Teaching residents the knowledge, skills, and ethical values of orthopaedic
surgery is critical to our profession. Currently, the standards for
orthopaedic residency training are set by the Orthopaedic Residency Review
Committee (RRC) of the Accreditation Council for Graduate Medical Education
and the American Board of Orthopaedic Surgery. However, the means by which
those standards are to be achieved is largely left up to individual residency
programs. This article considers how we might improve the quality and
effectiveness of orthopaedic education if we apply to residency programs the
core principles of adult education. These core principles form the central
theme of the American Academy of Orthopaedic Surgeons (AAOS) Course for
Orthopaedic Educators, the first course among all medical specialties to be
devoted entirely to education and the longest-running continuing medical
education course offered by the AAOS. This article reviews the critical
elements involved in educating orthopaedic residents, applying the core
educational principles established by the Course for Orthopaedic Educators. We
suggest that if orthopaedic educators understand the educational process and
the principles that underlie it, they will be able to improve the quality and
effectiveness of residency education and thus ultimately improve the
profession. This article presents eight core principles of adult education and
outlines how they can be applied by orthopaedic educators—both by
program planners and by physician-teachers.
Core Principle 1: What Students Learn Is More Important Than What Is
Taught
The first and most important principle of adult education is that what
students learn is more important than what is
taught4,5.
This first principle governs the seven that follow because all ask us as
educators to look at learning, not at teaching, and at what students
understand rather than what we think we have imparted. Imagine spending time
teaching a resident only to realize later that the crucial information or
skill set was not actually learned. There are many reasons why this
could—and often does—happen: perhaps the resident did not really
understand what was being taught, or maybe he or she understood but soon
forgot. If orthopaedic education is to be effective, we must think in terms of
what the residents are actually learning, not just what we are trying to
teach. By focusing on the end effect—on what is actually
learned—educators can take steps to identify program deficits and
ultimately improve resident learning. The seven core principles that remain
all represent ways of ensuring that true learning takes place. As such, all
seven relate back to the first: what students learn is more important than
what is taught.
Core Principle 2: Program Planning Is Critical to Effective Teaching
and Learning
This principle challenges orthopaedic educators to review all of the
elements of the program that influence a resident's
learning6. Because
program planning is critical to effective teaching and learning, orthopaedic
educators must attempt to arrange the elements in a manner that optimizes
learning. Asking questions such as: "What type of clinical experiences
are the residents having?", "Who are their role models?",
"How effective are their formal teaching sessions?", and
"How are they being evaluated?" will help educators to focus on
the whole residency program, not just one or two elements of that program.
Failure to do so risks putting residents in an environment that undermines
their learning.
Core Principle 3: Residents Learn from a Hidden Curriculum
As we plan programs, we should be aware that the curriculum exists at two
levels: the overt curriculum that we deliver deliberately and the hidden
curriculum that we deliver unawares. The hidden curriculum has been defined as
"the indelible message, often non-verbal, that a person takes from an
event or an
experience."7
Why do we use the term hidden? We mean that this aspect of the
curriculum is actually hidden from teachers, who may not be aware of the
values that they model in day-to-day activities. Students, we must be aware,
learn as much from what we do as from what we say. In terms of medical
education, then, we must grasp that residents learn values and ethical
reasoning by watching how we behave toward colleagues and patients and by
observing how we deal with challenging
situations8-11.
They also learn from the entire milieu in which they (and we) work. They learn
from how the faculty treat the patients and interact with each
other—they learn, in short, from the whole interpersonal and
professional environment. They may also learn things we did not intend to
teach them, such as habits that long ago became invisible to us but remain
obvious to others. Role modeling is a powerful mode of teaching, and the
hidden curriculum is a powerful mode of learning; indeed, the importance of
this hidden curriculum is now recognized in medical education
literature10,12,13.
Effective medical educators must take into account the fact that students
learn from them as role models, and therefore they should try to model as well
as to teach the highest ethical values of the profession.
Core Principle 4: Learning Is Driven by the Resident's Perception of
How He or She Will Be Evaluated
Resourceful students figure out how they are being evaluated and then focus
on learning and doing the things that they think will lead to a positive
evaluation14,15.
When used correctly, evaluation provides a powerful tool to drive a resident's
learning. This principle challenges program planners to establish key learning
objectives and then to link them firmly to evaluation. By organizing residency
programs so that residents are motivated to act in certain ways and embrace
certain values, we can dramatically improve resident learning.
Applying Principles 1 Through 4 to Program Planning
These four principles can be used to plan orthopaedic training programs
more effectively. Orthopaedic training is delivered through both informal and
formal programs: residency programs, individual service rotations, and grand
rounds are examples of programs designed to foster learning. The level of
planning in such educational programs varies. Many programs are structured
intuitively—and often quite successfully so. However, educators should
be aware that the way in which a program is organized has a direct bearing on
how successful it is at fostering desired learning outcomes. Good program
planning, therefore, is based on the first four principles. Such planning
involves assessing the program in terms of what the students need to learn (in
educational terminology, this is called a needs assessment), setting
clear learning objectives based on these needs, using these objectives to
guide opportunities for learning (remembering both the overt and the hidden
curriculum), and linking these objectives to effective evaluation techniques.
While a variety of program planning methods have been outlined, most include
four key planning
steps6: (1) conduct
a needs assessment, (2) set learning objectives, (3) provide opportunities for
learning, and (4) design appropriate evaluations.
For example, these planning steps can be applied to a residency rotation.
Most residency programs offer residents a series of rotations, often divided
by subspecialty. These rotations can be analyzed, and often improved, by
performing a formal program assessment
(Table II).
1. Conduct a Needs Assessment
Performing a needs assessment does not have to be a complicated matter. An
orthopaedic surgeon who is responsible for coordinating a three-month rotation
for second-year residents on the arthroplasty service, for example, might ask
the following questions: Who are the learners on this rotation? What is their
background knowledge? What are they to learn on this rotation?
Possible answers to these questions might seem obvious: the surgeon is
training a group of second-year orthopaedic residents who need to learn how to
perform primary hip and knee arthroplasty. On closer examination, however, it
is clear that the second question can lead to important insights for program
planning. For example, not all second-year residents have equivalent
background and experience. Those taking the rotation early in the academic
year are likely to be substantially less experienced than residents assigned
to the service toward the end of the second year. In other words, while there
may be a certain core content that all residents on the arthroplasty rotation
should be expected to master, not all second-year residents start with the
same level of knowledge and skill. A needs assessment will bring these issues
to light.
2. Set Learning Objectives
Setting learning objectives is a key educational practice that leads to
good learning. What is meant by learning objectives? These are the intended
learning outcomes of any educational program. In the case of orthopaedic
surgery rotations, learning objectives should be rotation-specific as the RRC
assesses an orthopaedic program by looking at the objectives that have been
established for each rotation. Such objectives should, in turn, guide
instructional methods and drive the evaluation process.
In many residency programs, learning objectives are implied or unstated.
Learning can—and indeed often does—occur without explicit
objectives. However, educational programs are more effective if learners know
the objectives before the start of the
program16. For this
reason, rotation-specific objectives should be discussed with residents at the
start of every rotation. These objectives should be presented in a concise,
well-written document that outlines the core knowledge and skills to be
learned. Most importantly, these learning objectives must specify the
knowledge, skills, and ethical values that will form the basis of the
resident's evaluation. This is an example of the fourth principle in action:
residents will quickly determine what they should master in order to receive a
good evaluation.
3. Provide Opportunities for Learning
The heart of program planning lies in providing opportunities for learning.
In a residency rotation, opportunities for learning may include spending time
in the clinic or the operating room, teaching in morning rounds, doing
assigned reading, or participating in a variety of other activities designed
to foster learning. However, residents also learn from the hidden
curriculum—that is, they learn as much from what their teaching
physicians do as from what they
say8-10.
Residents also learn from their working milieu about the ethics and
interpersonal dynamics of the profession. Taking the time to examine the
opportunities for learning—including direct and indirect
teaching—in a residency rotation is a key step in improving resident
learning.
4. Design Appropriate Evaluations
Designing appropriate evaluations is the final element of effective program
planning. Here we refer to two forms of evaluation: the assessment of
residents and the assessment of the program by the residents themselves. These
evaluations are critical for two reasons. The first reason, as outlined in the
fourth principle, is that students quickly figure out how they will be
evaluated and focus their efforts accordingly. The second reason is that
residency programs are themselves evaluated in turn. An educational program
that is not organized to promote ongoing improvement through systematic
evaluation by learners runs the risk of becoming outdated and ineffective.
Experts in the field of adult education divide evaluation into two
categories: formative and summative evaluation. Formative evaluation provides
information (usually in the form of feedback) for the purpose of making
improvements, and it is most effective when it is given in advance of, and
separately from, a final assessment. Summative evaluation is the final
assessment or judgment of a learner. Often the most important component of a
summative evaluation is not what happens in a formal evaluation process, such
as a test or examination (or in the case of a residency program, the
resident's final evaluation form), but rather the informal gathering of
information along the way. For example, residents may not be very concerned
about what is written on their evaluation form, but they probably care deeply
about whether their orthopaedic educator will give them a strong
recommendation when they are trying to secure a fellowship or find a job.
Often the best way to improve resident learning is to improve the way
residents are evaluated by effectively deploying both formative and summative
evaluation techniques.
A. Use Formative Evaluation Techniques
In a prolonged program such as a residency, educators should make regular
formative evaluations that should be discussed with the resident. Residents
need feedback if they are to identify and address deficiencies in skills,
knowledge, or ethics. In order for residents to improve, such deficiencies
must be brought to their attention quickly, clearly, and constructively.
However, many of us avoid giving feedback on such deficiencies because we find
giving negative feedback extremely difficult. A tool that can help with
delivering such formative evaluations is Pendleton's rules for providing
feedback (Table
III)17.
Applying Pendleton's rules to formative residency evaluations would suggest
that we start by having residents themselves assess "What went
well?" and "What could have been done differently?" in a
rotation or learning event. This approach works well for three reasons. First,
it starts with the positive—what has gone well. Second, it gives the
resident the opportunity to identify what could have been done differently.
Finally, it uses the expression different rather than the negative
term wrong. Very often the resident has the same concerns about his
or her skill and knowledge that the orthopaedic educator has. Pendleton's
rules provide a useful framework for giving both constructive and critical
feedback. This tool can be used during mid-rotation evaluations or at any
point when a resident needs to receive feedback. However, whether or not
Pendleton's rules are used, residents must receive a midrotation (formative)
evaluation that allows them to identify and address deficiencies before the
summative evaluation.
B. Use Summative Evaluation Techniques
Summative or final evaluations are also important and can be generated in
many ways. To be effective, however, the evaluations must mirror
rotation-specific objectives and must accurately assess the resident's
knowledge, skills, and behaviors. To make an effective summative evaluation,
supervising physicians should try to get feedback from multiple sources (such
as nurses, allied health-care personnel, and other physicians), especially
when assessing such things as interpersonal
skills18-20.
While it is natural to use one's experience with residents to form an opinion
of their abilities, it is important that this subjective (and thus possibly
biased) opinion should not form the sole means of evaluation.
C. Evaluate the Program
Finally, the residents' evaluations of their training program are critical
for program development. Residents are usually in the best position to comment
on the quality, efficiency, and effectiveness of the educational program that
they have experienced. For this reason, the RRC looks closely at the mechanism
by which residency programs get feedback from their residents. Regular
evaluation of the strengths and weaknesses of a rotation by residents should
be considered by anyone who is involved in teaching orthopaedic residents at
the rotation level. This type of feedback, when acted upon, allows the
educational component of the rotation to be improved over time.
Whereas the first set of principles relates to promoting learning more
broadly through program planning, the next set of principles (5 through 8)
promotes effective learning in interactions between the resident and the
physician-teacher.
Core Principle 5: Educators Should Foster Active Rather Than Passive
Learning
Learning is more intense and more permanent when the learner's mind is
actively engaged. Experiences that actively engage the learner in the process
typically lead to deeper and more sustained learning. This means that teaching
is more effective when it actively involves the learner either physically or
mentally21-23.
The physician-teacher can accomplish this by asking probing questions at an
appropriate level, actively involving residents in surgery, and/or encouraging
residents to write summary notes or draw diagrams while studying. In summary,
active learning means engaging residents with authentic questions and tasks
appropriate to their level of knowledge and ability.
Core Principle 6: Teaching Should Engage Residents at a Level
Appropriate to Their Knowledge and Ability
Teaching that focuses on knowledge and skills that the resident already
knows is not helpful. Similarly, teaching that is directed well beyond the
comprehension of the learner also limits a resident's learning. To be
effective, teaching should engage residents at a level appropriate to their
knowledge and
ability24-26.
In other words, teaching must be focused at the resident's zone of
development—that is, right at the point where the learner is
beginning to have knowledge gaps or misconceptions. In medical education, this
means that residents learn best when the physician-teacher takes account of
their level of prior knowledge and skills. These can vary widely among
residents, and they are not necessarily related to the resident's year in
training. To foster the acquisition of new knowledge and skills, the
physician-teacher must identify what a particular resident already knows and
can do. A first step in any learning encounter, then, should be to identify
the resident's zone of development. To do this in an efficient manner, an
orthopaedic educator must ask probing but nonthreatening questions to
determine the limits of the resident's knowledge. Teaching should then be
directed to the zone between what the resident already does safely and
competently without supervision and what the resident can do only with
guidance.
Core Principle 7: Avoid Cognitive Overload of Residents
Most individuals have a short-term memory that is limited to seven (plus or
minus two) discrete bits of unrelated
information27. This
means that teachers should avoid cognitive overload of residents as they are
unlikely to retain a large number of isolated, newly acquired
facts28,29.
However, if facts are organized into a logical framework, they are much easier
to learn and retain. As an example, information that is organized according to
specific disease processes, classic clinical presentations, or treatment
regimens for certain conditions is more likely to be retained than if such
information comes in a piecemeal fashion. An orthopaedic educator can make
learning more efficient by suggesting a framework for a certain aspect of
medical information or by questioning residents to see if they have already
developed effective frameworks for understanding and organizing such
information.
Core Principle 8: A Threatened Self-Concept Diminishes Learning
Educational research has shown that emotions and cognition are interactive.
Excessive anxiety decreases our ability to process
information30,31.
As a result, a negative learning environment, however it is created, limits a
student's ability to process, synthesize, and retain information. Learning
requires a receptive mind; negative emotions interfere with our cognitive
functioning. Therefore, a threatened self-concept diminishes learning. In
terms of medical education, this means that high expectations should be
accompanied by a positive learning environment and support until residents
have gained a measure of mastery over the new material. Positive assessments
should never be seen as the result of favoritism or of effort alone in the
absence of actual achievement. The corollary is that negative assessments
should not be seen as unfounded or lacking in constructive advice. Residents
may forget what we said, but they will never forget how we made them feel.
Applying Principles 5 Through 8 to the Teaching of Residents
These core principles can be applied as a framework for the effective
teaching of residents. These four principles go back to the first and
overarching principle: the measure of teaching effectiveness is what was
actually learned rather than what was taught. This section illustrates how
these principles can guide orthopaedic educators across the variety of
settings in which they teach residents: (1) in the clinic, (2) in the
operating room, and (3) in large and small groups, as in grand rounds, core
curriculum lectures, or regularly scheduled teaching rounds.
1. Teaching in the Clinic
For many orthopaedic surgeons, seeing patients in the clinic is a busy
time, often with few free moments for the formal teaching of residents.
However, this setting is one of the primary places where residents learn. The
ability to assess a patient, develop a diagnosis, and outline an appropriate
treatment plan lies at the heart of our specialty. In addition, the clinic is
the main location where the doctor-patient relationship is established and
developed. Therefore, orthopaedic educators must look for strategies to take
advantage of the teaching opportunities in the clinic setting, and ideally
they should strive to integrate teaching seamlessly into clinical activities.
An efficient approach to teaching in the clinic is essential. We therefore
divide clinic time into a beginning, middle, and end to consider which
teaching strategies to apply before, during, and at the end of the clinic time
in order to maximize the learning experience.
Meeting the resident before seeing patients in the clinic to review the day
is the first step to successful teaching in this setting. The physician should
assess the resident's experience with the type of patients who are going to be
seen and elicit the resident's goals for learning in the clinic. In light of
this information, the physician should briefly review the learning
opportunities that the resident is likely to encounter in the clinic as well
as set realistic learning goals.
During clinical encounters, it is important to promote active participation
by the resident. This can be done with use of a technique such as the
One-Minute Preceptor (Table
IV)32-34.
The One-Minute Preceptor involves five steps, done in two sessions. The first
session (the first two steps) takes place outside the examining room after the
resident has seen the patient but before the attending surgeon has reviewed
the patient. The first step is to get a commitment from the resident regarding
a diagnosis. The second step is to probe for supporting evidence that has
allowed the resident to come to this diagnosis. This step helps the
orthopaedic educator to identify the resident's zone of development—what
is known and understood and what is not.
The second session (the final three steps) takes place after the teaching
surgeon has examined the patient and established the diagnosis. This session
can occur in front of the patient (if done diplomatically) or can occur
outside the examining room. The third step is to teach general concepts
illustrated by the case of the patient. The fourth step is to reinforce what
the resident has done correctly, while the final step is to correct any
mistakes the resident has made. The One-Minute Preceptor is congruent with the
fourth through the eighth principles and formalizes what many successful
orthopaedic educators already do. This tool takes very little time, fosters
active learning, helps to identify the resident's zone of development, and
forces the resident to be active rather than passive during clinical
encounters.
Finally, at the end of the time in the clinic, the surgeon should try to
cement some of the learning experiences that occurred during that time. One
way to do this is to spend a few minutes identifying and reviewing the lessons
learned from the clinic experience.
2. Teaching in the Operating Room
Acquiring competence in surgical technique represents a core objective of
orthopaedic residency training. However, patient safety must always be
paramount, and operating time is expensive. Teaching a resident to operate
safely without jeopardizing patient care and wasting operating time can be a
challenge. However, it can be achieved by adhering to a few basic principles.
These include teaching basic skills outside the operating room, clarifying
learning objectives and expectations before each operation, dividing the
operation into component parts and deciding in advance which parts the
resident will do, reviewing the results of each operation with the resident to
identify lessons learned, and remembering the hidden curriculum—that
what we model is as important as what we teach formally.
A. Teach Basic Skills Outside the Operating Room
The first recommendation for teaching surgery is to teach basic skills
outside the operating room whenever possible. There is convincing evidence
that controlled practice improves surgical performance of basic
skills15,35,36.
However, despite an increasing use of surgical-skills laboratories and
improvements in surgical training devices, many residency programs do not have
a formal approach to teaching outside the operating room. There is a limit to
what can be taught in a surgical-skills laboratory. However, skills such as
suturing, applying uncomplicated hardware, and basic arthroscopy techniques
can be learned effectively in the laboratory setting. Furthermore, the limits
to what can be learned outside the operating room will continue to expand as
more advanced surgical simulators are developed.
B. Clarify Learning Objectives and Expectations Before Each
Operation
The second recommendation is to clarify learning objectives with the
resident before each operation. This can be done at the scrub sink before an
operation although it is perhaps more effective if it is carried out formally
in preoperative rounds. It is essential to ensure that the resident knows what
the operation is, why it is being performed, and the various steps of the
procedure. This is a concrete example of the sixth principle—determining
the resident's zone of development with respect to the operation in
question.
C. Divide the Operation into Component Parts and Decide in Advance
Which Parts the Resident Will Do
Before surgery, the teaching surgeon should establish which parts of the
operation the resident will do. All but the most basic operative procedures
require multiple steps, and some of these steps, or modules, are more
difficult than others. To ensure that residents are not working beyond their
comfort zones or zone of development, it is helpful to divide the operation
into modules and assess the resident's level of involvement for each section
of the operation. The type of operation as well as the background and skill of
the resident are factors that should determine the resident's involvement in
each step. By identifying the various steps, the orthopaedic educator will be
in a better position to determine whether the resident should be observing,
operating with major assistance, operating with minimal assistance, or
operating independently.
D. Review the Results of Each Operation with the Resident to Identify
Lessons Learned
The fourth recommendation for teaching surgical skills is to take time to
review the lessons learned from each operation. This can be done after each
operation or at the end of the day. There is always something that can be
learned from each operation. Without ongoing reflection, the resident may not
learn key points or may acquire a misconception.
E. Remember the Hidden Curriculum
A final point to bear in mind is that much of what a resident learns in the
operating room does not occur by means of direct teaching but rather by role
modeling. What we do is as important—perhaps even more
important—than what we teach formally. The hidden curriculum plays a
major role in how we learn to be
surgeons37.
Consider, for example, an attending physician's interaction with the surgical
support staff. Residents often base their own behaviors on how their educators
interact with other operating-room personnel. Therefore, it is critical that
physician-educators attend to what they are teaching unintentionally through
their own behavior or role modeling.
3. Teaching in Groups: The Art of Asking Questions
Formal teaching in a residency program occurs during grand rounds, core
curriculum lectures, or scheduled teaching rounds. It is these types of
structured sessions that many medical educators associate with teaching
residents. As we have seen, these sessions are in fact only one component of
such teaching, but they remain a key component and one that we can improve by
applying the core principles of adult education.
Formal teaching can be divided into large-group and small-group teaching
sessions. Large-group teaching typically occurs through formal lectures. Good
lectures are characterized by content that is clearly presented, meaningfully
organized, and delivered in manageable chunks—all of which should be
defined from the learner's point of view. In an effort to counteract the
inherently passive nature of large-group lectures, presenters should try to
make their lectures interactive. Interspersing questions, encouraging audience
participation, and using an audience response system are all strategies for
keeping the audience engaged in the presentation.
In contrast, small-group teaching is characterized by direct interaction
between the orthopaedic educator and the learner. This often takes the form of
asking challenging but nonthreatening questions. Asking questions in a small
group setting serves two purposes. It can "diagnose the
learner"—that is, it can help to identify a resident's knowledge
gaps and misconceptions. It can also stimulate critical thinking by
challenging residents to move beyond what they currently know and understand.
When it is done well, questioning ensures that residents are actively engaged
in the learning session.
Both small and large-group teaching rely on good questions to be effective.
But what is a good question? A good question has three components. First, the
question should relate to key concepts that are central to the understanding
of the subject. Second, the question should have a specific purpose. This may
include identifying relevant knowledge gaps and misconceptions—in other
words, finding the resident's zone of development. Third, a good question
should demand critical thinking. Questions that ask how or why typically
demand more critical thinking than questions that demand only a recall of
facts. It is entirely appropriate to set clear expectations that require
preparation by residents. Indeed, knowing that one will be on the spot is a
strong motivating force. However, deliberate attempts to intimidate or
embarrass should be avoided, as they tend to interfere with information
processing and diminish learners' confidence.