© everything possible / shutterstock.com
“In the real world, a surgeon will face different situations. The concept of surgical education is that you will have already worked through these scenarios and know how to react,” said Carol R. Bradford, MD, MS, executive vice dean for academic affairs and professor of otolaryngology-head and neck surgery at the University of Michigan Medical School in Ann Arbor.
Expanded Role for Simulation
Newer simulation tools may incorporate some of the latest technology from the entertainment world, but not all are well validated for usefulness. In one 2017 systematic review of otolaryngology simulators, 54 out of 64 products had been vetted by only one validation study, and none received the highest level of recommendation from these studies (J Surg Educ. 2017;74:203-215).
“Simulation and gamification (game-based technology) deliver experiential learning through highly interactive, engaging methods that often include complex graphics and 3D components,” said Sonya Malekzadeh, MD, FACS, director of the residency program in otolaryngology-head and neck surgery at MedStar Georgetown University Hospital in Washington, D.C. The use of simulation-based medical education has exploded recently due to recent medical education reform and political and societal pressures for quality and safety, she said.
“Simulation is becoming increasingly utilized not only as a method to teach skills and behaviors, but to assess the performance and even competency of our trainees,” she added. “Simulation training can also enhance team performance, reduce errors, and, ultimately, improve patient care. We need to invest in simulation technology, simulation curricula, and outcomes measurements.”
Weigh the cost of any simulator against its utility before investing in it, said Christie A. Barnes, MD, associate residency program director and director of resident education, at the University of Nebraska Medical Center department of otolaryngology/head and neck surgery in Omaha.
“Otolaryngology is a hard specialty to simulate because of the varied modalities we utilize, including lasers and scopes. We are lacking in good simulation tools. We have some good temporal bone models right now,” said Dr. Barnes. Her institution tested and then passed on buying a $50,000 new temporal bone drilling simulator. “We already do more realistic training with our cadaverous models. Cadaveric dissection is one area of training where we have had great feedback from our residents that this is a good educational tool.” Electronic textbooks that can be updated quickly will be more useful to the surgical trainees of the future than printed books, she added.
Interactive online educational modules, web-based workshops, electronic medical libraries, and simulation-based learning appeal to tech-savvy, young residents, said Dr. Malekzadeh.
“Mobile learning is popular with the current generation of medical learners. It involves retrieving information and resources over a cellular network, and uses mobile technologies as tools and platforms so learners can access instructional materials remotely for just-in-time learning,” but all of these high-tech tools should be used in a complementary way, she said.
“Blended instruction supplements the e-learning curriculum through a hybrid of electronic, face-to-face, or hands-on methods. Studies have shown that blended learning is more accepted and effective,” she said. “Active participation with increased learner engagement results in better student performance and improved educational outcomes.”
A Team-Based “Sport”
Surgical education should include team-based medical management, communication, and leadership skills training, program directors said.
“Interprofessional care and education are important, because both medical and surgical care have become team-based sports. How will you work with a radiation oncologist, a nurse, an anesthesiologist, a speech pathologist, a dentist, a pharmacist, or a social worker? The interprofessional team is crucial to delivering care that is safe, timely, compassionate, value-based, efficient, and high quality,” she said. The University of Michigan Medical School has a Center for Interprofessional Education to prepare surgeons to work in an interdisciplinary care model. “As a head and neck cancer surgeon, there is no question that I want to deliver that type of care to my patients and to have a strong interprofessional team.”
At Vanderbilt University Medical Center in Nashville, the department of otolaryngology instituted a leadership curriculum nine years ago for its head and neck surgeons that includes four intense modules over four years of study: leadership training modeled after programs used by the military, public speaking, a “micro-MBA” course, and a capstone project focused on
prevention and population health. They include leadership and management skills training with peer-to-peer critiques, not criticism, designed to give constructive feedback to learners on how they deliver a research talk or communicate the death of a patient to family members, for example. This innovative program includes techniques used in graduate business schools, such as group discussion and feedback instead of traditional lectures, said Roland D. Eavey, MD, Guy M. Maness Chair and professor of otolaryngology, chair of the department of otolaryngology, and professor of hearing and speech sciences at Vanderbilt University in Nashville.
“We tell our residents that your job is changing in the future, and the whole healthcare system is changing,” says Dr. Eavey. “Do I assume that, as a doctor, I am a leader because I write a prescription and a pharmacist fills it? Or that I give an order and the nurse on the floor implements it? Doctors need to realize that there is a lot of talent around them. Leadership training is important, because 99% of the work that we do is taking care of problems that are not glamorous. Our purpose is to serve others, not to be served. We have to inculcate that in our residents. This is a cultural shift.”
Rapid changes in health care mean that surgical trainees need better preparation to manage a broad range of skills in the evolving practice of medicine, said Dr. Malekzadeh. “Many graduate with limited knowledge of government regulatory requirements, health policy, quality and safety, and the general business of medicine. We need to identify pathways to better integrate and impart this information during residency,” she said.
We tell our residents that your job is changing in the future, and the whole healthcare system is changing. … Our purpose is to serve others, not to be served. We have to inculcate that in our residents. This is a cultural shift. —Roland D. Eavey, MD
Vanderbilt’s surgical residents engage in interactive exercises on how to manage challenging scenarios, and sometimes use paid actors or actresses to portray colleagues or patients, said Dr. Eavey. “We like our residents to have more hands-on involvement and be participatory in the learning process. Our didactics approach is very different. Someone might project a face onto a whiteboard, draw a skin cancer on a nose or cheek, and ask, ‘How do you remove this?’” he said. Vanderbilt residents also practice clinical scenarios with paid actors; the encounters are recorded for later discussions.
Dr. Eavey emphasized the value of interactive learning models, including post-operative debriefing exercises where residents share feedback with each other on how an operative case was performed (J Surg Educ. 2016;73:448-452). “There is a different, better way to teach so that knowledge is reinforced. With adult learning and team learning, you read the information, go over cases, ask questions, and discuss the information with the whole class,” he said.
Physicians have the skills and acumen to be leaders and lead healthcare organizations, and learning advanced business leadership skills will help them achieve this, he said.
“Residents can evolve into leadership positions that don’t exist yet, because nobody has even thought of these positions yet. But they need to be well prepared for those roles,” he said. “We are teaching trust, how to build teams, the domains necessary in leadership, and how to be an effective leader. There are different styles of leadership. Some people have not explored their personal strengths. We inventory [residents’] strengths.”
Some residents in Vanderbilt’s program have questioned why they need to take public speaking training, because they have given talks at international academic meetings, said Dr. Eavey. They may not be aware of how they could improve their speaking style until they practice and absorb critiques from their colleagues, he added. In their micro-MBA course, residents may talk with a
Vanderbilt hospital administrator about funds flow or contracts, for example. “We don’t expect someone to have one talk about funds flow and become an accountant. But they are exposed to this information. We want them to be empowered to take on a leadership role. Our program underscores how important resident education is, because residents should know how to build teams and build trust.”
Program Size and Content
Residency programs in otolaryngology remain small compared to those of other surgical specialties, which Dr. Malekzadeh sees as an advantage. “Successful mentorship depends on developing strong relationships, and this can be challenging in a large residency program, where residents are rotating at many hospitals with limited long-term faculty interactions. In the end, I believe the department culture and faculty dedication to education [are] more important than the program size,” she said.
Residency training should include not just skills training and leadership, but taking a leadership role in quality improvement and safety, said Dr. Bradford.
“Residents are on the ground level of patient care. They can find opportunities for improvement. Also, they come in with no preconceived notions. They see things that others may not notice because of the way they move through the healthcare system,” she said. “Surgical training has become competency-based. Surgical education has largely been a preceptorship, a model with a growing responsibility for the surgical trainee. In a competency-based model, the learner can set individual educational goals, and the faculty members can facilitate the process of achieving them.”
Faculty may ask residents about their educational goals at the beginning of training for a surgical procedure; then afterward, they can provide evaluative feedback and discuss whether the learner’s goals were achieved, which helps learners create and achieve their own educational goals, said Dr. Bradford.
“Self-evaluation is helpful, but so is peer evaluation. It’s good to have a cadre of residents evaluating each other, and we’re moving toward a 360-degree evaluation process” at her institution. Peers offer perspectives that faculty cannot, she said. “How do they function in a team? How do they function in the surgical theater?”
Burnout Still an Issue
Program directors juggle time-consuming responsibilities that may lead to burnout and stress, including meeting evolving accreditation requirements, balancing resident education and service, updating curriculum in the face of growing medical knowledge and new procedures, and ensuring the competence and professionalism of graduating residents, said Dr. Malekzadeh. “The greatest obstacle is time, as program directors are also often juggling research, teaching, and patient care in addition to the program director duties.”
Program directors must master a “balancing act,” and burnout is a real concern, said Dr. Barnes.
“I don’t think we do a fantastic job of ensuring that our program directors have enough time to do all that is necessary. There is a time constraint for resident education. We need better awareness of this issue so we can address it and carve out more time for true educators to do their work. In academics, if you’re not publishing, you’re not advancing your career,” she said. “Many things can take time away from training. We have to train our residents, but we have less time to do it.”
Susan Bernstein is a freelance medical writer based in Georgia.
Simulation: High-Tech, Low-Tech
New simulation tools may use technology such as virtual or augmented reality to educate learners on how to perform surgical procedures or respond to emergencies like a patient bleeding from a tracheotomy site, program directors say. But low-tech simulations are highly valuable too.
- The University of Nebraska Medical Center’s surgical residents completed a simulation model that trained them to manage challenging patients or break bad news. “How do you manage an emotional storm? And how do you do this with grace, dignity, and empathy? The skills our residents took away with them were great, and we plan to do this module regularly. It’s not done enough in practice. We will give our surgeons the tools they need to navigate these situations,” said Christie Barnes, MD, UNMC’s associate residency program director.
- Surgical residents can simulate how to manage complex or stressful circumstances. “All doctors have awkward situations, and they often don’t have any training for them. We want them to feel that they have had their dress rehearsal. They have been through it before. We critique each one to talk about how the situation was handled,” said Roland D. Eavey, MD, who created the innovative leadership training program at Vanderbilt University.
- The University of Michigan puts residents through an otolaryngology boot camp and other simulation-based education throughout training, but also teaches residents how to work with others, said Carol Bradford, MD, MS. “I see a growing opportunity for simulation, including learning how to perform procedures, but also simulations of interprofessional, team-based care.”—SB