Chapter 2 Teaching Technical Skills—Errors in the Process

INTRODUCTION

The primary duty of a surgical educator is to help instill the knowledge, skill, and attitudes that will help develop the trainee into the very best surgeon possible. Experience tells us that the success of an operation depends on innumerable factors, some controllable, others not. A successful operative procedure is the cumulative sum of thousands of perfectly done steps. It follows logically that our primary responsibility as surgeons is to ensure that our technical input is as perfect as possible, given that much else is subject to chaos, chance, and the attention of others. When teaching surgical technique, it becomes even more important to ensure the quality of our craft by our precise and professional instruction of our residents, while at the same time allowing the necessary “graduated responsibility” that is important for the professional development and maturation of a surgeon.^1a

Our technical input is, in fact, the only factor that is in our direct control. The other external factors—the patient’s premorbid state, anesthetic care, alteration in normal physiology and unanticipated physiologic deterioration—are far less controllable. All of these conditions continually threaten the surgeon’s best intentions and technical skill. A surgeon’s technique must, therefore, be as perfect as possible in order to tip this precarious balance in the favor of the restoration of the patient’s health. As Bosk remarked in his wellknown sociologic study of surgery training, Forgive and Remember, “Every time a surgeon operates, he is making book on himself. Besides the enormous amount of theoretic and technical expertise that is his cognitive capital, the surgeon carries in his head an odds-book for each procedure.”¹

Much attention had been focused on how the principles of aviation safety and training might apply to the practice of medicine in general and, specifically, the training of surgeons.² Training strategy in both aviation and surgery share some important similarities: (1) They require a body of prerequisite knowledge; (2) They are highly technical; (3) They are done in the setting of unforgiving circumstances; (4) They require quick, precise decision making; and (5) They require a sequence of subroutines and graduated responsibility. The fundamental inescapable fact in both activities is that human life is held in a precarious position: Our patient’s life is suspended by general anesthesia as the plane and its pilot are suspended in the air by aeronautical engineering. Both medicine and aeronautical engineering are constantly defying unforgivable laws of nature. Ignore either of these basic supports during the endeavor and death is imminent. Both activities are pressed by time, are charged with intensity, and occur in a variable physical environment in which errors can quickly result in morbidity and mortality. Both require training, skill, practice, and quick decisions that are often made with limited data.

However, important differences between training surgeons and training pilots limit the application of the aviation model to surgery. Recently, a consulting firm has even proposed to help apply the principles of the highly technical training of fighter pilots to surgical programs and to our professional organizations that seek to improve the training of surgeons. The differences are notably in the setting, engineering parameters, and the resultant simulation equipment. Pilot training in the last several decades has occurred in a very controlled setting. Candidates are selected after extensive examination with batteries of tests grading their intellectual, physical, psychomotor, and emotional abilities. Before any actual flight training begins, they attend months of didactic lectures in “ground school,” learning the principles of aeronautic engineering, meteorology, and finally, the engineering specifics of generic and individual aircraft.

The previously described process sounds fairly similar to our medical schools’ curriculum in the basic sciences and clinical clerkships in the various medical specialties. Aviation, however, is much more focused and, by its very nature, precisely defined, described, and quantified by the principles of aeronautical engineering. As a consequence, simulation techniques have been somewhat easier to develop. Equally significant, the threat of war and a substantial military budget helped catapult the field of flight simulation in its inception during the days leading up to World War II.

Actual flight training begins in a simulator, safe from the unforgiving reality of gravity. When the student proves proficient, she or he takes to the air in a real plane with an instructor. Obviously, pilots must learn to fly in less threatening, noncombat conditions before they learn the more complicated and dangerous skills of air-to-air combat. Further screening and selection finally distills the pool of aviators to the select group of highly skilled fighter pilots. Here, too, however, training is done in the absence of “live fire” from a real enemy. Ironically, military aviation has not been faced with a real-life, direct lethal threat from a capable enemy force for more than 50 years, other than occasional fire from surface-to-air defensive missiles. The enemy is usually a colleague who chases the trainee through the air or a computerized threat in a highly developed virtual environment. Following the live flight exercise, the scenario is reviewed and dissected in a lengthy “debriefing” often lasting many hours.

In stark contrast, surgery training has traditionally been conducted under the live fire of a real patient who may suffer dire consequences from our mistakes. In decades past, the instructor was often a senior resident, with barely more experience than the learner. In addition, a very large portion of surgical education occurs in our large, mostly public-sector, “safety-net” hospitals and trauma centers in which logistic challenges heighten the high stakes of a real-live patient. Ironically, all too often, the number of patients and the serious degree of their illness are inversely proportional to the logistic support and supervision provided to the trainee. Our trauma centers often serve as our major training centers in which precious little time is available to methodically train residents in the aviation paradigm. Fortunately (and ironically), supervision by attendings has improved as a result of considerable pressure and actual laws enacted and strictly enforced by the federal government that require the attending to be physically present in the operating room in order to be paid. Unfortunately, a frequent occurrence in this resource-constrained environment is for the attending to find himself or herself trying to juggle several overlapping cases with trainees who have little prior experience.

It is exactly these constrained resources and variable experience of trainees that may make aviation-based models all the more important and potentially helpful adjuncts to our classic training model of “see one; do one; teach one.” The knowledge of such approaches can help make the surgical instructor more efficient and the resident better educated. Often, the “teaching moment” is effectively the only opportunity for the teacher to cover the various tenets of surgical and technical training, from the assessment of the resident’s prior experience to the review after the case of “what might we have done differently.” Surgical educators, lacking the luxury of hours to accomplish activities like their counterparts in aviation training, must recognize and make effective use of these fleeting “teaching moments” to ensure the safe conduct of the patient’s surgical care.

Our primary objective as surgical educators should be to present to the trainee the most basic, conservative, reliable, and safe techniques. Short cuts that require advanced clinical judgment can be saved for later as the resident matures. First and foremost, the trainer must emphasize attention to detail, adherence to Hallstead’s principles of surgery, and consideration of the emotional needs of the patient and staff. It all boils down to what they know, what they can do with their hands, and what they do with their hearts—otherwise known as the cognitive, psychomotor, and affective domains of learning.