This would also let the student and the teacher track the theoretical learning results. With a personal profile, the student could create, add and later review their content and decide what they want to share with the community. The public information would also be reviewed and developed based on feed back from the students and teachers.
My imaginary platform allows collaboration for orthopedic residents at my hospital both within their group of students but also between different generations of residents (approximately 12 residents per year) and teachers sharing and comment on information but also provide the possibility to ask and answer questions. The community could also include other pediatric orthopedic departments and other subspecialties included in the orthopedic residents curriculum.
I am not proposing that future Orthopedic Surgeons should do there surgical training online and the key to acquiring surgical knowledge is experience. Since without some form of shared experience, it is hard for teacher and student to share one another’s thought processes. Therefore the student will in the next step move from being online to the real world in the surgery theater and observe while I carry out the surgical procedure and deconstruct it to distinct steps.
One function of the e-learning platform could allow the student to later review these steps by watching video clips and perform the procedure in a computer game/simulation before moving to the next stage.
The next time we perform the surgery I am observing and comment the student, who now is in the integrative stage, doing the surgery. With out this critical stage, it is hard for me to transfer my knowledge and for the student to reflect and truly learn the surgery.
It would be of great value to video record the event and let the student observe and review his own performance before moving to the last stage. The video recordings could also be edited to a library with short video clips illustrating the most common mistakes novice surgeons keep doing and hopefully prevent future residents repeating the same mistakes. In surgery there is a tradition of only learning from your own mistakes and not from others. I am aware of the practical and ethical issues regarding patient privacy but this is a proposal in a blog.
Another important aspect of surgical training is to gradually give the student confidence to perform the surgery alone. Therefor the final step and exam is that I try to be quite and not interrupt while the student who now have reached the autonomous stage, execute the surgery independently.
In reality, I am not always the teacher I would like to be (the one described in this blog), mostly due to the everyday workload at the hospital. But I am convinced that both residents and the teachers in their life long surgical training could benefit from collaborative learning.
However, I would like to finish this blog post with a citation from another blog post by a Surgeon and fellow student at this ONL-course.
”Today, Google and Johnsson & Johnsson are getting together constructing a surgical robot that not only have superior skills compared to human hands, it can actually think and take independent decisions. In a near future there will be no place for human surgeons.”
Miller G. The Assessment of Clinical Skills/Competence/Performance. Acad Med. 1999;65(9):63-7.
Taveira-Gomes et al. A novel collaborative e-learning platform for medical students – ALERT STUDENT. BMC Medical Education 2014, 14:143