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Education and teaching in plastic surgery
Introduction
The American Association of Oral Surgeons was founded in 1921. It subsequently became the American Association of Oral and Plastic Surgeons, and the American Association of Plastic Surgeons in 1942. Both the field of plastic and reconstructive surgery as well as the training of plastic and reconstructive surgeons have been constantly evolving over the past 100 years. The specialty has evolved over a similar period worldwide though the specific format of training differs from country to country. Simultaneously, as plastic surgery training has changed, so has graduate medical education. Adult learning theory has influenced undergraduate medical education as well as graduate medical education. The development of influential learning theories including andragogy, Bloom’s taxonomy, and Miller’s pyramid have urged educators to revamp old paradigms of surgical training. New paradigms include competency-based training, simulation, and more meaningful forms of feedback and assessment. With this educational evolution comes considerable growing pains, and there is not yet evidence to demonstrate that this is a superior means to train our future surgeons. Similarly, there is no evidence to demonstrate that our prior ways were superior. Future efforts in medical education must focus not just on learner assessments, but also on programmatic evaluation to determine the most efficacious way to train our future surgeons. In this chapter we will review the learning theories that have shaped today’s graduate medical educational paradigm, current shifts in plastic and reconstructive surgical training, and the history and foundation on which our current training programs were built. As plastic surgery evolves as a specialty, the education of plastic surgery trainees will need to do the same. Perhaps the most useful skill we can instill in our learners is to have an appetite for growth and fervent interest in living and working as a lifelong learner. Finally, the contents of this chapter are a static representation of current trends but will need to be cross-referenced to present-day.
Medical education theory
While educational theories abound, there are several key theories that have substantially influenced graduate medical education today. These changes include the development of milestones, entrustable professional activities (EPAs) and different forms of assessment. The concepts of andragogy (adult learning theory), Bloom’s taxonomy, Miller’s pyramid, and the Dreyfus’ model of skill acquisition are just a small sample of educational theories, but perhaps the ones that have had the most influence on modern graduate medical education. We will explore each of these. While considering new training paradigms, it is essential to familiarize oneself with these theories. However, it is also important to recognize that learning theories, whilst constructed from a large volume of research that substantiates their positions, are occasionally replaced by more current and culturally relevant theories as time and research progress.
Adult learning theory
Andragogy is the method and practice of teaching adult learners and is derived from research in the late twentieth century that suggested adults learn differently than children. In 2005, Knowles laid out his tenets of adult learning and argued that adult learners differ from children in six key ways. First, adults need to know why they are learning something. They want to know why they should pay attention and how it will benefit them. Second, they have a learner’s “self-concept” in that they want to feel responsible for their own decisions. Adults do better with self-direction and control over their own learning. Third, adult learners come with their own previous experiences, which need to be valued and respected. The new material they are learning should be tied to what they previously have learned or experienced. Fourth, adults need a readiness to learn, or in other words, they need to know what they are learning is relevant. They want to know the information they are learning will help them solve an immediate problem. Their motivation increases when there is an immediate reason to learn. Fifth, adult learners learn best when the content is problem-oriented. They are much more likely to learn if they feel the material will help them solve a problem they are currently dealing well. Finally, adult learners are at their best when they are internally motivated to learn rather than externally. External motivation can help, but adults thrive when they learn because they want to, not because an external force is acting on them. These six tenets of adult learning are crucial to designing both didactic and on-the-job curriculum.
Bloom’s taxonomy and Miller’s pyramid
In 1956, Benjamin Bloom and colleagues published Taxonomy of Educational Objectives: The Classification of Educational Goals , which created a classification system of cognitive skills that later came to be known as Bloom’s taxonomy. Bloom’s taxonomy is frequently referenced when designing curriculum, as it allows for better refinement of the desired learning outcomes and objectives. Rather than a list of knowledge a trainee or student should have, Bloom’s taxonomy suggests that learning outcomes should be associated with verbs, or action items (e.g., “remember”, “understand”, “evaluate”, “perform”), which can be more easily observed and are therefore more measurable. Bloom’s taxonomy, which has subsequently been modified by a number of authors, starts with lower-order cognitive skills related to knowledge retention, such as “remembering” (e.g., remembering the difference between a graft and a flap), and increases in complexity to higher-order skills such as comprehension, application and analysis (e.g., understanding which procedure, a graft versus a flap, is more appropriate given certain clinical indications). Bloom’s taxonomy has become a staple in educational theory.
More specific to medical education, Miller built upon Bloom’s ideas in developing his eponymous pyramid, first published in 1990 ( Fig. 37.1 ). The pyramid can be used to describe the hoped-for evolution of a trainee during their time in residency. First, they “know”, then they “know how”, they then “show how” and finally they “do”. Miller’s pyramid is especially relevant to the development of assessment methods as many of our current assessment methods fall short by testing only knowledge and not ability. Consider the in-service exam, didactic quizzes, and the written board examination. While these traditional methods assess “knows”, they do not adequately assess the higher order “knows how” (applied knowledge), “shows how” (skills) and “does” (performance). Mock oral boards can help to assess applied knowledge, while simulation labs and objective structured clinical examinations (OSCEs) can assess skills. However, “does” can be the hardest to assess and is arguably the most important to evaluate whether a trainee is in fact competent. “Workplace-based assessments” can be used to assess performance. Workplace assessments are assessments done while the trainee is actually performing their duties as a physician and are the best representation of how a trainee actually performs and whether they are competent. Some medical educators have attempted to develop different tools for better assessing trainee performance, but these tools continue to be refined.
Dreyfus model
The Dreyfus model of skill acquisition was initially developed in 1980 by brothers Hubert and Stuart Dreyfus. They described five levels through which learners would advance as they acquire skills: novice, advanced beginner, competent, proficient, and expert. The milestones project, as developed by the ACGME, used these five stages as a framework for their design. Using the Dreyfus model, a picture of what each learner stage will look like can be developed, acknowledging that learners may straddle stages, but also instructional strategies for how learners should be taught in each stage can be refined. The Dreyfus model also emphasizes the need for lifelong learning, a particularly important aspect of any medical professional, but especially a plastic surgeon within their ever-evolving field.
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