Now,
with our TV knowledge of the surgical residency, an intern may expect
to first assist on a complicated cardiac procedure, or in my realm, a
complex spine procedure, such as a pedicle subtraction osteotomy. As
the intern first assist, when my hands start to tremble, you will take
over because you have read the book and looked at the pictures. Au
contraire, mon frair. The development of surgical skill can not be
learned like the Kreb's cycle. Surgical decision making can not always
be fit into an algorithm. It is more complex than that, just because I
slept at a Holiday Inn. Becoming a surgeon is a process. It takes time
to develop. Your vision gets better, like a running back who can see
the holes in the defense. Some develop quicker than others, some are
more skilled and some less skilled. Let's talk about surgical skills
development.
In
an article by one of my mentors, Dr. Robert Hensinger, he describes the
development of masters. In his editorial, "The Making of Masters: Some
Assembly Required." (SPINE 2003; 28(18): 2046-2048), he describes the
different stages of surgical development.
THE NOVICE LEARNER
At this level, the learner is given rules that define the actions. The
learner is told precisely how the procedure is to be performed. It is
the exact formula to attain a specific goal. Unfortunately, the formula
cannot predict all the variables for each instance, patient or
procedure. This level requires a great deal of memorization. Because of
this, the learner never reaches a level of incorporation of information.
THE ADVANCE BEGINNER
At this level, the learner gains experience in coping with real
situations and patients. The person begins to understand the problems
that can occur in clinical situations. The learner begins to notice
subtle variations in outcomes that occur within the same diagnostic
theme. It is at this stage that the learner begins to organize the
information within a frame reference. As the student incorporates more
principles and rules, the teacher assumes the role as coach, evaluating
and providing feedback.
This is a rule-based phase. Because, algorithms become longer and more
complex, the learner can become overloaded and experience burnout.
THE COMPETENT
The Competent is the level which we as educators would like to see our learners reach prior to you leaving our supervision.
This is the level when performance and expectations can be
overwhelming. In prior levels, when rules didn't work, the learner
rationalizes that maybe they have not been given enough or adequate
rules. This is when the learner may wonder "how can this be mastered?"
Competence is more than rules based; It is problem solving. It is the
ability to manage ambiguity and tolerate uncertainty, making decisions
with little information. Competent physicians sort better and can
compare patient patterns. They transform knowledge to fit the task. The
learner becomes accountable for their actions and begins to take some
responsibility for outcomes. They become emotionally invested and begin
to develop a sense of remorse for their mistakes.
THE PROFICIENT
At this level, there is an incremental incorporation of technical
skills, rules, and principles. As experience is assimilated, the rules
become subliminal. Answers become intuitive. Certain findings jump out
as important without the learner standing back and going through the
tiresome mental process to select a plan.
Due to past experiences, the learner is able to select one of several
possible options based on relating the patient's presentation to
others. With this "pattern recognition", the learner needs fewer clues
to develop a plan. This specific trait of "pattern recognition" is one
of the most important trains in determining surgical excellence.
THE EXPERT
This is accomplished performer, the skillful practitioner. The expert
sees what to do and has an immediate intuitive response. Envisioning
becomes a part of the practitioners’ behavior. The ability to represent
mentally the physical environment and the movement to be performed are
major determinants of surgical technical performance. Specific
strategies associated with this stage include imagery and mental
practice. Aristotle noted that we acquire our craft from the master
through observation and experience. In problem solving, experts draw on
many strategies, while the student uses the same cognitive strategy.
THE MASTER
The master has style. The master is a truly unique individual. The
master loves surprises and challenges. There is a danger that the
apprentice will merely become a clone of the master. Musicians have
learned from this experience that those who follow one master are not
as creative of a performer. Professors in the School of Music encourage
association with several masters, taking bits of style from each to
develop a completely unique performance.
Surgical mastery—the ability to gain knowledge, although necessary—is
not sufficient to develop superior operative skill. Pure psychomotor
skills and manual dexterity are not the major components that
distinguish the outstanding surgical performance from the mediocre.
More important are visual–spatial problem-solving abilities, for
example, the capacity to rapidly analyze and organize perceptions based
on multisensory information. They have the ability to distinguish
essential from nonessential detail even when the signal-to-noise ratio
is high. This appears to be most crucial to superior technique and
correlates better with operative skill than board scores. It is
essential that the surgeon manage anxiety and tolerate stress.
So, I guess we are not all trying to be masters, but our development as
surgeons does go through various stages. Those who are in training or
have completed training know the point we all of the sudden, they began
to see clearly. We all remember when the process of seeing patients in
clinic and making a plan became easier. The mental work became less. We
became quicker or more efficient. Becoming a surgeon is a process, it
takes time. It is not innate. Sometimes we want to force the situation
before we are ready. Be patient young Padawan, your time will come.
