So welcome to today's webinar. I'm Dr. Lauren Stewart, the moderator for the webinar. Before we begin, I'd like to share that we'll take questions at the end of the webinar, but you can submit them at any time by typing them into the Q&A section located at the bottom of the window. Today's webinar is entitled The Surgeon, Learner and Educator, and is being presented by Dr. Jorge Carrillo. Dr. Carrillo obtained his MD degree from Pontificia Universidad Javeriana in Bogota, Colombia. He then completed his OB-GYN residency at Rochester General Hospital in Rochester, New York. After that, he completed a fellowship in minimally invasive gynecologic surgery through the American Association of Gynecologic Laparoscopists, the AGL, and the Society of Reproductive Surgeons, the SRS, at the University of Rochester School of Medicine and Dentistry in 2014. This fellowship had an emphasis in assessing and managing patients with chronic pelvic pain conditions. He then joined the University of Rochester as assistant professor and as a provider for their Center for Chronic Pelvic Pain and Vulvar Disorders. He subsequently completed a Dean's Teaching Fellowship, a two-year training program on adult learning and medical education. In 2017, he joined the Orlando VA Healthcare System as a chronic pelvic pain specialist and minimally invasive gynecologic surgeon, and is an associate professor of obstetrics and gynecology for the University of Central Florida College of Medicine. He serves as one of the Orlando VA FMIGS faculty and as the site director for the UCFHCA Consortium OB-GYN Residency Program. Currently, he's completing his first year of a master's for the public health professions education at the University of Maastricht in the Netherlands. Dr. Carillo is one of the board of directors recently elected secretary of the executive board for the International Pelvic Pain Society, is the former clinical foundations course chair and currently the associate scientific program director for the 2021 IPPS annual scientific meeting. His special interests are in chronic pelvic pain, pudendal neuralgia, abdominal pelvic neuralgias and neuropathies, endometriosis, minimally invasive procedures and techniques, abdominal pelvic anatomy, adult learning, healthcare professions education, curriculum development, simulation and laparoscopic skills and self-determination theory. Thank you so much for presenting and you can take it from here. Thank you very much, Dr. Stewart. I thank you for the introduction and thank you, Ox, for the invitation. Really it's a pleasure and an honor to be here talking about this topic that I'm really passionate about. And as you will see in the presentation, I think there's a lot of reasons of why we should be talking more about this. I'm really happy and excited that I've been given this opportunity to do so. So with further more, we'll start. These are my disclosures because I am a federal employee. I have to say that the opinions expressed here do not necessarily reflect those of the VA, the US government or any of its agencies. And just to start with, and I know there's only like four or five participants, but still I think that this part is very important. I would like to poll the audience with a few questions that you'll find throughout the presentation. I would like to make it as interactive as possible. So to join the poll, please go into your browser to pollev.com slash Jay Carrillo. That's with two R's and two L's, Jay Carrillo, C-A-R-R-I-L-L-O or you could text Jay Carrillo to the number 22333, once to join, and then you can answer the questions. So the first question is, I would like to have an idea of who the audience is, if you're either a learner or an attending. So again, if you can log in, let me see if this... Or maybe since it looks like it's not going through for some reason, maybe if you can type in the chat, what is your role if you're a learner or if you're already an attending, that'll be great as well. Great, wonderful. So most of those attendings, okay. So the objectives of this talk is to question our current educational strategies, to analyze from the perspective of a specific theory, which is the experimental learning theory, the experiential learning theory, what is the applicability in surgery, from the learner perspective to identify strategies to improve the learning experience and from the educator perspective to apply educational concepts. And why is this talk important? And when I was starting to draft this talk like six months ago, when I've done it already like three, four times, I was thinking that this slide is very important. Why do we need to hear about this? And the first reason that I could think of is because number one, no one teaches or educate us on how to educate. It is always assumed that the more titles you get, the more specialized you are, that you will know how to teach. And it's not always the case, but we are always given the opportunity to have either medical students or residents or fellows, or even coworkers to transmit what we know and our knowledge. The second reason is because definitely we cannot continue relying on the apprenticeship model exclusively. There have been a lot of changes in healthcare and how we practice medicine, which really makes it a strategy that is not the best and it's not the ideal. Number three that I can think of is because education needs to be meaningful and efficient. And again, this comes along with all the changes that we have in medicine. Number four, because we all learn in different ways and it's important to acknowledge that and to recognize that in all our learners. Number five, because by doing this, we would help develop strategies as educators to promote meaningful and long-term learning, which in the end is the goal. Everything that we teach or that we try to educate in our residents or our fellows, we expect them to be able to have it handy and available for years to come by. And the last thing is because not everyone is a dedicator and that's totally fine. I mean, we should not be obligated to educate, but we should seek and promote those who are really devoted in education and interested on and help them nourish this knowledge and these practices. So the anatomy of this lecture is basically three big components. Number one, we're gonna talk about structure and you will go through terminology, frameworks, learning theories. We'll talk a little bit about expertise, motivation and feedback. And each one of these topics can be a totally separate lecture. So I'm gonna be as brief, as concise, but also as relevant as possible. The second part is we're gonna talk about the role of the surgeon as an educator, specifically as an experiential educator. We'll talk about what is to be an outstanding surgeon and we'll talk about non-technical skills. And the third part is gonna be the most important part of the talk, which is the applicability of the first two things. We'll go through an example of how to apply number one and number two in the operating room. And hopefully we'll come up with some very important and helpful conclusions. So let's start with the first part. So let's see if this works. What is learning? And if it's not working, please feel free to just add in the chat. What is learning for you? If you can put it with one word, what will be that? Or if you don't wanna type it, that's fine. Just think about it. But for you, what means to learn? Okay, so to growth is an answer. What else? What else can you think of? What is learning? Enlightenment. Any other thought? This is an important question because we need to understand that if we look at all the different definitions of learning, they all mentioned some kind of change in behavior or in the capacity of behavior, which is the basic result of either practicing or changing some kind or acquiring some kind of experience. Very important is that learning more than an outcome, more than a result is a process. It's a process in which the person by using different things in the environment will in the end change some kind of behavior that in the future we'll be able to use it and adapt it to different kinds of situations. Because that's the key thing, again, as I was saying at the beginning, that this process should lead to long-term changes. And then it comes to the next step or the next part, which is meaningful learning. And meaningful learning has a much more defined and concise definition, because it's the process of understanding or comprehending. Meaningful learning, the idea is that it's gonna help you facilitate not only the storage of information, but the retrieval as well of the information. And it's gonna make it easy to retrieve the information. So when you're crafting this meaningful learning, the learner is gonna be able to retrieve that information in the future in the easiest way. And when we look at the type of knowledges, there are many type of knowledges, but I wanna focus on three that are relevant for us as physicians. The first one is declarative knowledge, which concerns on the nature of how things are, where or might be. It enables interpretation of what we see, what we hear. So basically we're using a lot of senses in order to create this knowledge and craft this knowledge, which is gonna be declarative. Then there's also procedural knowledge, which for us as physicians, as surgeons is very important because it's knowing how to do things, either mentally or physically. Now, when we combine these two types of knowledges, you have what is called conceptual knowledge, which it helps you to understand why certain event happens. So the combination of declarative knowledge and procedural knowledge will lead to conceptual knowledge, which in medicine is important to have a certain type of concepts that are clear. But again, this comes from the combination of this two other type of knowledges. And when we operate, for example, is like the idea of knowing why a procedure works better than another one or understanding why we can offer one thing over the other for the patient. And there are three big pillars in education and we call them frameworks. And there are three big learning frameworks, which are gonna define different kind of practices in education. The first one is the behaviorism, which is the oldest one. And it's this one that promotes a response from a stimulus. So basically what happens here is that the educator assumes that the learner knows nothing, that is like an empty glass. And the educator is the jar filled with water. And then you just start, you come into the classroom and you just start pouring water into everyone, the same amount to everyone. And this does not really take into account the background of each person, does not take into account what the person might know or might not know. So there might be people who have already the glass almost empty, other ones who have it almost full. And you're just going around pouring water the same amount to everyone. And it's a type of learning process that is basically fostering or is focused on reward. So basically there's a stimulus and you should expect some kind of reward or reaction from that stimulus that you're doing as an educator. Whereas in cognitivism, there was a shift in mentality and this current looks at promoting mental processing. It looks at the states of knowledge. It helps the learner prioritizing and it will create a structure into that specific curriculum or to that specific learning task that the educator is giving. It's gonna help structure and it will prioritize on memory also and how knowledge is applied in different kinds of contexts. So this is related to different strategies that we use on a day-to-day basis, like chunking information, like classifying information, like linking information in order to store it into our memory. It's based on modeling and social factors. So there's not only that one-to-one interaction between the educator and the learner, but there's interaction amongst learners as well. And then there's the kind of newest one, which is not that new anymore, which is the constructivism. And this framework, there's a construct learning based on interactions with the environment and with other people. And the learner becomes a much more active person in this process. So the learner is the one who's gonna actually create the knowledge rather than the educator giving it directly and baby spoon feed it to the learner. And this is where we see all the different activities that we often see nowadays. PBL, problem-based learning, TBL, all these are constructivist approaches to how we teach in which the learner, again, is learner-centered and the learner is the one who's gonna start building its own knowledge. And there are many, many, many adult learning theories. The ones that are shown here in the slide are ones that I think that are important for us as physicians, the social cognitive theory, and which basically is something that relies into observing others and modeling others. The cognitive load theory, which looks at the human cognitive architecture and is something very important that should be considered when we are designing instructional messages or curriculums. The self-directed learning is like one in which the focus more in self-motivation, self-direction, self-management. But the one that we are often exposed to in medicine and that we're more used to is the apprenticeship model, which is based on the situated learning theory. And the pioneer in medicine with this model was Dr. Halstead, which was a surgeon who basically was the one who created the residency training here in the States. And it was very, very reliable and it was very relying a lot into clinical volume and clinical experience. And the way how he approached it was into a greater responsibility. It was a true apprenticeship in which the mentor was overseeing the student. And as they progressed, they were released in terms of, they were more autonomous. They were given more liberty in doing things. And that's where the old adage of see one, do one and teach one comes from. But the issues that I was saying at the beginning that the apprenticeship model is heavily based on volume and clinical volume and times have changed and how we practice medicine has changed too. And now we encounter and we face multiple challenges like financial constraints, time in the operating room is not the same that it used to be 50, 60 years ago, the concern of quality of care, the legal claims, the growth of the medical knowledge. I mean, we are now sub specialists of different kinds of things. And we have, there's so many technical advances and knowledge keeps growing every day. The shorter work week of the residents, of course, is another big impact in this clinical volume and the lack of consistency, right? Because they're not there all the time like they used to be before. Also, there's a concern in terms of lack of motivation, how we can motivate people to be more interested in learning. And then the other side of the balance, there are things that often will help counteract all this pitfalls like mentoring, motivation, decrease in anxiety and practice and simulation, right? So this is where this theory that I think that is very interesting if you have the time to go through it, it's called experiential learning theory. I think that is very important to medicine. This theory looks at the subject to be learned, being experienced by both the educator and the learner. And for this theory to occur is very important the environment because the environment should enable to move from experience to deep reflection and then conceptualization and action, which is the cycle called cycle, which you'll see in a minute. And basically this learning, what it says is that the process of creating knowledge is through the transformation of experience. And the adage for this one is that all learning is relearning. So it basically goes from the principle that there's no repeat experience whenever you do it. And this learning has shown to produce the highest and most complex form of memory, which is episodic memory, which is the kind of memory that you can easily apply in different scenarios and different situations. And this is Kolb cycle. So basically what Kolb cycle says is that you have four parts of the cycle. The first part starts with concrete experience, which is what you do and having the experience of whatever you're gonna go through. Then there's a phase of reflective observation in which you review what just happened. And that goes into an abstract conceptualization in which you think about what just happened, but you really tease it out. And that's when you start kind of reflecting into what happened. And then it ends up into an active experimentation in which you change, you kind of get that feedback from what just happened, and then you change your experience. And then the cycle starts again. And if you see that this cycle, it has two components, this two right here, the concrete experience and reflective observation, which are heavily relying on experience, the abstract conceptualization, which is the grasping of that information and the active experimentation in which you transform the experience that you had. And then in the end Kolb cycle, and what they say is that instead of being this, a single cycle in which you go through one time through a particular experience, when you start all over again, this initial cycle will transform and it will become more like a spiral that is gonna have different levels of experience. So you'll go through experience number one, then you'll go through experience number two of the same task or the same surgery, but it's just, it's gonna give you different kinds of levels of experience. And that's what it is. I mean, in the end of you think, and we'll talk a little bit about expertise, but if you think about expertise, you don't stay stuck on a single thing and you don't stay stuck on your 100 hysterectomies or 100 procedures that you've done, because every single time, every single procedure, there's something new, there's something different, there's something there's something that you can actually sit down and reflect on that is going to make you grow. So and that's when you actually deliberately do that, that's called deliberate experiential learning, which is the process of experiencing with awareness in order to create something meaningful and actually make choices of learning strategies based on this. And this is something very important that for us as educators, we should think about in order to be able to transmit this to the learners. Because by doing this, we're hitting metacognition, which is basically the capability of self-analyze and self-think about your own thoughts. That's metacognition, so thinking about thinking. And you go through the deep experiencing, the learning style of the student, the learning identity of that student, the learning spaces, the learning relationships, and then the deliberate practice. So let's do a quick exercise, and I want you to all kind of think about this for a minute. So pick a procedure, and here for example purposes, just so we can all speak the same language, let's think about dissecting the ureter, doing ureterolysis. So let's say you just did the procedure, and then you walk out and you focus, you create your own learning space. So you focus on it, and then you think about the immediate experience, which was dissecting the ureter. So then you move to reflection. So you sit back and review what you experience, and how that was. You think about yourself as an observer, you replay in your mind every single step as possible. You conceptualize your experience is the next step, so you replay those reflections and try to make sense of them. You create a concept, an idea that summarize the aspects of the experience, and then you move to action. You think about what your explanation means for action, so you do something with it, and then you restart the cycle. After this, the next point is expertise. So expertise was described by Erickson, and expertise and expert performance was initially drafted for musicians, for chess athletics, and what they looked at was the consistent, it was consistently superior performance on a specified set of representative tasks or domains, and that's how they define expertise. And that's where it came the whole concept of 10 years or 10,000 hours of sustained deliberate practice. Now the thing is that we emphasized specifically on time, which is a big mistake. You know, we should not emphasize in time, because emphasizing in time is simplifying the theory, because there are many other factors that affect expertise, such as motivation to improve, self-situational awareness, training environment, and coaching. Now the skill has evolved with time, and there are different theories in which they've described different kind of skills. But expertise in surgery is under-researched, because most of the research is focused on surgical experience, competence, and there's a lot of studies that look at novice and expert simulation studies, but they're very anecdotal. And something to keep in mind with expertise is that although practice is very important, it should not be the only domain to focus on, because if you think about it, the quality of the time spending practicing can totally influence outcome. So you can actually do 10,000 hours of laparoscopic suturing, but you could do it wrong if you're not coached, if you're not receiving feedback, if you're not looking at the steps of what you're doing. Whereas you could do the same thing with a coach and achieve the same level of expertise, and many many less hours, if that makes sense. Another important point to discuss is motivation, and there are many theories about motivation, but only one looks at quality of motivation instead of the level of motivation, and that's the self-determination theory described by D.C. and Ryan. And this theory looks at motivation as something linear, that starts with a totally amotivated state, which is a motivation, to the most pure form of motivation, which is intrinsic motivation, with extrinsic motivation being in the middle, which is what we often go through. Extrinsic motivation is basically what we see when we're in school, right? So we have to study to obtain grades, we have to read in order to pass an exam, you know, or let's say you learn how to play football just because, you know, you you have, you like your family going and watching, right? So there are external motivators to do that. What this theory says is that if you complete certain things around the person, the learner, you can change something from being extrinsically motivated to intrinsically motivated, because motivation is impacted by these three things. Autonomy, which basically has to do with the, your level of, of, of freeness, how free you are, what are your choices, what do you pick to do, what do you pick to learn. Competency, which has to do more with how comfortable you feel doing whatever task you're asked to do, or you're supposed to do, if you think that it's something that is too complicated for you, or if you think that it's something that you can actually achieve and do. And relateness, which has to do more with your environment and the people that surrounds you. So they say that if you fulfill these three components, that you can actually move something that is extrinsically motivated to more intrinsically motivated. And if you think about it, we can do this when we teach, you know, if you, if you give a little bit more freedom in terms what things the person can do in the operating, or would like to do in the operating room, or they think that they will need to improve, and we'll see that in the example at the end. Or in the operating room, if you allow the resident or the fellow to do tasks, small tasks that you think that they will be competent enough to do, that will give them a little bit more of a boost of self-confidence, and might impact their ability of, of, of looking forward to repeating the procedure again, or to learning better that technique. Same thing, it is different when you have a single student versus when you have a group of students that are sharing the same kind of activity. Feedback is another big issue when it comes to education. And, you know, the important thing about feedback is how do we do it, and what do we do when we're giving feedback. And basically feedback is, is describe the performance in a given activity in order to guide for the future performance of that same activity. So the idea with feedback is to generate an improved work. And there are many ways, or many types of feedback. There's a formal and an informal feedback. The informal feedback is usually the most effective when it's given soon after the activity. And usually you want to try to start with positives followed by the areas to reinforce, but it's always a good approach to start with questions. For example, did the procedure go, went as intended? And why did you think that it go or not as intended? What would you change or repeat? Did you feel confident? Or how would you feel if you did the procedure again? So enabling the learner to answer questions instead of you just going there and just giving your thoughts. It's a good way to help the person do kind of a self-assessment and really analyze in depth and get into what needs to be changed. The formal type of feedback, there are two forms. One is formative and the other one is summative. Formative is always have been advocated to be the best kind of feedback because it looks at improving or modify the learner's behavior. Whereas the summative is the typical test or exam that is done at the end of the semester, at the end of the year, that usually has a passing or failing or has some kind of grade or rubric that is a high stake feedback or assessment. So summative assessments are not the best way to really get information of how the person is performing, nor also depending on how you do it is not the best way on how to modify some kind of behavior. But whatever type of feedback you use with your learner is very important to have every three to four months meetings in order to keep the training on track. And there are things that are going to impact towards being or making feedback strong or making or being feedback weak. And the very most important thing about feedback is that the feedback should be about something that you observe, something that you were present on. The expert should observe and provide that feedback. It should be very, very specific. It should be very, very explicit. The idea is that there is a plan to re-observe that whatever you're assessing or whatever you're providing feedback, because really it means nothing if you just get feedback without reassessing it in the future or re-observing in the future. And weak feedback will be totally the opposite from what I just said. When you get feedback about non-observable competencies, or it was something more like, oh, I was told, or someone came and told me about this, or there is something very general, like to say to someone, well, you don't have good hands. What does that mean? Or there's no intention to re-observe. It's someone that just giving feedback and you're never going to have contact with that person ever again. And this is a paper that gives very important principles about how to give feedback that is effective. So again, first, the feedback should be precise with attention specific. It should be relevant to practice for the person who's receiving the feedback. It should be outcome-based with clear aims. It should be something measurable where improvement can be assessed. It should be something possible and attainable. So the person who's receiving it should get feedback about something that they should be able to really do. It should be time determined. So it's very important to get feedback at the moment when it occurs. It should be something encouraging and constructive, not destructive, and it should be something descriptive. So follow the PROMPT acronym, and you'll be good at giving feedback. I want to share this video with you, and I want you to listen to it for a minute, and then we'll talk a little bit about it. Oh, miss spot. What spot? Hey, hey, how come you didn't tell me you were going fishing? You not here when I go. Well, maybe I wouldn't want her to go. You ever think of that? You karate training. I'm what? I'm being your goddamn slave is what I'm being, man. Now, we made a deal here. So? So? So you're supposed to teach, and I'm supposed to learn, remember? For four days, I've been busting my ass. I don't learn a goddamn thing. Ah, you learn plenty. I learn plenty. I learn how to sand your decks, maybe. I wash your car, paint your house, paint your fence. I learn plenty, right? Not everything is a thing. Oh, bullshit. I'm going home, man. Daniel-san. Daniel-san. What? Come here. Show me sand the floor. I can't move my arm, all right? Please. What are you doing? What are you... Ow! Ow, what are you doing? Now, show me sand the floor. How did you do that? Show! Sand the floor. Stand up. Show me sand the floor. Sand the floor. Sand the floor. Big sucker. Sand the floor. Sand the floor. Now, show me wax on, wax off. Wax on, wax off. Wax on, wax off. Wax on, hat. Wax off, hat. Concentrate. Look my eye. Look my eye. Lock your hand. Thumb inside. Wax on, hat. Wax off, hat. Wax on, hat. Wax off, hat. Wax on. Wax off. Show me paint the fence. Up, down. Up, down. Up, down. Other side. Look eye. Show me paint the house. Side, side. Knuckle wrist. Side, side. Side, side. Show me wax on, wax off. Wax off, hat. Wax off, hat. Show me paint the fence. Show me side, side. Show me sand the floor. Start. And look eye. Always look eye. Come back tomorrow. So this is a very interesting video because if you think about it, about what we just discussed, um, so this could be considered more like a behaviorist kind of approach in which, you know, the educator told Daniel, okay, so go and do all this thing, the fence and, you know, paint the house and do all this stuff without needing to explain anything or without getting into explaining why he was supposed to do that, which most likely made that learning experience awful for him because he was always thinking, well, this guy is just using me and blah, blah, blah. Uh, but then in the end, because of repetition, he gained what he needed to gain, which was to do all those karate moves at the end. Right? So think about how would have been his experience and how much more he probably would have have learned if it was explained from the beginning, the purpose of doing those movements and the applicability of all that and allowing going through that cycle that I was talking about the beginning. So this is just an example, you know, and often we, we get into that in medicine and, and, you know, especially in surgery, we get into that issue of, of going and repeating and repeating and repeating without really not thinking. Um, so this question, I just want you to think about it. Like, how, what do you consider yourself or how do you consider yourself when it comes to being an educator? Are you a facilitator? Do you feel that you're more a coach or you're more a subject expert or an evaluator, um, or just an educator? Um, so this is important to keep in mind because there are many, many roles that we fulfill as surgeons and educating, mentoring, coaching, you know, are just a small parts of what in the end of the day we do. And we all have different styles, but going again to the same theory, the experiential learning theory, um, looking at from that perspective and through those lenses, the experiential educator has four roles. It has the role as a facilitator, which is based in the personal relationship with the learner. So that facilitator is that person who's going to help, um, uh, is going to help the learner, uh, creating the environment appropriate for the learner to learn, right? Um, the subject, the subject expert role, it has to do more with our own expertise. So we will, in that role, we will help the learner organize, connect their reflections to the knowledge base of the subject matter. So we are the ones in charge, helping them organize the thoughts, the concept, the knowledge, um, you know, the, the procedural skills, the procedural knowledge. Then we have a role as well as the standard setter or an evaluator because we're constantly giving feedback and we're assessing the, the, the learner in order to make the learner accountable of what they're reaching and what are the performance requirements that they need to meet in order to become proficient. And then we have the role as a coach and what, in which we help apply the knowledge to achieve the goals with a specific learning context. And it's a very active role. So for the role of coaching, really, we need to get to know a learner. So if you see this, this theory is, is starting off with the, with the thought that every learner is unique and that's very important to identify. And I feel that, you know, in residency, often we have many, many residents, we have many, and fellowships is probably a little bit easier because we have less amount of learners, less number of learners, but it's something to keep in mind. What do you think that makes a good surgeon or what, what do you think that makes a surgeon an outstanding surgeon? If you, you want to type quickly in the chat, what do you think that will make that? That's an important question that I think that we need to think about. This is extracted from a book that I would recommend you to read, which is called Attending Medicine Mindfulness. So this was the experience of the author being a medical student in the middle of a surgery that was a complication. And basically he was comparing two different experiences that this person had in the operating room. One with, with both were very, very skillful surgeons, it's just that they both behave differently. So he wrote unlike Gunderson, which is the first one, Medha noticed that something was already before anything anyone else did. By the time we realized it, Medha had already shifted seemingly from autopilot to a more deliberately choreographed action. First tango, then ballet, then a few minutes later back to tango, all without missing a beat. No panic, only calm focus, surgical mindfulness and action. His shifting of gears was so smooth that I wondered if he was even aware of it. And I think that's what really struck me. The word that really struck me from this was the surgical mindfulness. And, and it's a word that is very important to, to really implement in the OR, because it's not only about the surgery and what makes a surgeon an outstanding surgeon. So if you think about the things that we have to fulfill as surgeons, so we have to have the knowledge, we have to have the technical skills, but also the non-technical skills. And there's a paper that look into this, into the principles that guide the operating room behavior. And they found that there's like different things that we have to fulfill. So like there's the psychomotor domain, there's the interpersonal skills, the advanced cognitive skills, the personal resourcefulness of the surgeon, and of course the knowledge. But the non-technical skills is something that we usually don't learn that much. I mean, we learn it by experience. We learn it by, by, and probably recently we're much more aware of it, but it looks at four categories. The non-technical skills looks at situation awareness, decision-making, communication, teamwork, and leadership. And are things that often we don't emphasize enough in the operating room and even before the operating room. And what is situational awareness? Basically knowing what's going on around you to quickly detect and integrate and interpret data gathered from the environment basically is to be aware, to be mindful of what's outside. And the thing is that the operating room is a complex scenario, it's a complex classroom, you know, because there's a lot of things that are going on in the operating room, you know. There's a change in the setting, which is a good thing, so that makes it novel for the learner. It's a multimodal stimuli environment because you have the visual, you have the tactile, you have the smell, you have the vivid action of what's going on, right. There's also the concepts of knowledge, so also you learn about the surgical culture of what, how people behave in the operating room. It gives you a better understanding of surgical specialties, it's usually the hook and how we hook people in to get into our specialties, and it can inspire future careers. But it's also a very stressful environment, and the OR is something real. And the issue with us as educators, as surgeons, is that now the surgeon fulfills different kind of roles. We are functioning as clinical, you know, surgical caregivers, as coaches, as leaders, as learners, because we're still learning a lot in the OR, as experts, and as mentors. So all those roles fulfilled by one person, and in the end we're trained to be just a surgeon, you know. So this is, these are things that we need to really get a deeper understanding in order to become good educators. So how do we apply all these things? And this is the third part and the last part, and I want to use this traffic light symbolism to practice this. So whenever you see red, you should stop doing whatever it says in the slide. If you see green, you should start doing it, and if you're already doing it, continue doing it. And if you see yellow, just be careful, yield, just be mindful that sometimes that might be a useful technique, sometimes it might not. So pre-op, in the pre-op scenario, there are a few things that we can do for the cognitive aspect of it. So you have to resonate, you're about to go into a hysterectomy, so you can discuss this case, you can discuss the history, the exam, the labs, reflect on alternatives to management. So the way how you can help the resident or the fellow, you know, you ask questions initially. So you activate the prior knowledge. There's a lot of educational research that shows that activating prior knowledge helps the learner establishing relationships between concepts and link them. That's called association. By doing this, you're promoting storage and long-term memory, and not the working memory, which is the short-term memory. When you explain why of an approach, understanding why certain procedures are important or effective in promoting meaningful learning, remember the conceptual knowledge part of understanding why one thing could help or why one thing could not help. Organizing the knowledge, helping the learner organize what is it that you're, so don't be disorganized, don't go all over the place throwing out different kind of thoughts and ideas. No, have something structured in mind, you know, and help them understand that structure. That helps them store that information in a much more structured way, because it will help them, again, relate to prior knowledge and establish relationships. And also this pre-op part is the opportunity to correct misconceptions or reconceptualize the person. I mean, there's a lot of times that they come with inaccurate knowledge in which there's a specific theory that's called the conceptual theory or reconceptualization that is actually used also in patients, you know, to help change practices. But it's something that you can apply and you can help. It's a good opportunity to do that. Then, red, so don't do this. Avoid rote learning, which is memorization. This is done when you try to learn something by remembering without a meaning. So the whole 1, 2, 3, 4, 5, 1, 2, 3, 4, 5, what we almost, everyone, every single one of us have done for the steps, like what we do for prior, do three days before the exam, in which you memorize things, and then you come to the exam, you throw everything out, and then you forget about it. So rehearsal of declarative knowledge, it helps maintain the memory when you maintain the rehearsal. And it's effective to preserve information in the short-term memory, but not effective for long-term memory. So if someone does this, they're going to have trouble remembering what they've learned. The other thing, avoid answering questions for your student. Let them elaborate the knowledge. If you ask a question, let them go through the thought process of how you get to the answer. And that's what everything about small group work, PBL, TBL, is so focused on, because it forces them to mentally do something with the material. Oops, sorry. Also, deliberate practice, and this is based on Erickson, with expert feedback. So simulation, this is pre-op, do not overload. So it's okay to go to the box and train, but you need to be there to coach them. It's not worth if they go five, six hours on their own, and they're doing things how they're not supposed to do. So it always needs to be coached. Ask about how many cases they've done, which part of the case was done, which one they feel that needs improvement. When you do that, you're helping with the motivation part, because you're allowing the participant to have more autonomy, to feel more competent, and to relate with you, which could increase the motivation, impacting the skills part. So the learner before the surgery should have one or two very focused, clear objectives or goals for the surgery. So it's not about, okay, so you're going to go in, and you're going to do the hysterectomy. No. So think about it. Break it down in pieces. So what part do you think you feel less competent? What do you want to focus on? The bladder flap, skeletonizing the vessels, transecting the uterine vessels, or doing the copotomy, or sewing up the cock, right? So make them think about that, and let them make that decision. Deconstructive surgery goes along with that. So go through the steps of the surgery, assign roles so they know beforehand what is it that they're going to do, and make sure that you don't assign unreasonable tasks. What ifs? Go through the complications, right? This helps impact the non-technical skills, situational awareness. Ask them to mentally rehearse or visualize the procedure the day before the procedure. So mental rehearsal, or visualization, or imaginary. This impacts procedural knowledge and skills. By doing this in periodic intervals over the course of weeks, or months, or years, it can enhance memory and performance. Although it's very important to clarify that it's not as effective as doing it, but that rehearsal before the surgery will allow those memories stuck in the brain in the past to come, you know, easier when the time comes for the surgery. Interoperative. What things can we do to help improve the environment? So first thing, ask the learner to talk about their experience as they're doing it. You know, if they're operating, tell them to practice, okay, so tell me what you're doing. Why are you doing this? It allows them to get that experience into the long-term memory, and that's called verbalization. It fosters applicability in other situations. So the fact that you're not only doing it, but that you're able to express that verbally as you do it, will enhance the memory. The other point is that the learner should do what they consider needs to focus on. That's called enactment. By doing this, it promotes long-term memory, and it will help and facilitate the learner to acquire procedural knowledge. Constantly assess the learner's strength and weaknesses. You know, look at the skills or areas in which the learner needs to be improved. Provide instructions, and why it makes sense. You know, okay, so lateralize the peritoneum this way, or, you know, move it medially, or move the structure, or look at this, but why are you doing it? Why are you holding the scissors this way? Why are you throwing the stitch this way? Again, this is going to impact the cognitive aspect. Again, provide regular feedback. It helps storing the experience into the working memory with recollection of what they just have done. Suggest recording. There's a lot of coaching experts that are now looking at video recording, and going back and reflecting on that is something very important. We'll talk about it in a minute. And involve other specialties. So, talk about the role of other specialties in the OR. Promote the non-technical aspect of this interdisciplinarian teamwork. That is going to foster the non-technical aspect. Be careful with automaticity. Automaticity is when you start doing things automatically without even thinking. Like, you take the same path every day to work, and sometimes you got to work and you don't remember if you made a stop, or if there was a light, or if you have someone, you don't even pay attention because you became automatic. Same thing happens with surgery. The problem with this happening in surgery is that you might not remember if you actually did something or not. So, you close the patient, everything, everyone is going, and then, did I check on this bleeder? Did I do this? Because if you do it repetitively every single time, it might become something automatic. So, always be mindful and be careful. The more expert you are, the more chances you have to fall into automaticity. During the surgery, avoid taking over as an educator. Of course, safely, right? Allow the learner to struggle in a safe environment, and make them think to identify and define the problem on their own. Why are they struggling? So, let them elaborate that. Allow the trainee to do more. That's going to enhance competency. And also, every performance is an occasion for learning. So, you have to make sure that the learner knows that. There's no such thing as, oh, I already done 10,000 vaginal deliveries. You know, that's the same thing every single time. Doesn't work that way. If you need to take over, let's say something's going on, you need to take over. Ways to enhance that educational experience for the person who just stopped doing whatever, you verbalize. You verbalize what you're doing. By verbalizing and sharing your thought process, you will still share that experience with the person who's there. Bring awareness to the surgical field. Share declarative knowledge to link with the visual elements that you're seeing in the surgery. If the learner fails, help them control the emotional response, because that's going to hinder their learning experience. And remind them that failure is the most important ingredient to success. We all fail sometimes. Post-op, a debriefment is very important. Do that in an isolated area with a quiet environment. Give always formative feedback. We talked a little bit about this before. And say, I am going to give you feedback. So, start with that. That will allow self-reflection and metacognition. Doing dictations will help declarative knowledge or, you know, typing the up notes. It will help long-term memory. And again, as I said before, video review, peer review, is very, very important because it will help them overlearn on their prior practice and might help them go through that cycle in an easier way. It will allow them to apply this in different contexts with stronger association. And it makes it easier to recall. So, in summary, knowledge of different learning theories and principles are imperative to build an adequate learning environment and foster meaningful learning. The educators and learners should work as a team to achieve a common goal. And the learner should be involved in the learning process, should not be just a mere recipient of knowledge or skills. Being a health professions educator is not for everyone. But every department and academic institution should have a champion educator and should foster this. And everyone should have opportunities to learn on how to become an educator. That's something that we really miss in med school and residency and fellowship. And again, we're a throwout to the lions to expect to do all this. So, it's good that you have given me this opportunity. I really appreciate it. This is a simple graphic of Kolb's cycle and the relationship with motivation and feedback and the three components that makes a surgeon an outstanding surgeon. And this is my email if anyone has any questions. Awesome. Thank you so much. That was an amazing presentation. I think we have a few minutes for questions. You can submit your questions in the Q&A section at the bottom of the event window. Our first question, if it's okay, Dr. Carrillo, is from me. First of all, thank you so much. This is such a fantastic topic. And I think probably most of us who are tuning in, myself included, are educators ourselves. And your comments about how educators are really never taught how to educate, we never really learned that, really resonated with me. It's something I've been thinking a lot about even since residency when I was in the role of the learner and I was thinking about my attendings and if they've had formal education about how to educate. And I think that there's so much out there about learning theory and adult learning theory in particular, and your talk really highlighted a lot of it. I'm curious if you have a good recommendation for a resource for people who, like even a review article, a good book, somewhere where we can turn to reference a lot of the theories that you discussed in your talk tonight. Yes, yes. So there's a book that I read that is called The Experiential Educator, which is written by Kolb. It's a long book, but I think it's very fun to read. That's one of them. The other one, there's another book that is, let me have it in the tip of my tongue. What I can do is I can share with you the name of the book. Yeah, I totally lost the name of the book. But the one that I'm telling you, The Experiential Educator, is great because it goes in depth about not only the cycle that I just explained, but the different types of learners and the different types of educators that are there. And it gives strategies and tools on how to approach and how to approach a learner. I think that that's a great book to read. It's called The Experiential Educator by Kolb. Thank you so much. That's great. And, you know, I would encourage everyone, like before I did, before I started my Master's, I had the opportunity to do a Dean's Teaching Fellowship. But in all the academic institutions, there's always opportunities of CME and opportunities of growing academically that I think that we should be able to take advantage of. I know that a lot of times there's a lot of time constraints, but I do believe that departments should come up with a dedicated time for people who are devoted to this, like program directors or, you know, associate program directors or, you know, attendings who are in charge of residence all the time or fellows, you know, because those opportunities really help you grow a lot. It's amazing to me how much research is out in education from psychology and from high school and college. And, you know, we're starting to pick up more in healthcare professions and specifically in medicine, but we're still so behind that it's amazing. I mean, there's a lot to do. Yeah, for sure. There are a lot of thank yous. Great thoughtful presentation. Thank you. Thank yous. Not many questions. Does anyone have any questions? If not, I might ask another one if that's okay. I think one of the other things that I've noticed, I'm a very young attending just recently out of fellowship. And one of the things that I've noticed is as a surgical subspecialist, trainees are very, very eager to come into the OR, particularly for my vaginal surgery cases. And I've had surgeries where I have three, four residents all trying to come to my OR. And I find that both very overwhelming because I'm a new attending and trying to manage, you know, everything, all of those different tasks and fulfill all the roles of just being an attending and taking care of my patient, but also trying to manage so many different learners. And I'm curious if you have experience with that at your own institution and if you have any advice for sort of, yeah, managing, trying to make sure that everyone gets at least something out of the case. Yes. And that's a great question. Actually, I think recently I saw one of those questions like that in Twitter that was kind of similar, like, what do you do when you anticipate a difficult case that you know that the person is not going to be able to do much during the surgery? And I think it's almost the same thing that, you know, you have a large group of people that is coming to your surgery and you know that not all of them are going to do. So if you think about the few tips that I give you as an example on the pre, the intra and the post-op, there are a lot of them that will be beneficial to all of them. You know, in the pre-op area, they're not scrubbed, they're not operating. So basically all the things that I mentioned, like linking prior experiences with experience that they're about to go through, you know, bringing up, activating prior knowledge, you know, making mindful comments or thoughts about what's going to happen, you know, or designing roles. You know, you assign roles to different people, right? So let's say you have one person who's going to be the uterine manipulation, right? The other person is going to be the first assistant and then the other person is going to be operating with you in the console, let's say it's a robotic case, right? And I had that scenario when I was in Rochester. I had, there were residents with me, I'll have a junior, a senior resident, a fellow, and then me. And, you know, literally I was just standing and, you know, not doing anything kind of coaching, you know, and then, but then assigning a role. I think that talking with them before the procedure and telling them what they're going to do, what the expectation is, especially what they're going to gain. You know, a lot of times I always got the frustration from the junior, oh, manipulating. You know what happens when someone sucks manipulating? And, you know, give them examples and show them what will happen if they don't do it well. I think that's a, there are ways in which you can engage people, you know? But the tips that I give during the presentation at the very end, I really thought about them for like two, three weeks about, okay, so what did I think that might be, might have been useful for me in those kinds of scenarios? Because we've all been in that situation. Even like something as simple as recording the case, right? And we record the case and then you come out immediately after the case and you sit down, not only with the person who assisted, but with everyone who was there. You go through the different steps and then it's actually a good way for you, yourself, learn too and to keep improving. You know, sit down and you go through the steps. So, so those, I think those are things that even though the person was not there throwing the stitch and doing the actual movement, they will still get a lot, you know, because again, emphasizing that each case will give you a different kind of experience is something that is, I think, fundamental that we often kind of, you know, put on the side where like, oh, I've already done, I don't know, 150, 200 vaginal deliveries. I'm good at it. No, because each one of them is different. Yeah. Awesome. Thank you so much. No, no, you're very welcome. And again, thank you for having me. Just going to say that quickly, on behalf of the AUGS Education Committee, I'd like to thank Dr. Carillo and everyone for joining us today. Our next webinar is entitled The Role of FPMRS in Global Health Going Beyond the Hole in the Wall and will be presented by Dr. Rachel Nardos on February 17th. Thank you so much. Take care. Bye.

learning environment

surgical education

experiential learning theory

feedback

clear goals

surgeon as educator

non-technical skills

communication

teamwork

professional development