Monkey see, monkey do or monkey do, monkey do?

At the beginning of each academic year, I attempt to reflect on the education we provide our current trainees.  Teaching styles will vary between attending surgeons in the same way that learning styles differ among residents.  In the short time in which I have been in practice, I have struggled a bit with knowing what might be the most effective approach for teaching upper extremity pathology and hand surgery in the operating room.

Surgical technique is a complex melding of coordination, finesse, muscle memory and knowledge of anatomy and pathology.   Residents must first become comfortable with the anatomy and basic surgical skills before tackling more complex pathology.  Fitts and Posner (1967) proposed a three-stage theory of motor skill acquisition.  The first stage is “cognition,” in which the learner begins to understand the task at hand.  The second stage is “integration” during which the resident may begin to comprehend and perform the mechanics of the specific surgical skill.  Finally, “automation,” stage 3, where the task can be performed with efficiency and speed.

With limited time spent on a hand rotation, how do we best guide residents to the “automation” stage while also balancing patient care and surgical efficiency?  Although a successful surgery should be judged primarily on surgical outcome, speed is also a necessary component. But, speed should not be accomplished in exchange of a less meticulous technique.  It is challenging to allow the residents to take a case from “skin-to-skin,” especially a junior resident, as it may double the operative time and affect cases scheduled later that day.

Recently, there has been quite a bit of focus on gaining experience via surgical simulation. Gone are the days in which residents perform unsupervised procedures, of any type, on actual patients.  Residents have the opportunity to hone their techniques in a surgical lab or on a cadaveric specimen prior to engaging in actual surgery. These repetitions may lead to a quicker progression through the “three stages of motor skill acquisition” so the actual surgical experience can be optimized.

As a young surgeon, I often find it challenging to hand over the knife.  First, I chose this profession in part because I love to operate!  Secondly, hand surgery is a delicate art performed through limited exposure in close proximity to very important structures.  Although I agree that hands-on experience in the operating room, i.e. actually operating, is an invaluable part of residency training, I also truly believe there is a role for observation in education.  Many of the mentors that I value from residency did not typically allow the resident to perform the majority of the case.  But, they did not operate in silence either.  I learned an immense amount from watching those surgeons operate and listening to their lessons while they performed their craft.

I have not quite found a comfortable equilibrium between operating myself and allowing the residents to take over the case.  But, I do believe that Dr. William Halsted’s model of graded responsibility, first introduced in 1904, can help guide operating room expectations and involvement. As the residents become more senior, I try to allow them to observe less and operate more.  And as I become more senior, I hope that it becomes easier and more comfortable to hand over the dissection scissors and ensure a high level of patient care from a seat on the other side of the hand table.

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Dr. Fishman is a hand and upper extremity surgeon at Loyola and the Shriners hospital in Chicago, Illinois. Her academic interests include pediatric/congenital upper extremity, brachial plexus and tetraplegia. Away from the hospital, she enjoys running, avidly following Duke basketball and all Boston sports teams.

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  1. Anonymous

    Anxiously waiting for tomorrow thank you for taking on the surgery of my son Zekke. I put my trust in God first and know he will guide you to do the beat job possible.

  2. Matt Tomaino

    Felicity—-very nice post. Outcomes after many hand surgeries have as much to do with with how well done as with what is done. For example— a trapezium can be very precisely removed during a basal joint arthroplasty with little trauma to the thenar muscles or in such a way that pain takes weeks to diminish. Narrating during a procedure is important but it takes a conscientious resident to appreciate the nuances of their attending’ s technical skill– and when the optics are not there it does contribute to some potential for friction because of a gap between our comfort level not holding the knife or doing the dissection, and the resident’s expectation that they should be doing more. During my fellowship my primary mentor never turned over a case—- but I came to appreciate his skill and efficiency. While that was not ideal— and I dare say would not be accepted by today’s fellows—- I became a competent and technically good surgeon because of my attention to his technical and decision making skill. I have seen colleagues give more freedom than I have ever felt comfortable with—but I have also seen some cases where this has impacted on the outcome—- so it’s all about individual comfort level ( not some standard right amount or not). If you truly love operating — and regard it as part of your offering to your patient— it’s normal , in my mind, to have anxiety about sitting on the other side of the table. It’s a lot easier in a shoulder arthroscopy or arthroplasty to assist the resident than it is in trigger finger, paradoxically. Over the course of a 4 year residency or even during a fellowship year, increasing responsibility is surely the objective —- assuming adequate technical skill and interest. Meanwhile, you should regard your discomfort— if you will— as a validation of your professionalism and commitment to your patients

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