Larry Benjamin MB BS, FRCS, FRCOphth, DO
It almost goes without saying that proper training is essential for producing good doctors. But how do those doing the training learn that particular craft?
Speaking at the 23rd Winter Meeting of the ESCRS in Marrakech, Morocco, Larry Benjamin MB BS, FRCS, FRCOphth, DO, Consultant Ophthalmologist at Stoke Mandeville Hospital, Buckinghamshire, UK, described an older form of training: “We used to do the old “see one, do one, teach one” – you’d expect a good surgeon to just watch something and then pick it up and be able to do it themselves.”
This was never appropriate and is no longer good enough. Nowadays, things are more structured, with greater support for teacher and trainee.
There are other reasons why a more structured approach is necessary. A 2004
BMJ article laid out the ways in which training time had decreased in the UK, between the European Working Time Directive and the UK’s own “Calmanisation”, a name given to the reforms brought in by Sir Kenneth Calman in the mid-90s. These meant that a training period for a general surgeon, of roughly 30,000 hours between becoming a senior house officer and getting a consultant post, was reduced to 6,000 hours. How to cram in the best training in that time?
In a study that examined surgeons at various points of their career carrying out a cataract operation and scored them using a task-specific grading process, it was demonstrated that there is a ceiling of experience. For surgeons who had performed fewer than 50 operations, they scored within a certain window. The spread was greatest for surgeons who had performed between 50 and 250 operations. The scores of those who had performed between 250 and 500 and those who had performed more than 500 operations were again significantly different, but above 500 cases there was no significant difference. “This evidence [shows] that people can be seen to improve with numbers as well as with time,” Dr Benjamin said.
As well as the more general banner of “experience”, the UK also has 183 competencies that trainees must achieve by various methods, which requires more work for the trainers. This involves meeting with trainees, discussing past cases and so forth. This means that: “Now we accredit people because they are competent, rather than just because they’ve done five or six years of training,” Dr Benjamin added.
The Royal College of Ophthalmology in the UK runs a three-day course in teacher training (Training the Trainers). This includes sections on adult learning theory, which asks how adults learn, what motivates them. “If you can write aims and objectives about a teaching session it very much structures it in your mind,” Dr Benjamin adds. It also gives the students an overview of the content of the teaching session.
There is also the four-step technique, which breaks down any practical procedure into four stages: Demonstration, Deconstruction, Comprehension and Execution.
Another thing for trainers to consider is constructive feedback. “It’s very useful to learn what you’ve done right and what you might do differently, we don’t call it what we’ve done wrong, we call it what you might do differently in the future, and try and keep it as constructive as possible,” Dr Benjamin said.
There are a variety of teaching techniques that can be employed. The traditional lecture may be a good way of giving out a lot of information to a lot of people, but retention of that information is poor. Small group teaching and brainstorming sessions can be more effective, as well as a technique entitled “Set, dialogue and closure”.
PYRAMID OF LEARNING
“The dialogue is telling them the story and then the closure is summing up,” Dr Benjamin explains. “The Americans call this tell them what you’re going to tell them, tell them, and then tell them what you’ve told them. It’s important to have that kind of structure, so people remember things.”
He cites the pyramid of learning, which at its base has knowledge, then moves upwards through comprehension, application, analysis, judgment and finally evaluation. “You’ve got to know what it is you’re talking about,” explains Dr Benjamin. “You’ve got to understand how to use that knowledge, how do you apply that knowledge and comprehension to say phaco surgery – you know the phaco probe oscillates 40,000 per second and it’s got a fluid sleeve around it to cool it, but how do you apply that in the operating theatre?”
Beyond the Royal College of Ophthalmologists three-day course in Training the Trainers, Dr Benjamin recommends a book by Irish general surgeon Rodney Peyton entitled Teaching and Learning in Medical Practice. Of course, for those who are really determined to improve their own standards of teaching, there is the possibility of a Master’s in Medical Education.
“All these other things make your training for your trainee, a much more rewarding affair,” he concluded.
Larry Benjamin: larry.benjamin@btopenworld.com
