The apprenticeship model of surgical training is the gold standard worldwide. However, increasing evidence shows that its traditional method of teaching surgical procedures covers cognitive skills inadequately. Therefore, the traditional teaching method for surgical procedures may be liable for producing surgeons who are not fully proficient in cognitive decision-making. This study designed a digital teaching method for surgical procedure cognitive skills and compared it to the traditional teaching method.
The inadequacy of traditional teaching method.
The apprenticeship model of surgical training is practiced worldwide. It has its basis in a strong relationship between the trainer and trainee formed over many years of working together closely(1). In this training model, the method of teaching a surgical procedure entails a surgical trainee incrementally developing the skills required to perform an entire surgical procedure by repeatedly observing the trainer. The process is traditionally carried out in the operating room on live patients(2). A surgical procedure involves an incision with instruments to repair damage or arrest disease in a living body(3). This method of teaching a surgical procedure is summed up by the adage ‘see one, do one, teach one’(4–6). The trainee is expected to be capable of performing a particular surgical procedure after observing the trainer perform it, followed by being able to teach another trainee (4, 5). This method of teaching a surgical procedure in the apprenticeship model is referred to as the traditional teaching method in this study. Unfortunately, studies have shown that 28–42% of trainees feel inadequately trained to perform surgical procedures safely after this teaching method(4, 7, 8). This is attributed to the emerging evidence showing that the traditional teaching method inadequately covers surgical procedure cognitive skills (9–12).
Surgical procedure training requires that one master the psychomotor and cognitive skills of a surgical procedure (13, 14). The traditional teaching method emphasizes psychomotor more than cognitive skills(13, 15). Psychomotor skills encompass motor activities and are primarily movement-oriented (13, 16, 17). Cognitive skills of a surgical procedure include higher-order thinking skills involving decision-making, error detection, and planning for a surgical procedure(18). Cognitive skills of a surgical procedure enable a surgical trainee to make safe critical decisions before, during, and after the procedure(19). Bloom’s taxonomy provides educators with one of the first systematic classifications of cognitive learning processes. A brief review of the cognitive learning domain and cognitive skills is given to situate the research problem.
The cognitive learning domain is concerned with acquiring, retaining and using knowledge(20). It is commonly referred to as Bloom’s Taxonomy after Benjamin Bloom, who formulated the concept in 1956 with other researchers (26). It was later apportioned into six levels of increasing complexity. These six categories of cognitive skills range from lower-order cognitive skills requiring less cognitive processing to higher-order cognitive skills requiring deeper learning and greater cognitive processing(21). The six categories were knowledge, comprehension, application, analysis, synthesis, and evaluation. Bloom’s Taxonomy was subsequently revised and refined by Anderson and Krathwohl (22). Figure 1 provides a summary of the revised version of Bloom’s Taxonomy.
Bloom’s taxonomy is a cumulative hierarchical framework that requires the achievement of the prior skill before the next, more complex one (23). This should be born in mind by educators as they wish to develop learners’ cognitive skills to function at the higher levels described by Bloom’s Taxonomy(21, 23–26). Complex tasks such as making a critical decision during a surgical procedure require one to have the ability to function at higher thinking levels incorporating various data points and, at times weighing and evaluating contradicting evidence (21). There are numerous learning taxonomies (such as Miller, SOLO, and Dreyfus) (27–29). However, this study focuses on Bloom’s Taxonomy because it relies upon the gradual increase in cognitive abilities and how they scaffold. These abilities should be sequentially developed.
Over the past three decades, the adequacy of the traditional teaching method in teaching surgical procedure cognitive skills has been increasingly questioned(12). Good judgement through critical thinking requires grounded cognitive skills.
Kohls-Gatzoulis asserts that Surgeons need to be trained to judge the correctness of their actions and that cognitive skills training enhances the ability to execute a surgical skill correctly(15). In his study, junior residents were randomized to two total knee arthroplasty (TKA) training course groups. One group was taught only technical skills and had more task repetitions (5 to 6), while the other focused on teaching cognitive skills and had fewer (3 to 4) task repetitions. An objective structured assessment of technical skills (OSATS) was done for both groups pre- and post-course. Both groups completed a pre- and post-course error-detection assessment to assess cognitive skills. The performance of both groups was equivalent for the OSATS technical skills assessment, but the cognitive group scored better in the error detection assessments: t = 2.67, p = 0.02. A take-home message from this study is that good technical skills due to operative caseload do not necessarily translate to good cognitive skills. Furthermore, cognitive skills training needs to be intentional and not assumed. Next, a review of the causes of the inadequacy of the traditional teaching method in teaching surgical procedure cognitive skills is provided.
One of the limiting factors in teaching surgical procedure cognitive skills in the traditional teaching method is how the training is conducted. Junior surgical trainees learn surgical procedures through observation in the operating room(13, 16, 17). An attempt to teach cognitive skills of a surgical procedure in the operating room prolongs the operation time and raises ethical and legal concerns regarding patient safety (30). Hence limiting the time available to teach cognitive skills during a surgical procedure. Even when educational opportunities present themselves in a clinical setting, they cannot be utilized because of the pressure for speed and maximum efficiency. This is compounded by overcrowded faculty and staff schedules(31).
Additionally, the traditional teaching method of surgical procedures in the apprenticeship model is unpredictable since it is based on available opportunities rather than structured pre-planned educational objectives(11, 12, 31). The knowledge acquisition for surgical trainees mainly depends on the available medical problems of the patients they care for(31). There are very few standardized and systematic instructional strategies to ensure that trainees are exposed to all surgical procedure cognitive skills during training(10, 12). Consequently, there is a lot of variation and omission of relevant information during the trainees’ instruction(31).
Research also indicates that expert surgeons typically omit up to seventy percent of the information about critical actions and decisions they make when training novices. As a result, they do not report how they solve problems or perform tasks during a surgical procedure(11, 12). The omission is attributed to this part of their knowledge being procedural (the how-to knowledge), which they have mastered and comes automatically without a conscious effort. Most procedural knowledge is implicit and cannot consciously be recalled or explained. It becomes a stable component of a task over time and no longer requires conscious thought. Noel Burch called this type of procedural knowledge unconscious competence in his four stages of learning any new skill(32). Unfortunately, trainees must be taught this part of knowledge to understand why expert surgeons do things the way they do to build their own cognitive skills of the observed procedure.
Sullivan et al. elaborated on why the traditional teaching method in the apprenticeship model is inefficient in teaching surgical procedure cognitive skills(11). He demonstrated the unintentional omission of relevant procedural knowledge due to unconscious competence. He used cognitive task analysis (CTA) to capture steps and decision points that were not articulated during the traditional teaching of a colonoscopy. CTA gives access to the cognitive decisions that are made during procedural tasks and allows them to be broken down into discrete steps of a procedure that learners can understand. This is done through a series of structured interviews with a subject matter expert (SME). He video-recorded three expert colorectal surgeons during their traditional teaching of colonoscopy. The videotapes were later transcribed, and the experts participated in a CTA. A 26-step procedural checklist and a 16-step cognitive demands table were generated from information obtained in the CTA. The videotape transcriptions were transposed onto the procedural checklist and cognitive demands table to identify steps and decision points that were omitted during the traditional teaching. Surgeon A described 50% of “how-to” steps and 43% of decision points, Surgeon B described 30% of steps and 25% of decisions, and Surgeon C showed 26% of steps and 38% of cognitive decisions. This study demonstrates how significantly the unstructured and non-systematic nature of the traditional teaching method leads to the omission of relevant information.
Tirapelle et al. further elaborated on the omission of relevant information due to unconscious competence(12). He also used CTA to elicit knowledge from experts essential for comprehending a surgical procedure. The elicited knowledge was then used as instructional support for novice trainees. This elicited information would otherwise be omitted and not be transferred to the trainee during the traditional teaching method (12). The elicited information covered major steps, tasks and decisions employed to perform the surgical procedure effectively. He argues that this information enables novices to successfully process and organize a surgical procedure's actions and decision steps. Due to their extensive experience, expert surgeons perform tasks automatically without the need for conscious guidance or monitoring. Therefore there is no guarantee that a surgical trainer will teach a trainee all cognitive skills of a surgical procedure because of the automaticity inherent in unconscious competence (11, 12).
Arthur Whimbey concludes that many university students have weak thinking patterns because of a lack of systematic and sequential thought. Systematic and sequential thought, which is the ability to proceed through a sequence of analytical steps, is the foundation of all higher-order reasoning and comprehension(33). It is a cognitive skill(33). Systematically and sequentially training cognitive skills of a surgical procedure enables the trainee to climb the cognitive function ladder and perform at higher levels (judgement and critical decision-making). Such an approach is lacking in the traditional method of teaching surgical procedures. A proficiency-based system should be used, where advancement is allowed once competence in subordinate skills has been achieved(34). For example, the trainees should demonstrate that they understand the steps of a surgical procedure outside the operating room before observing and performing it in the operating room. Novice trainees, in particular, experience challenges associated with the traditional teaching method. Such challenges include the inability to identify the most pertinent elements requiring greater attention. Secondly, they struggle to understand what happens during a surgical procedure in the operating room(35). Systematic and sequential training in surgical procedure cognitive skills is essential (11, 12, 31).
The literature on methods of teaching surgical procedure cognitive skills.
Grantcharov et al. recommended a sequential surgical procedure cognitive skills training that starts with acquiring knowledge specific to the procedure, including instrumentation, surgical anatomy, indications, complications, preoperative work-up, postoperative management, and successful completion of an assessment (29). This would then be followed by a video demonstration of the surgical procedure and an assessment of the understanding of the steps of the surgical procedure. He recommended that these steps precede an attempt to observe or perform a surgical procedure in the operating room.
The literature also suggests that educational videos effectively teach surgical procedure cognitive skills (36–39). Shariff et al. assessed the effectiveness of video as an educational tool for cognitive skills acquisition in open and laparoscopic colorectal surgery(40). Multiple operations were filmed, developed into procedural steps, and integrated into an interactive navigational platform using Adobe® Flash® Professional CS5 10.1. The teaching resource was availed online to general surgery trainees and compared with conventional teaching of cognitive skills. During an assessment survey, the video group improved their decision-making (67%) and factual and anatomical knowledge (88%), and 96% agreed that the video teaching tool was a useful cognitive skill teaching resource. The study concluded that video education was more effective for teaching cognitive skills in colorectal surgery.
In surgical training, the use of educational videos, such as recorded and 3D animation-generated videos, is not new. Video-based teaching methods are associated with significant knowledge retention, satisfaction levels, short training time and reduced learning duration (39, 41–43). These are welcome benefits to a surgical trainee who has to study while keeping up with a busy clinical schedule (38). In addition, 3D animation has been shown to facilitate the acquisition of cognitive (36–39) and technical skills (42). The illustrative power of 3D animation videos has particularly been demonstrated in the illustration of surgical anatomy(30, 44, 45). The dynamic topographic views of the surgical anatomy make the demonstration of the steps of a surgical technique realistic. Consequently, studies have suggested the use of 3D animation videos in teaching surgical procedures cognitive skills (14, 38, 46). The effectiveness of 3D animation video illustrations in surgical education is attributed to their visual realism (41, 47).
The past two decades have seen an evolution of 3D software enabling the creation of complex 3D models and animations(48). The animation of 3D models, when done well, conveys a large amount of information in a short space of time(48, 49). 3D animation is best for illustrations conveying an understanding of 3D spatial relationships(48). Such is true for surgical procedure training. Research has shown that the brain can absorb pictorial information better than text-based data(49). Students were also shown to learn more, remember content longer, and show more interest in learning when educational videos were used(50). Therefore the literature suggests that 3D animation has a vital role in surgical procedure training.
Additionally, assessments have been used in conjunction with teaching and learning activities (TLA) in cognitive skills training(12, 31, 33, 51). In most of these, they served the purpose of assessing the efficacy of a teaching intervention. However, there is another role for using TLA and assessments together. It is their joint contribution to achieving the intended learning outcomes, a concept described by Professor John Biggs in 1999 as constructive alignment(52). “Constructive” refers to the idea that students construct meaning from relevant TLAs, while “Alignment” refers to the situation whereby TLAs, and assessment tasks, are aligned to the intended learning outcomes (ILOs)(51). Intended learning outcomes must be set clearly at the beginning of learning, telling students what, how, and to what extent they have to learn. In constructive alignment, assessments facilitate learning instead of assessing learning. Assessments and instant feedback help cement learning, especially when spaced and spread throughout the TLAs.
In medicine, assessments were traditionally performed at the end of a module (modular tests). After completing all the modules, the marks are summed up or averaged; failure to achieve a set pass mark implies underperformance. This is called summative assessment. Summative assessment is an ‘assessment of learning as opposed to formative assessment, which is an ‘assessment for learning. The marks achieved by the learner after the summative assessment give limited information about the details of the strengths and weaknesses of the learner. Secondly, the limited feedback to the learner comes at the end of the module, denying them the opportunity to remedy their weaknesses (53, 54) and learn from their mistakes. Formative assessment involves continuous monitoring of a learner’s progress towards achieving specific outcomes through regular feedback and updates to the teacher and the learner. This directs teaching and learning continuously. Continuous assessment, as the name suggests, is more formative. It assesses learners over a period of time, and the learner’s abilities in specific areas are made cumulatively to facilitate further positive learning(55). Current learning theories emphasize continuous assessments and constructive, ongoing feedback to facilitate learning.
To conclude, the identified problem of the traditional method of teaching surgical procedures is: It inadequately teaches surgical procedure cognitive skills. The inadequacy stems from limitations resulting from the apprenticeship approach to teaching surgical procedure cognitive skills. These include limited time for teaching cognitive skills in the operating room, ethical concerns, dependency on available clinical opportunities that are not guaranteed, and unconscious competence that limits cognitive skills transfer from experts to novices. Therefore, there is a need for a reproducible, systematic, and sequential approach to teaching surgical procedure cognitive skills to circumvent the mentioned limitations. Currently, there is very limited research that investigated reproducible, systematic, and sequential methods of teaching cognitive skills for surgical procedures. Therefore, there is a need to conduct research investigating such methods.
This study designed a digital method for teaching surgical procedure cognitive skills and compared it with the traditional teaching method. The digital method used 3D animation videos with embedded continuous assessments with instant feedback to teach surgical procedure cognitive skills.
The rationale.
The traditional teaching method may be liable for producing surgeons who are not fully proficient in cognitive decision-making as there is no reproducible, systematic, and sequential teaching of surgical procedure cognitive skills. If surgical trainees’ cognitive skills are well grounded, they can make critical decisions before, during and after the surgical procedures. The assumption is that not only will such trainees have lower surgical morbidity and mortality rates and consequently improved surgical outcomes, but they will also become better teachers.
I hypothesized that trainees who were taught surgical procedure cognitive skills using the digital teaching method would perform better than those taught using the traditional teaching method in terms of knowledge gain and self-reported satisfaction level. Furthermore, I hypothesized that the trainees would find the digital teaching method to be clearer. The complete training package was delivered to the trainees via a learning management system (LMS).
Aims and Objectives
This study sought to design a digital teaching method for surgical procedure cognitive skills using 3D animation videos and continuous assessment. It was implemented and evaluated by comparing it with the traditional teaching method. An outline of how the objectives of the aims were achieved is provided next:
1. To design the digital teaching method for surgical procedure cognitive skills.
The ADDIE model of instructional design was used to design the digital teaching method for surgical procedure cognitive skills. The first four stages of the ADDIE model were used to design the digital teaching method, and the last stage, the evaluation stage, to evaluate it by comparing it to the traditional teaching method.
2. To create teaching and learning content.
3D animation videos for surgical procedure cognitive skills were created using Autodesk® and Adobe® software packages. Assessments were created and embedded into the educational videos using the Camtasia® software. Quizzes were also created using the Moodle quiz tool. The instant feedback logic was built into the education videos using Camtasia® software
3. To implement and evaluate the effectiveness of the digital teaching method in teaching surgical procedure cognitive skills
The digital teaching method was piloted at the universities of Botswana and Pretoria and their affiliated hospitals. The digital teaching method for surgical procedure cognitive skills was evaluated by comparing it with the traditional teaching method regarding trainee knowledge gain, satisfaction level and surgical procedure clarity. Surgical procedure clarity referred to the participant’s perceived clarity of the teaching method in teaching surgical procedure cognitive skills. The knowledge gained was evaluated using pre-, post- and retention tests, while survey questionnaires were used to assess satisfaction level and surgical procedure clarity.
The next chapter details the methodology followed to achieve the outlined study objectives.