Education and Knowledge-Base Acquisition and Retention

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Chapter 209 Education and Knowledge-Base Acquisition and Retention

Andrew M. Bauer, Chima Ohaegbulam, Isador H. Lieberman, Marc Eichler, Gregory R. Trost

The learning process receives relatively little attention by most students and teachers in clinical medicine. Significant changes have taken place in recent years at the medical school level with the introduction of problem-based learning systems and a transition to systems heavily reliant on technology. Residency training has traditionally been a hierarchical environment in which the teacher or attending physician wielded ultimate power and control over the learning situation. In some scenarios, residents learned by direct observation of their mentor in clinical situations, whereas in other programs, residents were placed in more “hands-on” situations with less clinical supervision. Surgical subspecialty training in particular has traditionally utilized the “See one, do one, teach one” method. This method certainly has both advantages and drawbacks. For residents, the increased level of autonomy places an increasing sense of responsibility on the individual to learn quickly and efficiently as he or she will not have the luxury of backup by the attending physician for the long term. From a patient-care perspective this method of learning is not ideal, however, because patients could have residents performing procedures with which they are not adequately experienced. In the current health-care environment, with litigation and quality improvement at the forefront, this method of training is in forced elimination. In its place, training either assumes a more didactic course with increased trainee supervision, or a less desirable route where the hands-on training disappears in favor of procedures performed by more senior physicians. This chapter examines the learning process in some detail to improve the efficiency of learning in the context of the current social and medicolegal environment.

Spine surgeons generally train in formal residency programs in either neurosurgery (6–7 years) or orthopaedic surgery (5–6 years), which may be followed by a 1- to 2-year fellowship in spine care. For residency training, the North American Spine Society (NASS) has defined five core categories of education that should be addressed during residency. These include (1) core knowledge, (2) clinical evaluation, (3) operative management, (4) postoperative care, and (5) rehabilitation.1 The fellowship should provide more in-depth study in hospital resources, teaching faculty, educational programs, research endeavors, and evaluation of the process.2 According to the NASS, the graduating resident should at least have a reasonable degree of comfort in caring for patients and performing surgery for disc herniation, decompressive laminectomy/foraminotomy, noninstrumented posterolateral and posterior spinal fusion, bone graft harvest, management of spinal fractures with appropriate instrumentation and external immobilization, and basic management of spinal deformity.1 As one might imagine, as technology advances, the knowledge base one must acquire during a fixed time period advances rapidly—especially given the fact that similar advances are taking place in the understanding of brain and nervous system diseases (neurosurgery residents) and long-bone and joint injuries (orthopaedic surgery residents), which also must be mastered by the end of residency. The response to this must be either an increase in the length of training or more focus in subspecialty training within a given specialty. Indeed there has been discussion of changing the traditional residency training system to include 2 to 3 years of general training followed by a 2- to 3-year subspecialty fellowship. This discussion has many implications to the health-care system in general, because fewer general providers are available. In any sense, maximizing the efficiency of education during the residency years is beneficial. Learning efficiency requires a more in-depth look at the elements of the learning process.

Elements of Learning

Learning is a process that cannot be directly measured, but its occurrence can be inferred when outcomes of the process are measured. Board examinations and recertification examinations are examples of the objective measurement of the learning process in a medical specialty. Observable or measurable changes in performance should result from learning. The more subjective aspects of the learning process are much harder to measure, however. These include the learner’s overall feelings about the learning process and ultimately the confidence and proficiency one shows in being in practice without the backup of attending physicians during residency.

The most rapid learning in humans occurs during childhood. This consists of learning mostly facts, such as language, and overall exploration of the environment. For adults, learning is intimately tied to application of knowledge. Adults have a more difficult time learning facts and things that are not put to use in general daily life. The most productive learning occurs when concepts and principles are linked to existing knowledge and experiences.3 All of the human sensory modalities are at work in the learning process, and learning is generally more effective when several modalities are used in any given task. People generally remember 20% of what they hear, 30% of what they see, 50% of what they hear and see, 70% of what they say, and 90% of what they do.3,4 This concept is highly useful when planning a learning program for trainees. This finding has greatly influenced learning as a whole. Presenters generally use audiovisual adjuncts to their lectures to assist in retention. It is particularly important to residency training, in that residents must be involved heavily in doing their craft. This phenomenon occurs due to the development of collateral brain pathways among the multiple sensory systems, which provides for more durable learning and knowledge retention.

It is now widely accepted that three major domains are involved in learning, the cognitive, affective, and psychomotor domains. These are often more commonly referred to as knowledge, attitude, and skills.

Cognitive Domain

This domain encompasses overall knowledge and is the largest component of learning. This involves mostly tangible information and emphasizes remembering, understanding, and reordering information, and combining ideas and concepts. Cognitive learning occurs in six progressive levels, which must occur in succession:

1. Knowledge and recall of information

2. Comprehension of information (to understand and know its meaning)

3. Application (to apply information in the proper context)

4. Analysis (to break the information into components)

5. Synthesis (to combine ideas and concepts resulting in new ideas)

6. Evaluation (to judge the value of the information)

Traditional teaching in the clinical setting tends to fall short of true efficiency in this domain because learning tends to remain in the first few levels. In short, trainees focus on memorization of the minute details necessary for the residency evaluation, progression examinations and board examinations. True understanding of information occurs at the higher levels, however, and it is here that the trainee can apply what is learned to solve complex medical problems. The “art” of medicine is found in these upper levels of cognitive learning where one can apply information over a wide range of scenarios rather than just memorizing the evidence basis for care in one particular situation. This was an area that excelled years ago when medical training occurred as more of an apprenticeship. The methods used for evaluation and promotion of the learner largely dictate to what level the trainee learns the information. Board examinations only require knowledge, comprehension, and to some extent application, whereas analysis, synthesis, and evaluation are lacking.

Affective Domain

This domain is largely based on feelings, emotions, and degree of acceptance or rejection of the learner. Unlike the cognitive domain, this domain is largely based on intangible information. This domain is extremely hard to assess by objective methods, and evaluation is often based on the subjective and affective experiences of the examiner.5 Skills learned in this domain are acquired throughout life and are based on a wide range of influences. In medicine, this domain is often referred to as the “healer’s art” and includes empathy and “bedside manner.”

This domain can be divided into a number of discrete areas, including clinical judgment, patient interaction, ethics, reliability, professional development, teamwork, and image or appearance. This division involves the way that cognitive learning skills are applied. Learning in this domain depends largely on the environment and the attitudes of both the teacher and learner. These skills are perhaps best learned by direct interaction with and observation of a mentor, such as the way an attending physician interviews and interacts with patients.

The other important aspect of the affective domain is its ability to affect the other domains of learning. This ability is perhaps best exemplified in the old medical tradition of “pimping,” in which a teacher, presumably an attending physician or other provider, asks questions of medical students or residents in the presence of their peers. The teacher in this case has power over the learner in the teaching process. Although some learners excel in this environment, most feel uncomfortable and this can cause nervousness that detracts from a valuable learning experience.6 On the other hand, embarrassment in front of one’s peers is often an effective mechanism for “driving home” a point, and information learned in this manner may be tied to an emotional response, which is often quite durable.

Psychomotor Domain

The psychomotor domain emphasizes motor skills. In medicine, standards for learning skills may not always be established, and objective assessment of these skills can be quite difficult. Ideally, psychomotor skills can be learned in a stepwise fashion in which the basic information about a procedure (cognitive) is learned and can then be observed as an expert performs the procedure or skill. From here, the learner can graduate to practicing the skill on a model or cadaver and then to performing the skill in real clinical situations with supervision from the attending physician. Eventually the trainee should be able to perform the task independently. This is the basis of the “see one, do one, teach one” philosophy mentioned earlier. The drawback to this learning strategy is that not all trainees can learn adequately in this manner. It requires intense observation on the part of the teacher to recognize when further training is necessary before the next level of independence can be obtained. It also requires some degree of responsibility on the part of the trainee to practice the skills learned in the laboratory or on a model so that when the clinical opportunity arises he or she will be well prepared. In spine surgery, based on patient referral patterns and the specialization of each individual center, a stepwise progression is not always possible. If the general surgical skill set is mastered, however, it can often be applied over a wide range of clinical surgical procedures.

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