Letter to (Fellow) Young Doctors More Kairos with Less Chronos

Sutton, MD Department of Surgery, University of Maryland Medical Center, Baltimore, MD 21201 Invited commentary prepared for the In-Training Sounding Board of Surgical Innovation Word Co

Letter to (Fellow) Young Doctors: More Kairos with Less Chronos

Steven C Cunningham, MD* and Erica R H Sutton, MD

Department of Surgery, University of Maryland Medical Center, Baltimore, MD 21201

Invited commentary prepared for the In-Training Sounding Board of Surgical Innovation

Word Count: ~3670

Key words: surgery residency; 80-hour; chronos; kairos; webcasts; DVD;

teleconference; simulation; communication; technology; MASTRI; surgical curriculum; surgical education

*Correspondence to:

Steven C Cunningham, MD

University of Maryland Medical Center

Department of Surgery

22 South Greene Street, Room S4B11

Baltimore, MD, 21201

Telephone: 410-328-4089

Pager: 410-460-7817

Fax: 410-328-1012

E-mail: scunningham@smail.umaryland.edu

I Introduction

In 1982, the surgeon and writer Richard Selzer wrote his masterful Letters to a Young

Doctor (title inspired by Letters to a Young Poet by the German poet Rilke).1 Selzer’s

Letters, in his own words, “while … entirely lacking in the genius with which Rilke’s Letters were infused, were meant to be pedagogical and comradely – a reaching out to

share.” It is from that vantage point, one of comraderie and collegiality, that we share with our resident surgeon colleagues our views on doing more with less as a resident in 2008

The 80-hour work restriction has presented us residents with the following

dilemma: How in this era to continue to derive the same or improved surgical experience and expertise but with less time to do so? If an average surgery resident in Richard Selzer’s residency in the 1950s spent, say, 100 hours per week in the hospital and today’s resident now spends 80 hours, then the net loss of time in the hospital is >1000 hours or

>40 days per year, or >200 days per five-year clinical residency The logical conclusion

is that efficiency must be a key guiding principle to shape the transition For the

purposes of this commentary, we will define efficiency simply as doing more with less time

Ancient Greek distinguished two words for time: chronos, chronological, linear, quantitative time as measured by clocks and calendars; and kairos: qualitative time, time

in relation to human activity, a moment of indeterminate duration in which something happens.2 Our efficiency goal as residents should be to gain more kairos given limited

chronos In this commentary we review a wide variety of tools, both concrete and

abstract, available to today’s surgical resident to maximize efficiency and effectiveness in

surgical education We suggest that, irrespective of the merits or costs of current

restrictions, residents equipped with an adequate tool box and know-how should be able

to benefit from as much or more kairos than was possible in the pre-80–hour,

chronos-unrestricted era

II Concrete Tools

The dictum “See one, do one, teach one” represents a model of surgical heritage that embodies much that we admire in our profession In six words, it envelopes our roles as apprentice, technician and educator The phrase succinctly implies that the learner is attentive, technically efficient, and adept enough to pass to another a skill newly attained And who, with such surgical giftedness, would feel constrained by 80 hours?

Realistically, we may have to observe a task a dozen or more times to recall its sequence, perform a procedure scores of times to surmount a logarithmic learning curve, and teach

it repetitively to achieve mastery In the context of the 80-hour work restrictions, how can we shore up our ability to reach this goal? Using as a framework the dictum “see one, do one, teach one,” we review several concrete tools that are available for trainees who seek to improve their operative skills using 21st-century technology

“See One”

Recalling the historical picture of the operating theater (Figure 1) we see there at the center of coliseum-style seating a patient, apprentice and master, surrounded by

observers, amateur learners, witnessing at various stages of their training the privileged practice of surgery Although operating theaters are less theatrical in architectural design

today, the modern operating room still may assume an ambiance of the historical

operating theater, when, for instance, a “big case” attracts an entourage of surgical

residents and students to gather about the operating table, and, upon tip-toes and step-ups, observe a master surgeon perform a complex operation In 2008, however, surgery enjoys several new adjunct media through which a new audience may similarly profit

The ability to perform live broadcasts from the operating room liberates the learning audience from tip-toes and step-ups We can be anywhere in the country, indeed

in the world, and witness a live surgical procedure with audio commentary by the

operating surgeon At our institution, for example, where the operating room has come full circle to again resemble a kind of theater – the recording studio – the surgeon may, for educational purposes, be equipped with a microphone, and the overhead surgical lighting with a camera, while a techno-tower captures, records and transmits the

operation to a conference room, which may be in a nearby room – or continent There, residents may observe and interact with those in the operating room The performance of surgery is therefore now widely open for surgical resident observation in a close-up way that, ironically, was not possible years ago for observers actually present in the operating room or theater This technology has made it possible for residents to avail ourselves of a new range of tools with which to “see one”: DVD recordings of procedures for

postoperative review (both for review of the master performance and for self-critique of resident performance), teleconferencing of case presentations with intraoperative video clips,3 and webcasts of procedures that are available to the public and residents alike.4

“Do One”

Concrete tools available to residents to “do one” are threefold: nonhuman simulations of treating humans, low-tech cadaveric simulations of operating on the living human body, and the traditional apprenticeship model of hands-on learning while operating on living humans under the observation of an attending surgeon The first set of tools, simulation models, is the most rapidly growing

As the Residency Review Committee (RRC) of the Accreditation Council for Graduate Medical Education (ACGME) begins to require skills laboratories for program accreditation, this requirement is providing the administrative stimulus for development

of simulation-based education in residency programs across the country Residents will thus soon be required to demonstrate competency in virtual or simulated operative

environments before training in operating rooms with live patients

The wide array of the tools available to 21st-century surgical residents is

evidenced in many surgical simulation centers across the country and the globe For example, in the Maryland Advanced Simulation, Training, Research and Innovation (MASTRI) Center,5 four converted operating rooms (ORs) house state-of-the-art tools, including virtual reality (VR) simulators, standard mechanical trainers, and hybrid units, that allow residents to “Do One” in a simulated environment One OR provides VR endoscopic (Figure 2) and laparoscopic simulators (Figure 3), as well as multiple

standard trainer workstations A second OR provides several nonhuman models for doing elective and emergent bedside procedures such as endotracheal intubation,

cricothyroidotomy, central venous catheterization, and placement of chest tubes, while a third OR provides Mannequin-based simulator systems for training in medical

emergencies These tools extend the “do one” paradigm from operating skills to bedside procedural skills to medical emergency skills The fourth OR has been converted into the Cognitive and Physical Ergonomics Research Laboratory for Advanced Study of Surgical Ergonomics (Figure 4)

In these operating rooms turned learning laboratories, there are new metrics to master Whereas time and number have been traditionally the most easily scrutinized measures of accomplishments and compentency (eg, completing a year of residency or a certain number of operations), we surgical trainees may in the future be increasingly evaluated on our ability to meet specific criteria (eg, achieving competency in a set of skills criteria) Such a paradigm shift in surgical education may provide a more

appropriate framework for advancement through surgical training In a training

laboratory, key components can be practiced repetitively without the real-life constraints

of an operative case (eg, need for a patient, consent, transport, OR time, order entry) And unlike a live operation, the feedback is reliably detailed regarding the frequency with which and the extent to which precision is achieved or errors made Time and number as surrogates for surgical mastery may, to our advantage, make way for the addition of criteria-based curricula that aim to instruct trainees on precisely how to “do (the first) one.”

Let us not forget that the availability of high-tech simulation tools is not mutually incompatible with the low-tech cadaver lab Quite the contrary, the dissection of fresh and preserved cadavers complements the advanced electronic simulation as a segwey to optimal preparedness for operating upon living humans As Richard Selzer has reminded

us, we should “[r]eturn as often as possible to the Anatomy Laboratory As the sculptor

must gain unlimited control over his marble, the surgeon must ‘own’ the flesh… You must continue to dissect for the rest of your life To raise a flap of skin, to trace out a nerve to its place of confluence, to carry a tendon to its bony insertion, these are things of grace and beauty They are simple, nontheoretical, workaday acts which, if done again and again, will give rise to that profound sense of structure that is the birthplace of

intuition.”6

Finally, the traditional apprenticeship model of hands-on learning under the tutelage of attending surgeons operating on living humans still holds an important place

in the tool box of resident education The availability of simulation tools doesn’t replace hands-on operative learning, but ideally precedes, and therefore shores up and optimizes the live experience

“Teach One”

While the “do one” tools discussed above are also useful, after subsequent role

advancement, as “teach one” tools, the act of teaching, per se, deserves special mention

In his essay, The Amateur in the Operating Room: History and the Scholarship of

Teaching and Learning, David Pace reminds us that “Behind every act of teaching there are two different forms of knowledge: knowledge of the subject matter, and knowledge of how it may be taught and learned.”7 While the medical field is characterized by a rapid growth in scientific knowledge, medical education, viz, knowledge of how the subject matter may best be taught and learned, has lagged in its adoption of standardized

methodology and practice of teaching surgery to residents A look to the past and to the future may provide a glimpse of useful tools to come Only in 1910, after the publication

of the Carnegie Foundation Bulletin Number Four (more commonly known as the

Flexner Report), was undergraduate medical education standardized.8 Though widely criticized for its negative impact on the diversity of physician trainees, the Report did accomplish a collective set of goals and standards for American medical education A similar revolution may be expected soon to come to surgical training as well Two groups, the Surgical Skills Curriculum Task Force (developed by the Association of Program Directors in Surgery4, 9 and the Surgical Council on Resident Education

(SCORE, a voluntary consortium of six organizations with responsibility for resident education in surgery and an interest in improving the training of surgeons)10, 11 are

charged with developing and implementing a national curriculum in general surgery training Future curricula produced by organizations such as APDS and SCORE will further expand the “teach one” tool box to include standardized web-based courses and learning modules Such curricula may be based on multiple organ systems divided into diseases/conditions and the teaching of specific operative skills The first web based iteration is expected to be available in July 2008 on a pilot basis to selected residency programs By the end of 2008, SCORE hopes to develop 115 modules that parallel subjects in the curriculum that will be available via website.11

III Abstract Tools

The concrete tools available to today’s surgical resident, including those described above, have the potential to be powerfully effective and are rapidly improving in quantity and quality But let us not lose sight of the abstract forest for the concrete trees The forest of the pre-80–hour era was not an overgrown wasteland to be razed altogether, but a fertile

timberland that, although perhaps not renewable, produced all of the master surgeons who built and shaped our cherished and lofty discipline As Selzer puts it, “If you

perceive Surgery as the loftiest branch of Medicine, remember that it is the one most vulnerable to injury and ignominy It is not the privet hedge that is uprooted in a

hurricane; it is the royal palm.”12 Although when he wrote those words the 80-hour work restriction was nowhere in sight, now that it is here it may be one of the greatest threats to which surgery is vulnerable So how do we preserve the soul and integrity of the surgery bequeathed to us by those who had more time to learn it? The solution, again, lies in the

exchange of chronos for kairos What can we do in addition to availing ourselves of the

above-mentioned concrete tools? The excess time and energy that our surgical

predecessors spent in the hospital we must be mindful to spend nuturing their surgical ethos, the distinguishing character, sentiment, moral nature, and guiding beliefs that tailored surgery into the discipline we chose for our life’s work

Although there is nothing magical about the abstract tools we should use to this end, the new ethos of limiting residents’ time in the hospital, and the constant concern about – and difficulty in avoiding – work-hour violations could well prove sufficient to distract us from seeing those tools Because this threat, if not already realized, at least has the potential to become real, it is not fruitless to review what may seem to be an obvious set of abstract tools designed to guide us toward maintaining all the desirable aspects of the old surgical ethos The optimal outcome would of course be to have the best of the old era and the best of the new era combined in current surgical education The following tools are presented in order of pyramidal heirarchy, insofar as the

development of each tool generally rests upon the base of the previous tools (Figure 5)

Abstract tool #1

Attitude: Have Fun The most important tool in Surgery, as in our nonsurgical lives, may well be simply Attitude For those of us who were drawn inextricably to Surgery, this tool comes naturally, for we love our job and there is no clear line between work and play As Dr John Cameron – among others – has put it: If you love what you do, you never have to work again It is because surgery is so demanding – 80 hours or not – that the tool of Attitude, when well honed, is one of the most important; the other tools are maintained by it Increasingly as we move through surgical training do we appreciate the full impact, the reorienting and grounding importance, of the simple two-word, often uttered imperitive of Dr Barbara Bass, one of our former mentors at the University of Maryland: “Have fun!”

Abstract tool #2

Work Ethic: Work Hard A robust work ethic is for most of us already integral to being who we are as surgical residents Yet, as new trainees enter into surgical residencies and are cautioned, Don’t work too hard (ie, more than 80 hours per week), the potential exists for a misunderstanding of our work ethic Because unrestricted hours in the hospital devoted to mastering the art and science of surgery is no longer a luxury available (or perhaps desirable) to us, we now have to work not less hard, but harder, given the

increased need for efficiency No one, as Dr John Tarpley has reminded us residents,13 ever drowned in sweat However, sweat can taste sweet or sour, depending on our Attitude toward our work The relationship between the tools Work Ethic and Attitude