At first, sitting in a classroom with future teachers and teacher educators was strange. I had just finished two years of clinical training, and rather than being in the operating room, I was discussing how important toy blocks and play “occupations” are in kindergarten and educational development.1 I struggled to grasp how this would make me a better surgeon. However, as time moved on I quickly realized how deeply this information mattered in my life. Surgeons are more than technicians. We have a responsibility to learn, to teach, and to create. The knowledge I gained obtaining my Master’s in Education deeply affected the way I think about each of these essential aspects of academic surgery: it changed the way I think about the nature of learning by doing, the way I conceptualize surgical attendings as teachers, and how I envision surgeons contributing to the field of education.
Surgical education is grounded in the Halstead tradition of apprenticeship and graduated responsibility.2 Interestingly, this model of surgical education mirrors the cognitive apprenticeship learning theory.3 According to this theory, education is most effective when teachers work to create classroom experiences that immerse students in authentic practice.4 They learn math through coin problems, engineering through simulated design internships, and writing through journalism projects.5 Learning occurs in a framework of observation, followed by practice, and then progression to independence that is supported by the teacher or coach.3 This appears to echo the old surgical adage of “see one, do one, teach one”. However, as education theorists are advocating to bring the student out of the classroom and into the real world, surgeons are questioning their ability to train competent surgeons in an actual operating room.6-10 A key difference between cognitive apprenticeship theory and actual surgical apprenticeship may lie in its explicit emphasis on the cognitive rather than physical aspect of performance. In this educational theory, the focus is on problem solving, taking on multiple different roles, and reflecting about ones work and how it applies to other tasks. Borrowing from this theory suggests we have to create more opportunities for surgical trainees to think critically, make decisions, and then reflect on those actions. Now when I enter an operating room as a student, or think about my future as an attending, a goal I hold close is to make each operative experience purposeful by trying to make the implicit become explicit.
Often, the focus of surgical training is case volume. However, case volume is a necessary, but not a sufficient condition for surgical expertise. Rather, it is the deliberate practice that moves us from novice to expert performance regardless of natural ability.11 Deliberate practice requires consistent, reliable feedback in an environment that supports exploration and learning from errors.12 Many of our attendings provide this type of feedback unconsciously in the operating room or on the wards. These persons are likely the attendings that stand out in our minds as good teachers. However, the actual clinical environment does not always afford the opportunity for exploration and learning from errors because of the risk to human life. Put in other words, while learning from errors is powerful – there are many errors that are too damaging for an attending to allow. One proposed solution to this conundrum is surgical simulation: if designed properly, the simulation environment can provide a powerful pedagogical tool from which residents can commit errors and learn from them. However, we cannot simply build a simulation mimicking the operating room and expect improved performance. Rather we have to design each experience with the intent to provide learning opportunities that are not possible in the current clinical environment because of patient safety, operating room time constraints, or clinical schedules. My ideal simulation setting of the future mimics more of an athletic training room than an operating room with time for repeat performance, consistent feedback, and exploration of different techniques and the consequences of those technical changes.
As we begin to focus on process and practice, the path opens to a final area where I see room for growth in surgical education. To improve our ability to be teachers and learners we need to reach outside of our field of surgery to other specialties. We rely on evidence based medicine, however, when it comes to education, we all too often rely on tradition and personal experience. To create new knowledge in surgical education, and to make our own conduct as efficient as possible, we need to engage experts in the field of learning theory. We do not need to bring toy blocks and kindergarten “occupations” into the operating room, but rather we must understand how the same ideas already exist in what we do daily, and how we can refine such practices. Interestingly, the application of learning theory does not necessitate changes to duty hours, restructuring the length of surgical training, or creating new national policy. Rather it requires changing how residents think about themselves as learners and how attendings think about themselves as teachers. This may ultimately turn out to be more difficult than any national policy change, but also potentially more beneficial on all levels. We are fortunate to train in such a complex and rich environment – we just have to figure out how to constantly be transforming that environment into a more evidence-based and efficient educational experience.
References: Brosterman, N. (1997). Inventing kindergarten, New York, NY: Henry N. Abrams.  Polavarapu, H., Kulayat, A.N., Sun, S., & Hamed, O. (2013). 100 years of surgical education: The past, present and future. Bulletin of the American College of Surgeons.  Brown, J.S., Collins, A., Duguid, P. (1989). Situated cognition and the culture of learning. Educational Researcher, 18(1), 32-42.  Lave, J., & Wenger, E. (1991). Situated Learning: Legitimate Peripheral Participation. Cambridge, U.K.: Cambridge University Press.  Dennen, V. P., & Burner, K. J. (2008). The cognitive apprenticeship model in educational practice. Handbook of research on educational communications and technology, 3, 425-439.
 Mattar S.G., Alseidi A.A., Jones D.B., et al (2013). General surgery residency inadequately prepares trainees for fellowship: results of a survey of fellowship program directors. Ann Surg, 258, 440-449 Coleman J.J., Esposito T.J., Rozycki G.S., & Feliciano D.V. (2013). Early subspecialization and perceived competence in surgical training: are residents ready? J Am Coll Surg, 216, 764-771  Nakayama D.K., & Taylor S.M. (2013). SESC Practice Committee survey: surgical practice in the duty-hour restriction era. Am Surg, 79, 711-715  Bucholz E.M., Sue G.R., Yeo H., Roman S.A., Bell R.H., & Sosa J.A. (2011). Our trainees’ confidence: results from a national survey of 4136 US general surgery residents. Arch Surg, 146, 907-914  Lewis, F. R., & Klingensmith, M. E. (2012). Issues in general surgery residency training—2012. Annals of surgery, 256(4), 553-559.  Ericsson, K. A., Krampe, R. T., & Tesch-Römer, C. (1993). The role of deliberate practice in the acquisition of expert performance. Psychological review, 100(3), 363.  Boot W.R., & Ericsson, K.A. (2013). Expertise. In: J.D. Lee, A. Kirlik, (Eds.), The Oxford Handbook of Cognitive Engineering (143-158). Oxford: Oxford University Press.