Sarah B. Bryczkowski, MD¹; Amalia Cochran, MD² ¹ Rutgers, New Jersey Medical School ² University of Utah, Associate Professor, Department of Surgery The FIRST Trial: The FIRST Trial, or as it is officially known, the National Cluster-Randomized Trial of Duty-Hour Flexibility in Surgical Training, was published online in the New England Journal of Medicine on […]
This t-shirt admittedly is one of my very favorite Far Side cartoons, and is an idea that has occurred to me more than once. It impacts how we function in our responsibilities, and it definitely impacts how we learn.
“Cognitive load” is a tricky thing. It influences our working memory, or how we process information. Although many of us would like to believe that our working memory is both broad and durable, the truth is that it can’t contain more than 4-5 items in it at one time, and that the items there last at most for 10 seconds. That sounds suspiciously like a Twitter feed, doesn’t it?
Most importantly, working memory is impacted by the complexity of information or the complexity of tasks that we are trying to manage in any given moment. In surgical education, we feel this as a learner when we’re trying to perform a skill that is new to us and we are distracted with a question, a page, or just something noisy happening in the corner of the room. Interns, if you find that you suddenly stop what you’re doing while suturing a wound when the attending asks you a question…well, it’s pretty normal. Suturing isn’t something that you’ve likely automated at this stage of your career. The distraction of the question, particularly if the question contains somewhat complicated information, can easily result in you needing to hit the “pause” button- which is easier to do with the suturing than it is with the question you’re being asked by a 3rd party. Even those of us with more experience still have certain operations or parts of cases when we’ll ask to not have any disturbances unless they are life and death; as an example, anytime I am grafting a pediatric hand, I make a request to not be disturbed unless it’s completely necessary. Anyone who has put a skin graft (or many skin grafts) on a hand of an 18-month-old understands how complex and intricate that is, and why even with experience we don’t necessarily have the brain “space” to be disturbed.
The other interesting bit about cognitive load relates to multitasking, which we are essentially being asked to do in the above scenario. If you are suturing, you’re likely to pick up speed as you go along because you are repeating the task. However, if you are interrupted by a question while you are suturing, you have two options:
- Respond to the question while suturing, or multitasking (unlikely for a novice), or
- Choose to focus on suturing by ignoring the question, or choose to focus on the question by stopping suturing.
If either choice in option 2 occurs, the switching between tasks makes you slower at both tasks. Essentially, there is a cost to switching between activities. This difference may be so small as to almost be imperceptible, but it is real.
As educators, what can we do to help our learners manage cognitive load and not exceed their brain bandwidth (or become frustrated by trying to do too many complicated things at one time)?
- Try to integrate information sources when learners are acquiring new data
- Reinforce using multiple modalities without being redundant
- “Chunk” the content- give learners a schema for organizing information (this is an advantage that the expert has over the novice is that we have schemas to help us retrieve complex information efficiently)
- Remember that learners come at different levels, and organize information appropriately
- Take out the frills- it’s a distraction from the key material!
Our job? It really boils down to figuring out how to create an environment that will support learners doing their job- even if there is a bit of stress added to that system.
Wednesday during the academic year always gives me the opportunity to consider grand rounds- the history, the why, the how could we be doing this better (since we all know that’s one of my favorite questions about almost everything). Today and last Wednesday served as no exception; the prior Wednesday was a break from my incessant questioning, mostly because I was away at Surgery Education Week.
Historically, grand rounds were Socratic in nature, and focused around patient presentations (usually by a junior team member) to more senior faculty. Often the patient was present, and the presentations were oriented around problem-solving of the cases. Attendance at grand rounds was expected as part of one’s civic duty in academia and the interactive nature fostered engagement through active learning.
Fast forward to the present- and I’ll open with a confession that I can be complicit in any/ all of these on a given day. Grand Rounds is typically a Power Point (or Prezi, for the more hip) based lecture, hopefully with a few minutes left for questions at the end. Minimal interaction occurs, and the audience engagement often reflects the paucity of direct interaction. Email gets answered, EMR charting gets caught up. Even those who are engaged and attentive are likely to retain no more than 5% of the information provided. The modern model allows people to share from a place of expertise, and for those in the audience it’s typically a fine exhibition of passive learning.
A side effect of the failure of engagement in modern grand rounds is a lack of attendance; if people’s learning needs aren’t being met, they simply vote with their feet and stop coming. Multiple sources have bemoaned decreased attendance at grand rounds in particular, and educational conferences in general, by faculty members. Sometimes those absences are unavoidable and are driven acutely by patient needs. Often they are simply a reflection of perceived relevance of the day’s topic, with citizenship “obligations” being inadequate to overcome the pull to take care of the myriad other things on the to-do list during that sheltered hour.
Grand Rounds in some form is likely a tradition worth maintaining, both for the citizenship/ networking benefits, as well as for educational benefits when it’s done well. The question becomes how do we resuscitate grand rounds before it’s too late? Better coffee? Bigger controversies? More interaction?
I’m not sure I have a single perfect answer, though I hope to open a dialogue on how we can best identify and meet the needs of our learners. My suspicion is that it won’t involve a long-term relationship with the lecture format, and it might even entail a return to old traditions with entirely interactive, case-based sessions. Or it might be something entirely different and entirely unexpected- something revolutionary, perhaps?
If you were designing an effective grand rounds for your Department of Surgery, what would it look like?
It’s a week for self-disclosure, mostly to let you know why my recent posting has been so irregular. Don’t brace yourself for something really exciting or you’ll be terribly disappointed.
A week ago I was meeting with one of my colleagues in my office, who commented on my Personal Kanban board in my office, which is covered with bright Post-Its (surprise!). I told him it’s really the only way I feel like I can begin to keep all of the plates in the air.
Until I can’t keep them in the air, that is. This week has definitely required lots of latitude from others, and has made me grateful that apparently none of the plates I was juggling were particularly fragile.
Here’s the truth: While the amount of time we all have in a given day or week is fixed, our energy is variable from one of us to another, and even for each of us as individuals at different times. I am generally a high-energy person, though I am also well aware of the things that are more likely to drain my energy. A series of days with early meetings drains me, and that’s been the case for my schedule this week. Not getting my workouts in or getting to yoga = draining (as counterintuitive as that may seem). Falling behind on my email = tiring. Not writing or creating = complete energy paralysis. You get the idea.
And, as luck had it this week, I did manage to run on Wednesday and Thursday and I am mostly caught up on responding to email (though not meeting all of the scheduling requests/ demands contained therein). It was a week when I had little control over most of my schedule because, as I often say, “We just take care of the people.” Blissfully, I did have little night call with our crazy days, which made the clinical demands generally achieveable. However…I was late to a session with the students on Tuesday, I missed a Tuesday night conference call, and I didn’t make it to conference on Wednesday morning. By Wednesday afternoon I had it all down to a dull roar and was able to not feel like I wasn’t struggling at every turn.
Why am I rambling about this?
Mostly to help people understand that sometimes even those of us who you often think do it all “effortlessly” aren’t effortless at all. We mess it up. We miss obligations. We get tired. We are human. I don’t try to be anything but that, and on Tuesday afternoon I apologized profusely and made sure that I was 100% present once I made it to class. Tuesday night I apologized via email for the whims of my schedule and was given a gracious, “It’s okay. We understand and we love it when you can be here.”
The best part of that response? It reminded me that I’m not failing dismally, and that I’m not even failing. I’m just managing more-than-a-few-things right now.
And that maybe, just maybe, I need to give myself a little grace when it’s like this.
Disclaimer: I have previously blogged on the topic of millennials and expressed my support for generational evolution.
After reading a column in General Surgery News in which the work ethic of the “youngsters” was again denigrated, my friend Justin Dimick commented on Twitter:
“Why does no one blog when they “catch” a millennial doing something right?”
His point is a valid one- while all of us seem to make plenty of comments about “these kids today…”, we seldom talk about the great things we see them doing. Rather than being moved by curiosity about people who were raised in a very different time and place than those of us born before 1970, we ascribe laziness and bad intent to them. Never mind that laziness and bad intent can be found anywhere if that’s what you are seeking.
So, what have I seen millennials doing right in the last couple of weeks?
- I’ve seen them doing many, many things (some of which appear to be small things, relatively speaking) with great love.
- I’ve seen them challenging themselves in ways that make them a bit uncomfortable, be that trying something new in the professional arena or declaring, “I am a runner!” when that’s an identity they’ve never considered before.
- I’ve seen them being incredibly curious and creative. Y’all know this is how progress is made at a societal level, right?
- I’ve seen them giving generously of time and/ or money to causes they are passionate about.
- I’ve seen them teach and learn in ways that are regarding and collaborative.
Yes, I know that none of those are a terribly specific example of things I’ve seen Millennials doing right recently, but the general themes help to highlight the point that I want to make…the 20 and early 30 somethings are the future of our planet, the future of our profession, and in many ways our own future. They are, just like those of us for whom 40 is well in the rearview mirror, people. They- and we- are all basically good, and we all have the occasional “off”day because we are human. We- and they- want to help make the world around us better.
I suppose some want to take a single incident and use it to generalize about a group in a negative way, and that is certainly their prerogative. As for me, I’ll keep looking for the light, looking for the good things that our millennial colleagues, and the rest of us, are out there doing. That’s my prerogative- that, and closing the 2015 blog posts with music from my senior year of college. Ah, the 80s…good times.
I spent last weekend and the early portion of my week in Napa for the annual Western Surgical Association meeting. I’ll start with the statement that this is one of my favorite meetings every year; it’s rich in high-quality general surgery research and I always get to hear interesting new findings in areas I don’t necessarily work in. And, of course, it’s a meeting I always enjoy because of the people. I love the fact that I get to spend time catching up with two of my mentors from medical school every year (Sam Snyder and Randy Smith). It’s nice to know that they are still as terrific as I thought they were when I was a starry-eyed MS3/ MS4.
During the scientific sessions I Tweeted out a few key items from various papers that were presented, and one deserves further mention here, if for no other reason than to continue the dialogue it started on Monday morning. Here’s a screen shot of the abstract in question:
Tyler Hughes, rural surgeon advocate extraordinaire- and fantastic human- addressed the elephant in the room- can someone pass their certifying exam (CE = oral boards) in general surgery in this day and age if they say they would either get an intraoperative consult from a specialist colleague or abort the case and refer a difficult cholecystectomy because they don’t know how to do them open due to lack of experience?
Or should we give a candidate credit for knowing when to call for help?
Do we need to modify our training paradigm to emphasize acquiring relevant experience, as proposed by the authors? Is this yet another reflection of the need for us to update/ refine training for people to become a “true” general surgeon?
I look forward to a robust dialogue continuing on Twitter, on FB, and/ or on the comments here.
Anyone who has been in the OR or in the ICU during a procedure is familiar with the concept of the “time-out.” It’s something that has been around for a number of years and came into being as a way to enhance patient safety in the operating room. The operative time-out itself continues to evolve, with many surgeons developing an “extended time-out” checklist for their OR, something I can definitely see benefit to doing. For the last week, I’ve experimented with a variant extension to the time-out; when we were at the American College of Surgeons my friend Mary Klingensmith Tweeted a challenge to the surgical education community to incorporate
an education time-out at the beginning of cases for their learners. I’ve been trying to find ways to increase the teaching focus in the OR, and this seemed an almost foolproof way to do it.
The education time-out in our OR occurs just after the patient safety time out. I identify each resident of medical student on the operative team, and I challenge them to tell me what their learning goal is for the case. Goals provided by learners last week were sometimes technical, sometimes about decision-making, and sometimes related to the patient’s overall medical status but have little to do with the operation itself. During the course of the case, I seek to address the questions raised by each learner, using a largely Socratic method (yes, I am still asking questions of them!). What benefits do I see a week into this “experiment”?
- The students and residents are pushed to be self-directed learners, and to articulate how they are guiding their learning. I’m not identifying their goals, they are. This is critical if we are going to “raise” life-long learners.
- Having the learning goals provides us with a focus for the case. While I like to think that I’m mostly above-average in taking time to teach in the OR, I have definitely noticed that this keeps me on-point.
- The entire team is learning from one another, including our anesthesia team members and our scrub techs and OR nurses. While patient care is still our #1 focus, the presence (and use!) of the education time out raises the perceived importance of education in what we are doing every day.
I’m still trying to perfect the system, and I am curious to take a good look at how it impacts both teaching and learning in the OR over time. From a subjective and personal evaluation, I’m finding the education time out to be an important improvement in my work as both a clinician and an educator. Surgical teachers, give it a try and I hope you’ll share your experience. Surgical learners, encourage your teachers to try it. They might just find themselves with an important new teaching tool!
This week, I have heard two different stories about limitations being placed upon interactions with medical students by institutions. To be completely honest, they both strike me as horror stories with a Draconian response to managing power dynamics. First, I was told that at a major medical school that very strict limits were placed on what residents and faculty are allowed to ask medical students to do. This was followed in short order by learning that at another medical school the resident or faculty member has to explicitly ASK the medical student if they can ask them questions to assess their learning.
I had recently been flabbergasted, reading about the climate in higher education at many institutions and concerns expressed by students about having their fundamental understanding of the world disrupted. And now, this piece in The Atlantic talking about the damage being done long-term to learners who are being overly-protected in their university environments since their professors can no longer teach them how to think.
For anyone who has been wondering why their interns aren’t always well-prepared to be a doctor on Day 1, I may have hit upon the “why.” I understand that questioning can occur in ways that are not conducive to learning and that can even be disrespectful to the learner in some way; I’ve seen it done. This is the exception, however, and often occurs in conjunction with other marginally professional behaviors. It seems that some medical schools have, in the interest of preventing “student mistreatment”, created an environment where their teachers are denied any of the tools available to assess clinical reasoning. If I may ask a question, how am I supposed to assess a trainee’s clinical acumen if I can’t ask them to walk me through their thought process?
I spend a tremendous amount of time discussing that we are behind the curve in medical education, where we still focus on single right answers and MCQs to assess knowledge that is largely based upon retention of facts. We test this way in a day and age when we all have easy access to facts, and in a time when the rate of knowledge acquisition cannot be matched by the human brain. If we are going to move beyond testing for facts- knowing that factual knowledge does not necessarily a good doctor make- how do we prepare learners for a new world order focused on clinical knowledge application if we cannot ask them to solve clinical problems?
More importantly, how do we turn back the tide? I’m not saying that we should yell questions at our students and residents, or that we should ostracize and humiliate them when they don’t know answers. But as educators, if we are going to responsibly create the next generation of physicians, we must be able to engage in questioning in a way that is both meaningful and constructive. Draconian solutions in which we’re simply not allowed to ask learners questions will have huge- and negative- impacts on the care we are all able to receive in time.
“Vulnerability is the birthplace of innovation, creativity, and change.”
I was introduced to the work of Brené Brown just before the publication of her book The Gifts of Imperfection. If you haven’t come across her work via Oprah or another major media outlet, Brené has a PhD in social work; her area of emphasis in her work is shame.
I Thought it Was Just Me was life-changing reading for me. It was that big. As I was reading her work on shame and the quest for perfection (and both of their complex relationships with power structures), I saw our medical education system. I saw so much of surgical education in particular, and could attach names to the pictures of “parents” (senior residents, faculty members) who adhered to the shame and blame paradigm rather than fostering compassion and a healthy sense of guilt. When my colleague Will Elder was conducting interviews for our work on disruptive surgeon behavior he brought back to me the use of the word “shame” by one of our interviewees, who was describing the educational philosophy ascribed to by disruptive faculty. On that day I knew we were on to something big. I still believe that.
Brené describes shame as “the gremlin who says, ah-ah, you’re not good enough.” Here’s the thing about shame: it has lots of dirty side-effects. Shame increases dysfunctional coping, be that addiction, violence, eating disorders…things that people do to maintain disconnection from the world around them. In our profession, shame looks like burnout and impaired physicians, and the perfectionistic tendencies of almost all of us in medicine put us at higher risk than the “average” person. Our culture and ourselves provide a set-up for us to self-destruct- and the data show that many (too many!) of us do just that.
Since my initial reading of Brené’s work, I’ve committed to trying to change my corner of the surgical world by making it a place where we strive to say, “I made a mistake and I’m going to do better” (guilt) rather than, “I am a mistake and can’t do better.” (shame) Like any parent or any human, I’m not perfect, and some days I am very, very far from perfect in leading that culture change. I try to provide a safe place for my trainees, particularly the students, to talk about the “hard stuff” that is inevitably part of medical education. And, to be completely transparent, I started this blog in hopes that it could be an antidote to shame as colleagues read it and think, “Yeah. Me too.” The most rewarding part of my electronic relationship with you, dear reader, over the last year and a half has been how many people have told me they’ve really connected with something that I wrote here. I have weeks that I suspect my crazy ideas here are more impactful than a great deal of my academic work. And I believe that my vulnerability here has been the nidus for a tremendous amount of innovation, creativity, and change.
For those curious about Brené Brown’s work, this TED talk is a terrific introduction to her ideas. And, of course, as a Texan she tells great stories.
I made an interesting choice this year for our surgery clerkship; I say interesting because it’s either going to prove to be absolute genius or complete catastrophe. Time will tell.
Didactics have been one of the biggest challenges for the last several years with the clerkship. Faculty attendance has not always been ideal, it’s been challenging to communicate that in advance to the students, and some of the sessions I initially thought would be helpful for broadening the base for shelf prep instead turned out to be consistently low-rated by the students. I also recognize that even though I asked faculty three years ago to make their class sessions case-based and interactive that this was not consistently happening- faculty often default to the lecture format simply to get their material covered. And, of course, there are little facts about how much material is retained from a one-hour lecture (which is, of course, the format we have inherited from the system). For those who haven’t seen any of that data, the short answer is…not much.
If you examine our goals for medical student learners, particularly once they come into their clinical years, we don’t just want them to have facts. The whole point of the clinical years is for students to learn how to apply all of those facts and knowledge that we have crammed into their brains during the non-clinical years of medical school; in other words, we’re striving for long-term transferability of information. We are also imbued with the responsibility of helping students become life-long learners, and the truth is that spoon-feeding them in lectures does little to achieve that end as well. What we should be doing in the learning environment, be it clinical or classroom, is facilitating student-led work and coaching by giving feedback and advice.
Have you guessed yet what my crazy move was?
Maybe the fact that we’re down to about 6 hours of faculty-led classroom didactics that all happen in the first two days of the clerkship?
Indeed. Almost no more “class,” per se.
I know, it’s not completely novel. 2012 and 2013 were essentially the years of the eulogy for the lecture in higher education as best I can tell. But there have been plenty of misgivings in medical circles about the death of the lecture, maybe because lecture done right can be amazing. But how often is it done THAT well? As I think back through medical school, rarely to never was my own experience.
I did maintain one set of didactic sessions that I am now trying to fine-tune; each student prepares a 20 minute case-based discussion on a topic they are assigned. These mini-clinical pathology correlation sessions are designed to be interactive, with the lead student facilitating and the rest of them working as a group to “solve” an unknown (but common) general surgery case. I’m there, both because it’s a graded activity and to provide real-time advice on issues that come up in discussion. These sessions have been terrifically successful for the last 3 years, and are honestly fun to moderate. It’s simply with the absence of other classroom sessions I feel even more strongly about coaching so that the critical material is covered during this contact time. The students have consistently excelled in these presentations, and I’m always impressed at how closely they are willing to listen to one another during these sessions. Levels of engagement are HIGH.
So, yes, student-led work is our new paradigm for didactics in the surgery clerkship at Utah. I promise some follow-up on how it goes. And since I mentioned feedback and advice as being central to where we are trying to get our learners, I promise more on that next week.