One of the biggest challenges facing the future of medicine is how to train the physicians of the future. This is particularly problematic in specialties such as general surgery, given the 80 hour work week restrictions that have been in place the past few years and the coming onslaught of proficiency evaluations (see Dr. Bard Parker's thoughts here and a few of mine here).
Rising to the challenge, an old acquaintance of mine has published an interesting take on things in this month's Journal of the American College of Surgeons. Basically, he feels that surgical educators can learn quite a lot from the field of aviation --- we have been treated to the idea of comparing pilots and surgeons in the past, but this is sharply different. Specifically, Dr. McGreevy (a surgical program director) feels that we can adopt many of the techniques used to train fighter pilots to train surgeons:
The key elements in skills acquisition and maintenance in the operational squadron are pre- and postflight briefings, desired learning objectives (DLOs), levels of proficiency (wingman, flight lead, instructor, and evaluator), and currency tracking.While dealing with the human body involves a considerably larger number of variables than flying a plane, certainly we can improve our method of teaching and acquiring many of the skills involved with caring for patients. Dr. McGreevy in particular is keen on identifying desired learning objectives for each procedure taught to residents; this can vary depending on the case or the level of the resident.
In my opinion, the DLO can be the most powerful aviation training concept available for adoption by surgery. The DLO is useful in daily encounters, as explained previously, but in a more catholic way. For instance, once a resident has done 200 laparoscopic cholecystectomies, I suggest that the DLO has been met for that training square, and the resident should be spending time in some deficient area, such as outpatient anorectal problems. This requires a training office to monitor the resident's experience and proficiency.I was never specifically "assigned a DLO" for specific operations during training, and was simply expected to learn it -- and literallly everything about the operation, from indications to contraindications, from techniques to complications, etc. While I am not sure that a rigid method of instruction like this will work in every circumstance, it may take away some of the "BS time" and ensure that surgeons get the training they need with the new work hour restrictions. Dr. McGreevy summarizes his recommendations in this way:
- Applicants can be tested for innate dexterity and personality traits. The tools are available with skills trainers and psychologic tests that measure normal traits, like the NEO-PIR.12
- Teaching faculty can be encouraged to define a learning objective for each clinical encounter. This will require faculty to attend workshops in which the concept of the "desired learning objective" becomes a part of their collective consciousness, and pre- and postengagement briefings become a standard occurrence.
- Resident rotations can be defined by a checklist of objectives, both operations to be mastered and disease processes to study.
- The most common operations can be dissected into essential steps to be drilled with "deliberate practice" in skills trainers and in the operating room.
- A checklist of essential skills, to include operations and other tasks, such as intubation, can track resident training and competency. These checklists will direct resident educational experience as we define the surgery rotations by skills acquired rather than time.
- With encouragement, the residents can acquire and use the DLO concept, so that their learning becomes active rather than passive.