PRESIDENT'S CORNER
HARRITH M. HASSON, MD, HILLIARD JASON, MD, EdD
INFORMATION RETENTION
Recent brain research [1,2] and expanded research on the learning process [3,4] have substantially increased our understandings of how to improve any teaching we do.
Short-term human memory is seriously limited. A widely accepted generalization, based on a classic study [5], is that short-term memory is limited to 7±2 discrete items and is subject to rapid degradation unless promptly reinforced. Under the right conditions, however, long-term memory can be fairly reliable. Moving information from short-term to long-term memory requires multiple repetitive acts of reinforcement. Several factors can enhance information retention:
1. A positive emotional context exists when information is first learned.
2. The new information builds on related, prior knowledge. Building on what one already knows is a critical requirement for meaningful learning.
3. Our brains are capable of an impressive, long-lasting visual pattern of recognition, if suitably reinforced, but this is separate from verbal learning.
4. Learners are helped to feel a genuine sense of “ownership” of whatever they need to learn. That is, they see the connection between what they are expected to learn and their personal and career goals (assuming that such a connection exists).
5. Learners are actively engaged in the process of learning. They are encouraged to:
a. raise questions and seek out information, not merely follow instructions.
b. take notes in classes, reflecting on, interpreting, and summarizing what they hear, not merely serving as stenographers.
c. review and reflect further on their notes and related information soon after their initial exposure, preferably within 24 hours.
d. thereafter, engage in repetitive acts of reconsideration, application, and reinforcement of the information they are seeking to learn.
IMPROVING INFORMATION RETENTION AFTER CME MEETINGS
Improving retention of information following a meeting is influenced and modulated by the quality of the learning experience at the meeting. SLS is pioneering an interactive format at the 2007 annual meeting, according to the principles outlined above. This new format will encourage a free exchange of information between presenters and participants, who will be encouraged to find a sense of ownership of the information and ideas being offered. For example, we will include town hall poster sessions and interactive round tables.
Engaging in repetitive acts of reinforcement of the information provided, and self-assessment after the meeting can be carried out using the Internet. Self-assessment, which can be done, in part, with multiple-choice questions, provides some guidance as to how much has been retained [6]. The testing process in itself can be a reinforcer and can boost retention of the information. SLS is planning to offer CME credits to participants in postmeeting Web-based learning programs.
LAPAROSCOPIC SKILL ACQUISITION USING SIMULATION-BASED LEARNING
The skills required to perform laparoscopic surgery include:
• The fundamental ability to operate on a 3D object from a 2D image using visio-spatial translation and perception.
• Psychomotor hand-eye coordination using dominant and nondominant hands separately and together [7].
These abilities are based on inherent Basic Performance Resources (BPRs) that measure innate abilities [8]. BPRs differ among various individuals and represent the operative-performance-limiting factor. With practice, the skills of an individual can improve to the limit of his/her ability (based on available BPRs) but not beyond it. Examples of pertinent BPRs include:
• Visual hand response speed
• Visual information processing speed
• Visual spatial short-term memory capacity
• Arm neuromotor channel capacity.
Fundamental abilities are manifested through basic skills, enabling skills and tasks comprising one or more basic skills to simulate procedures used in laparoscopic surgery. They are the building blocks for achieving technical proficiency in laparoscopic surgery using a simulated environment [9]. Enabling skills and tasks include:
• Camera navigation
• Cannulation or threading
• Clip application
• Cutting
• Suturing and knot tying
• Application of energy sources
There is a difference between acquiring (basically expressing) laparoscopic abilities and acquiring enabling laparoscopic skills. Basic laparoscopic skills reflect innate abilities and generally require only brief instructions and mentoring. However, a more elaborate learning curve is needed to adapt to the peculiarities of the simulator interface. The length of that learning task reflects the abstract adaptive skills of the trainees as well as their technical abilities per se [9]. On the other hand, enabling skills and tasks (especially suturing and knot tying) require detailed instructions and feedback from a mentor, without which proper learning may not be possible regardless of the innate ability of the trainee [10].
IMPROVING LAPAROSCOPIC SKILL ACQUISITION WITH SIMULATION-BASED TRAINING
Laparoscopic skills cannot be adequately learned in 1- or 2-day workshops. However, such workshops can serve to heighten the awareness and interest of participants and can provide them with a good start. However, the acquisition of skills to an expert level requires sustained, deliberate practice over many years [11].
Roger Kneebone [12] studied the subject and made the following pertinent observations and recommendations:
1. An effective skill curriculum is critical to the success of the program.
2. Skills are best taught by a sympathetic mentor who initially provides the student with guidance and feedback, then with contingent instructions as needed and finally fades away when no longer needed.
3. Students need to take ownership of their learning experience and become self-mentors (through reflection and deliberate practice) after receiving the external guidance.
4. Repetitive deliberate practice of a skill moves it into long-term memory where it is embedded, integrated, retained, and easily recalled. In fact, core technical skills, once mastered, become automatically available when called upon.
5. Skills decay over time and need to be reinforced and consolidated with repetitive training with intent to achieve and sustain expert status.
6. Practicing simulated tasks over relatively small segments of time (distributed practice) is more effective than practicing them in one long intensive session (massed practice).
It should also be noted that training should be geared to achieving proficiency criteria without regard to number of training hours [13]. Gifted trainees should be allowed to gravitate upward in the program. Periodic self-assessment using embedded simulation metrics are essential for providing evidence of change in manual skill aptitude with continued training over time [6]. Objective assessment also keeps trainees engaged, challenged, and informed, and may provide them with an incentive to continue working toward reaching higher levels of proficiency.
Simulation-based training can benefit from Internet technology. Virtual-reality simulators can be linked worldwide through the Internet. Computer-based augmented reality simulators can pool their data to a central location for studies of performance and toward establishing nationwide (or worldwide) proficiency standards. Individual centers can share anonymous performance reports for comparative analysis and review [14].
CONCLUSION
New understandings about human learning and skill acquisition provide progressive societies such as SLS with unique opportunities for improving the educational impact of their meetings as well as offering their attendees possibilities for continued learning and assessment after the meeting using the Internet and simulation centers.
Correspondence: Harrith M. Hasson, MD, 6250 Winter Haven Rd, NW,
Albuquerque, NM 87120. Telephone: 505 792 0240, Fax: 505 792 0241,
E-mail: DrHasson@aol.com
Harrith M. Hasson, MD, served as Assistant Professor at Northwestern
University, Associate Professor at Rush University, and Clinical
Professor at University of Chicago. Currently he serves as voluntary
Associate Professor at the University of New Mexico. Dr Hasson holds 52
patents in medical devices and has developed the technique and
instrumentation of open laparoscopy for which he received several
awards. He is President of the Society of Laparoendoscopic Surgeons.
Hilliard Jason, MD, EdD, is Clinical Professor, Family Medicine at the
University of Colorado and former Editor of Education for Health:
Change in Learning and Practice. He has consulted with educational
programs and run workshops for medical teachers in 34 countries and has
been an educational consultant to SLS since its founding. With his
wife, Jane Westberg, PhD, he is co-author of 7 books, many articles,
and more than 50 videos on aspects of teaching in medicine.
References
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2. Kandel ER. In Search of Memory: the Emergence of a New Science of Mind. New York, NY: WW Norton & Co; 2006.
3. Donovan MS, Bransford JD, Pellegrino JW. How People Learn: Bridging Research and Practice. Washington, DC: National Academy Press; 2000.
4. Jason H. The importance—and limits—of best evidence medical education. Educ Health (Abingdon). 2002;13(1):9-13.
5. Miller GA. The magical number seven, plus or minus two: some limits on our capacity for processing information. Psychol Rev. 1956;63:81-97.
6. Nahrwold DL. The competency movement: a report on the activities of the American Board of Medical Specialties. Bull Am Coll Surg. 2000;85:11.
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8. Gettman MT, Kondraske GV, Traxer O, et al. Assessment of basic human performance resources predicts operative performance of laparoscopic surgery. J Am Coll Surg. 2003;197:489-496.
9. Hasson HM. Core competency in laparoscopic surgery. JSLS. 2006;10:16-20.
10. Mahmood T, Darzi A. The learning curve for a colonoscopy simulator in the absence of any feedback: no feedback, no learning. Surg Endosc. 2004;18:1224-1230.
11. Ericsson KA. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med. 2004;79:S70-S81.
12. Kneebone R. Evaluating clinical simulations for learning procedural skills: a theory-based approach. Acad Med. 2005;80:549-553.
13. Gallagher AG, Ritter EM, Champion H, et al. Virtual reality simulation for the operating room: proficiency-based training as a paradigm shift in surgical skills training. Ann Surg. 2005;241:364-372.
14. Hasson HM. New paradigms in surgical education: web-based learning and simulation. Laparoscopy Today. 2004;3:9-11.
www.Laparoscopy.org The Laparoscopic Surgery Information Source
