Education and Knowledge-Base Acquisition and Retention

Published on 27/03/2015 by admin

Last modified 22/04/2025

Print this page

This article have been viewed 1263 times

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.

In spine surgery, as in most other training environments, the skills learned during residency form a foundation for more complex skills. This may have significant implications for learning in subspecialty fellowship training. An inadequate foundation established early in one’s career can become quite difficult to rectify.

Teaching–Learning Plan

The development of an effective teaching–learning plan requires commitment on the part of both the teacher and the learner. Three main components that rely heavily on each other should be evaluated in the development of such a plan: (1) objectives or goals for teaching, (2) teaching methods, and (3) evaluation strategy for determining if the goals for teaching have been met. Development of such a plan should be a mandatory endeavor for any organized teaching program so that both the teachers and trainees have a clear set of goals and objectives by which the learning process can be measured.

Establishing Objectives

Establishing objectives provides a strategic plan in which effective learning can occur. As mentioned earlier, learning can only be evaluated indirectly by secondary objective measures and learning outcomes. The learning plan should establish specific learning outcomes to be achieved as well as the conditions in which they should be achieved (e.g., how well a task should be performed, in what time frame the goals should be achieved).

Objectives should be outlined for all three of the aforementioned learning domains: cognitive, affective, and psychomotor. Cognitive objectives call for mastery of information and are the easiest to specify. These include such things as the study and passage of the written board examination, reading objectives, and other core knowledge curriculum objectives set forth by an individual department. A time frame for the mastery of these objectives is usually specified, and many institutions require yearly reassessment in the form of in-service examinations or practice board examinations.

Affective objectives are clearly the most difficult to specify. These include attitudes and professional behavior that can be quite difficult to observe and measure. These objectives usually include stipulations about professionalism (e.g., attendance, punctuality, and appearance) and attitude toward patients (e.g., understanding of dynamics of illness behavior, respect, empathy). These are now being tested at the medical school level with the use of standardized patient interviews and a number of observed clinical encounters. This, however, only partially mirrors reality for the students and examiners alike. For surgical training programs, these objectives are generally required to be met at all times. If a trainee is falling short, this generally becomes apparent to the program director via feedback from patients or other departmental staff, and the trainee can be remediated immediately. These behaviors are multifactorial and are established early in life and can be quite difficult to teach or change. The expectations in this category are also molded significantly by the life experiences of the teacher (e.g., if the attending physician has poor patient interactions, it is difficult to train the resident in different behavior). This factor is difficult to determine by an interview, but should certainly be taken into account at the time of hiring of clinical faculty.

Psychomotor (i.e., skill) objectives are easier to specify because observable behavior is the outcome. The means of evaluation are still somewhat subjective though. Similar to the affective objectives, the trainee’s skill in the performance of a procedure can only be measured against the skill of the teacher or that of other trainees, making the evaluation quite variable. In surgical specialties, the proliferation of technology has spurred the emergence of objective clinical skill assessment using virtual reality and computer modeling. Although these technologies have not yet attained universal usage, they are certainly becoming more widespread.

Teaching Strategies

The choice of teaching strategy in any specific situation depends greatly on the skill sets, goals, and objectives of the teachers and trainees as well as qualities specific to the learning environment (e.g., number of teachers and students, time). Different strategies are often combined to provide a complete learning program over the various learning domains. We will examine each domain separately, but it is important to remember that these strategies often combine to span several domains.

Cognitive learning involves mastery of a body of information, mostly factual, and contributes most prominently to the overall knowledge base of the individual. Affective and psychomotor learning often stem from this knowledge base. Strategies for cognitive learning may be split into two groups: learner-based and teacher-based methods. Learner-based strategies include self-directed learning and one-on-one tutorials. Self-directed learning is a technique used widely in surgical training programs and is primarily based on reading. This method of learning is an effective and efficient way of learning factual information, but has the disadvantage of being largely passive and highly dependent on the motivation of the individual learner. This may result in lower retention of content than in other types of learning. The surgical training program generally has a fairly good plan for self-directed learning in which the body of knowledge (supplied by a board), sources of information, and methods of assessment (board or in-service examination) are well defined. Generally, this method of learning can be facilitated by the utilization of a faculty mentor who guides the acquisition of information, answers questions, and ensures that the conclusions drawn are correct.

The one-on-one tutorial is the classic method for clinical teaching and is a bit of a hybrid between learner-based and teacher-based strategies. Its advantages include an individualized, learner-centered, active learning environment with immediate feedback. This method occurs within a well-defined mentor–student relationship and therefore depends on the rapport between the student and teacher as well as on the availability of both parties to participate in teaching sessions. This method becomes much more prominent in clinical medicine with advanced training levels as the teacher–student ratio becomes smaller and the majority of the knowledge base has already been acquired. This gives a final arena in which the knowledge base can be assessed, critiqued, and modified by the mentor. Subspecialty fellowship training is largely based on this principle, in which the trainee experiences one-on-one training from the leaders in his or her field.

Teacher-based strategies for cognitive learning include lectures and discussion groups. The advantage of these methods is that a larger group of trainees can be efficiently taught information from a teacher who may have accumulated expertise in an area not shared by the majority of physicians. The teacher is responsible for assessing the learners’ needs and most effective means of learning. These types of learning methods often place a higher degree of responsibility on the teacher regarding preparation of discussion materials, lectures, and audiovisual aids. Preparation for lectures should account for the average attention span of about 20 minutes. Active learning, in the form of questions and discussion, may be used to maintain interest in the topic. Lectures have the advantage of repetition of core concepts, which can then be elaborated on in smaller discussion groups. Evaluation and analysis are vitally important in these learning methods since the groups tend to be larger and the deficiencies of the individual may be missed. Questions from the audience should provide some information on content that may not be well understood and suggest areas for future improvement. When used in combination, lectures and smaller discussion groups can be highly effective as material is repeated several times, often by several different teachers.

In residency training, didactic lectures often take the form of grand rounds or invited guest speaker lectures. These allow trainees who may be used to the preferences and methods of care of their own mentors to gain further perspective on alternative methods practiced by others. Discussion groups give trainees the opportunity to review cases with staff and ask any relevant questions. They may also generate some discussion and new ideas for ways the plan of care could be altered in the future. It is not often practiced, but it may be useful to incorporate a small group discussion at the end of the clinic day or to review operative cases at the end of the week.

It is clear that a relationship exists between the quality of teaching and student performance.⁷ Residents who rated their attending surgeons as better teachers scored higher on national boards than those who did not think as highly of the quality of teaching. It is also clear that not all surgeons excel in teaching or have expertise in many different areas. These facts should encourage arrangements in which residents and fellows have higher exposure to more effective educators.⁴

Affective learning is one of the most difficult domains for developing effective teaching strategies. Attitudes are not taught; they must be experienced. The trainee generally emulates the behavior, attitudes, appearance, and general approach to medical care of the mentor. Some teaching can occur through videotape review and peer discussion groups, but if a good foundation of clinical medicine and patient care has not been established by the teaching staff at an institution, these methods are generally ineffective at changing behavior. This domain must be considered when hiring teaching faculty.

Psychomotor skills are learned by several methods. Observation is the primary learning tool because residents and fellows often learn procedures first by observing the performance of more experienced faculty and residents. For less common procedures, videotape review may be useful. With the precision and fine motor skills required in spine surgery, observation rarely translates into performance. In this area, there is a fine balance between the trainee’s observation and supervision of the trainee performing a task by the teacher. Residents, in general, are always looking for increased levels of autonomy and the ability to perform procedures on their own, but this must be balanced with the attending surgeon’s clear recognition that the trainee has mastered the required skills. There is clearly an intangible aspect to psychomotor learning with autonomy, and this probably largely has to do with confidence. Unfortunately, if an early foundation of surgical skills is not obtained by the resident, these skills can be very difficult to train or relearn. Models have the advantage of allowing residents and fellows to practice particular tasks without affecting patient care, but are invariably “nonhuman” and give an experience that does not quite measure up to reality.

One of the most exciting developments on the frontier for surgical skills training is virtual reality. This technology has been primarily used thus far in minimally invasive general surgical procedures. One randomized, double-blinded study of surgical residents performing a laparoscopic cholecystectomy found that residents trained on a virtual reality system were 29% faster and six times less likely to make a mistake than their conventionally trained counterparts.⁸ In neurosurgical care, these technologies have been employed in surgical planning as well as the performance of ventriculostomy and endoscopic intracranial surgery. These systems allow trainees to practice tasks in a virtual reality environment and compare their performance with that of their mentors. With the expansion of haptic (tactile) feedback technology, these simulators may indeed become more prevalent in neurosurgical training and integrated into residency and fellowship for spine care.⁹^–¹¹

Evaluation

There must be a means of evaluating the effectiveness of the teaching–learning process and make adjustments where necessary. This evaluation should be efficient and occur often. The trainee should get a concise assessment of his or her performance as well as the opportunity to evaluate the training program and communicate if his or her learning needs are not being met. This is essential even in established teaching environments because the needs may change with any individual group of trainees. The NASS guidelines have set forth a method for this evaluation.² It is also essential for a specific set of goals or benchmarks for each level of training to be well known to both the surgical trainee and teacher prior to the initiation of the program. If the goals are not clearly defined, then the resident and training program cannot be assessed by any reliable means.

Cognitive Skills

Cognitive skills are by far the easiest skill set to evaluate. Most commonly, this evaluation comes in the form of written examinations. In medical school training, the U.S. Medical Licensing Examination (USMLE) board examinations consist of three “steps” that evaluate different levels of training. In neurosurgical training, the American Board of Neurological Surgery (ABNS) mandates that a written board examination that evaluates cognitive learning be taken during residency and an oral board examination that aims to assess cognitive, affective, and psychomotor learning together be taken after the completion of residency. These tests often use true-false and multiple-choice questions to assess a certain area of knowledge. Reliability is increased with larger numbers of test questions per topic and larger numbers of possible answers.¹² Other testing methods using short-answer and essay questions are also useful, but are quite subjective in scoring and are somewhat cumbersome for the graders. The longer format for answering can be both an advantage and a disadvantage in that it allows the students to express a large volume of their knowledge in one question but may discriminate against students with large volumes of knowledge on the topic but poor verbal skills. These types of questions, if designed well, can also test synthesis of information and judgment. Oral examinations are also used to test cognitive skills, but these are somewhat difficult to standardize. Oral testing allows the flexibility to probe deeper into areas where the examiner notices deficiency; however, by nature this method eliminates a standardized experience and reproducibility in grading. With careful selection of questions and a clear set of grading standards, these examinations can have score reliability of up to 88%.¹² The most common themes to keep in mind with the evaluation of cognitive skills are validity, reliability, and standardization.

Attitudes and Skills

Evaluating attitudes and skills is clearly more difficult than evaluating cognitive learning. In spine surgery, the group of trainees at any institution is often small enough that attitudes and behaviors are regularly evaluated by the staff and communicated to the resident. Formal attempts at evaluation of these affective skills are not generally made. The USMLE has now made an attempt to evaluate these skills during medical school by requiring all U.S. medical graduates to pass the USMLE Step II: Clinical skills portion, which tests verbal communication and clinical examination skills. This, however, falls quite short of actually predicting which students will excel in these affective clinical skills in their career. By reviewing cases, the ABNS also makes an attempt to evaluate these skills, but often these are not as much the focus of the examination as the trainee’s clinical judgment and management. From the residency, goals for professionalism such as appearance, attendance, and punctuality are easy to establish. The use of patient surveys to evaluate patient interactions with residents is not common but can be a very insightful method for evaluating residents’ competence to communicate with patients. Patient complaints should always be evaluated and discussed with both patient and resident.

As mentioned previously, the objective and effective assessment of operative skills is difficult. Some suggest that this assessment is easier in the surgical skills laboratory than in the operating room.¹³ This alternative approach, however, tends to be a rather unrealistic, so true skills are still difficult to assess. The expansion of virtual-reality technology will undoubtedly change the evaluation of these skills in the future. Where skills were once assessed by comparing them with those of individual teachers at an institution, virtual-reality technology and telemedicine will allow trainees to compare their skills with those of the world’s experts.

Objective structured clinical examinations (OSCEs) have been used since the 1970s in medical schools,¹⁴ and have gained some limited use in residency training. In these examinations, clinical skills can be broken down into individual components that can then be evaluated by independent observers. Reliability in these tests appears to be at least 80%. These examinations have been modified to objective structured assessment of technical skills (OSATs).¹⁵ These tests use bench models of surgical tissues to evaluate performance. Still these methods fall quite short of reality and do not capture the intangible aspect of operating on real patients. They may also provoke an element of anxiety by being observed, which further deviates from reality. These tests are also costly and difficult to create and administer.

Finally, trainees are ultimately evaluated based on the body of work they have amassed by the conclusion of their training. This is the theory behind the submission of cases to the ABNS prior to taking oral boards. There is no better evaluation tool than true results with patient care. Unfortunately, these methods of assessment require the student to function in the community, participating in patient care and performing procedures, but also possibly causing morbidity prior to the evaluation. This is unacceptable to some, but truly, no better assessment tool is available.