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.
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.
BASIC PRINCIPLES OF SURGICAL TECHNICAL INSTRUCTION AND LEARNING
The specific conditions and psychomotor training principles have been outlined in various resources and can be helpful in discussing complications that may result from a lack of appreciation and application by the surgical instructor. Learning any motor skill is distinctly different from learning verbal or intellectual skills. Motor skill learning requires application of a “chain of responses,” or ordered, linked tasks, that cannot be accomplished until the preceding task is finished. Like the sign above the confused cartoon character’s bed: “pants first, then shoes.” The precise incision cannot be made until the right amount of tension and countertension is applied to the skin. The suture cannot be tied until it is precisely placed in the bowel wall. The artery should not be incised before proximal and distal control are obtained. This succession of tasks has also been described as the “organization of subroutines.”3
Analysis of common bile duct injuries in the early years of laparoscopic cholecystectomy revealed that most injuries occurred in the first 12 to 20 attempts at the procedure, implying that a plateau of initial competence was more likely after a dozen or so attempts.4
THE OPERATIVE PROCEDURE: SETTING, LOCATION, AND PITFALLS
PREOPERATIVE PITFALLS—COGNITIVE PHASE OF SKILLS ACQUISITION
Learning Needs Assessment
LNA is the process of determining the previous experience of a learner so that the teacher can better tailor the instructional focus to the individual resident or student. Failure to accurately inquire and appreciate the prior experience and knowledge can result in inefficient and unnecessary frustration for both the attending and the resident and affect patient outcome. Underappreciation of a learner’s capabilities may result in hovering unnecessarily, teaching skills she or he has already mastered, and wasting the time of all involved. This is more likely to be the case early in the academic year. As the year progresses, it is more likely to occur at the beginning of a rotation in a larger program in which the attending may have little or no prior experience or knowledge of the newly arrived resident on the service.
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