Michael E. Shapiro, M.D.'s surgical Grand Rounds lecture from September 11, 2015. He is the General Surgery Program Director at Rutgers-New Jersey Medical School and a Harvard-Macy Scholar. The presentation is all about how surgical residents learn. It provides a wealth of knowledge about adult learning theory and how it relates to teaching residents (and medical students). It is a great resource for all level residents and faculty. It challenges residents to take an active role in learning (and teaching), attendings to take an active role in teaching, and everybody to take an active role in communication and feedback. This presentation was uploaded with the permission of Dr. Shapiro. I truly enjoyed his Grand Rounds presentation and hope that all of the attendings from all of our hospitals check it out and buy-in to the process.

1. Surgical Learning – It’s Not Just
PowerPoint Anymore
or
What I did with my Winter Vacation
Michael E. Shapiro, M.D.
General Surgery Program Director
Rutgers – New Jersey Medical School
Harvard – Macy Scholar

2. “The ideal college is Mark Hopkins* on
one end of a log and a student on the
other”**
*Williams College President 1836-72
**James A. Garfield, Williams ‘1856

3. What we (now) need to learn/teach

5. An Experiment:
At the end of this talk, there will be a
quiz.

6. The Basics - 1
• As an educator, what is our prime role?
– To promote learning
• What is learning?
– Change (in knowledge, beliefs, behavior) that is
sustained
• What is teaching?
– The act of promoting/catalyzing change
– (ideally, done intentionally and informed by best
practices)

7. The Basics - 2
• What is assessment/feedback?
– Measuring change –
• To promote further learning
– Identify strengths and weakness to the learner
– Learner centered
• To demonstrate competence
– Patient safety
– Entrustable professional activities (EPAs)
– Certification
– System centered
– Need balance of both

8. The Basics - 3
• Who is the assessment/feedback we do really for
(i.e., who are the stakeholders)?
– Learner (e.g., student, resident)
– Teacher – is our teaching of value?
– Regulator
• NJMS
– Dean
– GMEC
• ACGME
• ABS
• How do their interests relate to promoting
learning or insuring competence?

9. The Basics - 4
• Deliberate teaching = defining planned change,
the developing appropriate strategy to
implement it, and assessment/feedback to
promote it and demonstrate it.
• As an educator, asking what do I/we need/want
to change, what is the best way to accomplish
that, and how would I know if I did?

10. Case Discussion – the “surprised” resident
• Bob (not real name) is a PGY-3 surgical resident in
the middle of the year. He graduated from a well-
known medical school, and has had excellent
evaluations his first two years. The CCC has just
met to review the PGY-3’s. The evaluations for Bob
this year were very different, and quite negative.
They all noted his failure to progress to a stage
where he can lead a team, make diagnoses and
plans, and make decisions for the patient. All
stated they had provided this feedback to Bob.
This case is a work of fiction. Any
similarities to any person, living or dead, is
purely coincidental and unintentional.

11. Case - 2
• You meet with Bob as Program Director. You begin
by asking him how he thinks things are going? He
responds that he thinks things are going pretty
well, in fact, “great.” He is happy in the program,
and feels that, although the transition to third year
was initially challenging, he now “has everything
under control.” At first gently, then more firmly,
you raise the concerns of his attendings.

12. Case - 3
• Bob claims to have never heard any of this negative
commentary before. You try to express your
concerns to Bob, who refuses to accept those
assessments, and states that he “respectfully
disagrees” and the faculty concerns are “unfounded
and incorrect.”
• Now what do you do?
• What do you suspect happened?
• How do you reconcile the different perspectives?
• Does this suggest anything about the need to track
real-time learning?

13. Adult Learning Theory
• Adult learning is different from children’s
learning.
• Children learn for the joy of learning.
– Some of us never grow up
• Adults learn for a purpose
– Further educational goals
– Gain skills that can be applied
– Pass a regulatory exam

14. ALT - 2
• Prior knowledge is the foundation for new
learning
• Adult learners should activate and build upon
prior knowledge
• Increasing the links to prior learning is critical
• Adult learners should be actively involved in
constructing individual educational goals and
meanings – they want to learn.

15. ALT-3
• Adult learners should own their learning
(intrinsic motivation) as opposed to primarily
responding to their teachers/evaluators
(extrinsic motivation). Intrinsic motivation is
associated with deeper learning.
• Teaching adult learners should promote both
learner autonomy and growth, ultimately
making the teacher unnecessary.
• Our job is, ultimately, to become superfluous.

16. ALT-4
• So, to maximize learning:
– Adult learners need to be actively involved in the
learning process, including:
• Initial self-appraisal
• Setting goals
• Developing mastery
• Participating in the assessment/feedback process
– Adult learners need to be active partners, not
empty vessels to be filled by the teacher.

17. A Simple Model of
CompetenceProfessionalAuthenticity
Behaviour
Does
Shows how
Knows how
Cognition
Knows
Miller, 1990
17

18. Spacing effect

19. Blocking vs. Interleaving in learning
and retention
Judged Performance
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
Blocked Same Interleaved
Proportion of participants
Actual Performance
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
Blocked Same Interleaved
Proportion of participants

20. Characteristics and Behaviors of
Expert Tutors
• Intelligent
– Superior content and pedagogical content knowledge
• Nurturant
– Establish and maintain personal rapport and empathy
• Socratic
– Provide almost no facts, solutions or explanations, but
elicit these by questioning
• Progressive
– Move from easier to progressively more challenging
cycles of diagnosis, solutions and new problems
Wood, W.B. and Tanner, K.D., CBE - Life
Sciences Education, 2012, 11:3-9

21. Expert Tutors, cont’d
• Indirect
– Provide both negative and positive feedback by
implication. Praise the solution, not the student
• Reflective
– Ask students to articulate their thinking, explain
their reasoning, generalize to other contexts
• Encouraging
– Use strategies to motivate students and bolster
their confidence
Wood, W.B. and Tanner, K.D., CBE - Life
Sciences Education, 2012, 11:3-9

22. Translating what effective tutors do to
the lecture hall
• Figure out where your students are starting
• “Flip” the classroom
– Provide the information to the learners to review
before the class – readings, podcasts, handouts
• Be Socratic
– Replace “telling” with “asking”. Allow learners to work
through problems together.
• Avoid direct criticism
– Use students to provide feedback to each other
– Rather than identifying an answer as wrong, find
someone with the correct answer, and praise that

23. “Lecture” (2)
• Include “testing” as part of the session
– Anonymous audience feedback engages learner
and shows where they fit without embarrassment.
– Teaching and testing gives better retention than
teaching and repeating.
– Real-time testing provides teacher with immediate
feedback about learning and areas of weakness
– Opportunities (digital media) to make testing of
teams, competition generates excitement.
Technology also permits re-testing for incorrect
answers, reinforcement, etc.

24. Lecture (3)
• Foster metacognitive awareness
– Have learners reflect on their thought processes,
articulate concepts they find difficult or troubling
– Allow learners to “know what they know”
– Encourage learners to identify which learning
strategies are most adaptive for them
• Be supportive – not always a surgical tradition
– “Why didn’t you just take out a gun and shoot him?”
– “Your patient just died…”

25. A humble proposal to help “Bob” and
all our Surgical learners
• ALT has shown that learners need to be
responsible for their own learning.
• Learning occurs at the “Zone of Proximal
Development”, i.e., the leading edge of the
learners knowledge
• Learners require continuous and immediate
assessment and feedback
• Teachers need to communicate with each
other to do appropriate learner “hand-offs.”

26. Educational Kanban
Time Frame Traditional Evaluation EK
Beginning of Rotation No formal meeting
Review general objectives
Self-appraisal
Review EK to date with
supervisor
Review rotation objectives
Set specific goals with superv.
Integrating past experiences
Every month None Interim self-appraisal
During rotation None Update EK
Mandated performance
feedback
Review and set new goals
Summative Evaluation
End of rotation
Summative supervisor form
No continuity to next rotation
No summative form
Collaborative self-appraisal
and formative feedback
Set future specific goals
Goldman, SJ, The Educational Kanban:
Promoting Effective Self-Directed Adult
Learning in Medical Education. Academic

27. Educational Kanban-2
Time Frame Traditional Evaluation EK
Twice-yearly review Summative supervisor forms
Program director review
Informal meeting
Not part of formal review
Mentor Meetings None/irregular Review EK quarterly external
to rotation
Continuity/collaboration
Ownership Training Program Files
Permanent Record
Resident Owned
Not “permanent record”
Goldman, SJ, The Educational Kanban:
Promoting Effective Self-Directed Adult
Learning in Medical Education. Academic

28. Humble proposal-2
• Applying Goldman’s EK model to our surgical
residency would require:
– Milestone-based individual goals for each resident,
each rotation,
– Collaborative assessment/feedback at beginning and
end of each rotation between faculty and each
resident,
– Communication between faculty from one rotation to
the next,
– More frequent interaction between residents and
mentors.

29. Humble proposal-3
• Mostly, it will require:
– Interest on the part of the faculty
– Dedication of time to teaching and assessment by
faculty on each rotation at each hospital
– Clear expectations from faculty to residents
– Honest, frequent, real-time feedback
• Last I checked, all three of our (non-VA)
hospitals have “University” in their names –
• Time to own up to that!

30. How many ELEPHANTS were there?
• A – 2
• B – 3
• C – 4
• D – 2 and a Northern White Rhino
• E – there were elephants? I thought the
Williams mascot was a purple cow!

32. Williams College, Class of 2015