The use of Technology when learning surgery

 The field of surgery encompasses a vast number of different conditions, all of which the surgeon needs to be aware of and they also be able to treat both operatively or non-operatively. But what makes a surgeon? How does one learn surgery? How do they gain their knowledge and skills? In the past it may be from textbooks or watching mentors or other surgeons operate. But nowadays there's new technological advances. Well today we're going to discuss what makes a surgeon in 2023. Good day and welcome to Aussie Med Ed, the Australian Medical Education Podcast.

 A program born during COVID times to emulate their general chit-chat and banter around the hospital with the idea of educating the medical student and GP alike. I'm Gavin Nyman, an orthopaedic surgeon based in Adelaide and it's my pleasure to bring Aussie Med Ed to you. In today's podcast was recorded at the Royal Australasian College of Surgeons' scientific meeting where I co-convened the surgical education section and ran a course on how to host a podcast. During this we recorded a live podcast using a panel of experts to discuss issues of relating to what determines how people learn surgery. And today we're joined on our panel by associate professor Peter Smitham, an orthopaedic surgeon from Royal Adelaide Hospital, Dr Robert Whitfield, a general surgeon from the Royal Adelaide Hospital, Dr Gayatri Asokan, a general surgeon recently graduated who's undertaking a fellowship in liver transplant, as well as Lisa Hadfield-Law, a surgical educator from the United Kingdom with 20 years of experience and our invited lecturer for the Royal Australasian College of Surgeons' scientific meeting this week.

In a panel discussion and a live podcast recording we're going to attempt to answer these questions on how people learn surgery in 2023.

I'd like to start by acknowledging the traditional owners of the land on which this podcast has been produced, the Kaurna people and pay my respect to the elders both past, present and emerging.

Gavin:-

Well thank you very much for joining us today, Pete, Rob, Lisa and Guy. It's great having you on board. Welcome to Aussie Med Ed. First I'd like to ask Pete and Rob, what inspired you on heading down to the surgical path of medical school? What was your most important educational tool? Was it mentors, peers, other aspects or textbooks? What did you use to really study the surgery and learn both the knowledge and the actual surgical skills? Peter, could you go first and then we'll go with Rob.

Peter:-

Thanks Gavin. I think everyone has their own sort of personal reasons why they went into surgery. For me originally actually at med school I wanted to do, obviously Guiney originally, because I thought it covered where you could do the medical side and the surgical side at the same time and I quite like that span of covering both. Quite rapidly I realised that wasn't what I wanted to do. Then it was between orthopaedics and vascular surgery in fact. I really like the sort of technical side of vascular surgery and seeing a leg pink up in front of you but I more like the case mix and the sort of team structure of orthopaedics that sort of got me into that eventually. And I thought orthopaedics at the time there was an opportunity to do a lot of the medical side as well. You've got all the hip fracture patients that have lots of multiple comorbidities, there's a lot more to get involved. In terms of who got me involved, the mentors were definitely there early on in my career. So do you think the mentors are actually what inspired you to learn as well? Were you learning your techniques from or was it more textbooks and other aspects that did it? I think it was a combination of all of the above really. So yeah I think mentors had a massive impact. Certainly as an intern for me, the registrar within a few weeks left and it was just me and the consultant and so I was running around doing the wards to clinics and being his sort of primary assistant in theatre so it sort of gave me a great exposure very rapidly into orthopaedics.

Gavin:-

And Rob, what made you go down the general surgical path and how did you learn surgery along the way?

Robert:-

So I left medical school not really knowing what I wanted to do with myself. I thought in fact that I'd probably be more likely to end up in the sort of physician training path. My first job was on a general medical unit and I hated it and I thought I cannot do this. Then my next term was a vascular surgical term. Surprisingly I really really enjoyed it because I don't really like surgery at all during medical school and it wasn't particularly interesting to me at the time but I think part of it or a lot of it was probably being made to feel part of the team in the vascular unit so I had to come to theatre and they made me close all the wounds as an intern and it was fantastic. I had a great mentor registrar and it was really helpful and encouraging and yeah so I sort of came out of that 10 week thinking this is what I want to do. I sort of had a look around other various surgical specialties and eventually sort of settled on the general surgery. In terms of what techniques were best for me, I think peers primarily, peers and mentors. Most of my learning is through talking, discussing and problem solving and that sort of thing with other people.

Gavin:-

So what you're both saying really is that the actual approach to your learning and why you went down the surgical path is what I also experienced. It was also associating with seniors and learning from them, watching what they did and reading books along the way but really more look see one, do one, teach one approach. What about in your experience, did you have any exposure at all to any technological advances like podcasts or video streaming or virtual reality in your days going through?

Peter:-

Well I actually set up a podcast about 10, 11 years ago for the BOA and UCL when I was there doing my training. It was a lot harder to set them up and edit all the ums and r's and everything in those days and they got put up on SoundCloud. But I mean I'm not sure I would particularly use it for my surgical education. It was sort of more of filling in the gaps around the outside. It was still back to mentors at the time and reading books to be honest with you.

Gavin:-

And Rob what about yourself? Did you have any access to podcasts or videos that you used to help study or learn the surgery?

Robert:-

So primarily my own education was reading books and occasional journals. The only kind of slightly sort of more modern thing that I got exposed to was when I was doing the anatomy tutoring and learning the anatomy for the first part. The anatomy department at the University of Melbourne just released a sort of interactive program where you could go onto a computer and onto a website and click through things and look at and then give you clinical scenarios and that sort of thing. But yeah never any podcasts or anything more you know more contemporary.

Gavin:-

Okay perhaps we can move to a more recent graduate and go to Gaya and she can ask the same question to her. So what did you rely upon in learning surgery? Did you have any modern technologies or did you use the same techniques as our more senior colleagues here?

Gayatri

Yeah so I think yeah initially the books that we were recommended, journal articles, notes that were recommended from previous trainees above me were very useful. And so that provided me with a fairly good framework I think initially just to build on. But what I found more important through training as I progressed through training was probably the clinical and operative experience that I gained. I think just you know simply being in theatre, you learn so much through osmosis, you learn so much through assisting. Listening to your consultants and fellows talk about operative decision making, all of that kind of stuff I think I found really valuable especially heading towards my fellowship exams. Even from a student perspective I think that clinical experience that one gains just from being in the hospital, being on the ward is so valuable. Unfortunately with the pandemic that affected students quite a bit. They were suddenly taken out of their placements and then you know next minute they're in internship with you know without that background experience that they had. And I guess that did open up other avenues of learning modalities which is good. So you know remote learning and flexible learning and teaching was then kind of explored a little bit more and I think that's here to stay for the future. But yeah I really do think that the clinical experience from a training perspective, the operative experience, being on the ward, being you know admitting patients, seeing patients is so so important. So what you're really saying is it hasn't really changed a lot despite the advances in technology to help you. It's still giving very similar answers as there are other to guess. I think they're an adjunct to everything.

Gavin:

 What do you think the critical aspects for medical students would be? Because I spoke to medical students just the week before asking what they rely upon and how often they use textbooks or go and look at other journal articles. And they at the moment purely on the audio-visual gear, take podcasts, YouTube videos and put stuff provided on our Canvas website at the university. Do you think that's got influence the way they learn in the future or do you think they'll suddenly jump back to the way you've done it?

Gayatri:-

I think a mixture of both really. It's what they're used to, the experiences that they gain from talking to other people. I think from a medical student perspective, the goal, the way that I see it, the goal is to be you know to learn as much as you can, to be a safe intern, a resident from a surgical perspective. It's to recognize a surgical emergency and to escalate things. And I think that and the nuances of surgery, I think you learn more on a placement which is ingrained in med school right and same with internship. You have to do a surgical term whether it's a subspecialty or not. So I think that experience, yeah I don't think you can get away from that. You can read the books and use all of these other resources but I don't think the value of experience should be forgotten. What about the third aspect too, things like lectures and tutorials? That's different from experience actually hands on. It's actually lecturing to the students and actually giving them presentations. Where does that fit in the picture? Does that have a role? Is that replaced by this audio-visual technology? There is a role for didactic learning in a classroom. I think especially early on, med school for me personally, early on in training, it provides a really good foundation for the basics, physiology, anatomy, pathology, all of that. I think it's more easily learned when you're guided through didactic teaching. I also think that in the format in a classroom, it's a supportive environment and so you kind of have this ability to build your confidence by asking the lecturer questions and it's just a different atmosphere to just being by yourself and learning that way. I think for me personally, as I progress through training, I just found that again, like I said, the experiences that I gained and the online resources at that point were useful. You mentioned YouTube, Gavin. That in particular, watching operations, watching the entire operation that I may not have been involved in through my training was so useful for my fellowship exams. I think there is a role in that kind of format, but the other resources are also very useful.

Gavin:-

Now, I might just ask Lisa Hadfield-Law, our special educator and invited guest for the Royal Australasian College of Surgeons this week, about her thoughts about the YouTube videos and podcasts as a source of education. Lisa, what do you think about this?

Lisa:-

It depends if we just let it happen. I'm hearing Gaya talk about learning by osmosis, Rob and Pete talking about reading. That is quite dated now. The stuff that's published is so out of date so quickly. You could turn around the podcast really, really quickly and make it completely up to date. The bottom line is that we as teachers, if we're left unchecked, will teach others the way we were taught. Things have changed. We know so much more about how people learn. If we know that, and if we know that medical students, core surgical trainees, fellows, consultant level people all have learning needs, when it comes to surgery, it's about knowledge, skills, judgment, and professionalism. There's been a big focus over the years on knowledge because that's quite easy to purvey. Give people information, tell them stuff, and they will learn it. That's not how people do learn really. We need to think about how we set knowledge foundations. Although lectures might have been what we've done traditionally, that's probably not a great way of learning. If we know, we do know, and we've known for 80 years that people will probably take away on a good day about 5% of any lecture, that's not a great use of an individual's time. It's great for a lecturer because we go 200 people, we're going to tell them some stuff, and we've done the job. But it's not an effective way of learning. If we know that, but we also know that people need some knowledge foundations, podcasts are a great way of doing that. Because if, for instance, Pete's rather quick at picking up stuff from a podcast, and I'm a bit neurodiverse, or I don't have English as a first language, I can go over it time and again. I can listen to it several times. We can speed it up and then go through much more quickly. You as a podcaster can work out where the gaps are. I think probably the next little bit is to think about where those gaps are, who you're aiming at, what they need to be able to do at the end of it, and then really focus on filling the gaps. We've laid some foundations now, and I think it's time to move up. We like skills we're okay at, judgment and professionalism, which is a massive focus now. There's not that much stuff out there.

Gavin:-

I think that's an excellent point. And I also would go back to the start of what you were saying before about the use of lectures not being able to take it all in. I do recall my lectures, part of the reason my handwriting is so terrible is the fact that I'm too busy writing down the notes and actually trying to get a copy of it because you can't recall everything auditory to actually listen to it live. And then you go back and read the notes and remember what you'd written. You don't have to worry about writing notes. If you actually can have podcasts, and in fact podcasts now, you can so much easily use AI to transcribe them. So my recent ones are actually being transcribed on the podcast and being published on the website. That allows people to read it as well. So there's lots of different ways to take in the knowledge. Now, Peter, you've got a comment.

Peter:-

Yeah, I just want to say, I mean, I think you asked us how we learned in the past that it's very different to how we may be learning now. And I think also, you know, looking at my children, there's no way the way I learn is ever going to come again from the way they're taught from a very early age, I can see, it's totally changed. What I do find interesting, and we're not really talking about here, but we're actually in a highest level in theory of orthopaedics as all seniors around here. And yet we're back to didactic. We're in a conference center here, which we're back to didactic teaching in some ways of someone presenting. And I wonder, it'd be very interesting, I think over the next 10 years, how conferences evolve to actually adapt for that neurodiverse and exposure of all the other medias around.

Gavin:-

It might take the opportunity to ask the audience whether they've got a question to the panel. Does anyone want to ask a question and be on the podcast?

Nick (audience)

Thanks very much for all the comments so far. I'm Nick, I'm a plastics registrar based in Sydney. I thought your comments on neurodiverse learning was fascinating. I wanted to know what you thought about whether this has been historically a chicken and egg scenario where surgical training has selected people who learn in a certain way. And now we're sort of catching up and providing different ways of learning content. And that way, surgery has actually opened up to more and more people.

Lisa:-

Can I respond to that? So that is really interesting because if you look at how my generation selected into medicine, it was based on exams where somebody listened to a teacher telling them stuff, they wrote some notes and then regurgitated it. And if they did that very well, they passed exams. It was about English and it was about numeracy. Really interestingly, as our educational systems have changed and made much more allowances for how people learn differently, people have achieved academically, come into medicine, and then a really interesting thing happened about a decade ago when I was picking up orthopaedic trainees who would whisper, "Oh, gosh, thanks so much for that. I didn't really catch that because actually I'm dyslexic or I've got some difficulties processing." And I said, "Oh, right, okay. What's your supervisor said about that?" My supervisor doesn't know. God, I definitely don't want them to know. So although we were getting neurodiverse trainees into training, they were still trying to struggle along being taught by people who were completely unaware. And lots of the good ways of teaching are good ways of helping neurodiverse people learn as well. So I think that the stigma attached has changed quite a lot and that's great news. But the important thing for all of us who aren't neurodiverse is that the principles that will help the neurodiverse learn are principles that will help everybody anyway. I would say though that medicine is very broad in its specialties as well. I think surgery as a whole is still going to be a lot more visually learned than other areas of medicine. Yes, there is going to be more allowances and things in the system, but it will still be a very visual and a very sort of mental setup. How you get that visual information, whether it's the assistant on the other side of the table, whether you're watching Vimeo videos, whether you're doing other things, that's totally different. How much is going to be haptic feedback and VR and all these other things, that's a different question. But it's still going to, I think, be unfortunately, or fortunately, depending on how you look at it, a visually based learning process and the vast majority of it is surgery more than the other medical fields as a whole. So you are going to have that slight selection of people going into orthopaedics that maybe have a preference or an ability in that field more than you may get in other fields of medicine as a whole.

Gavin

Perhaps I can ask the panel, what aspects of a podcast and also videos do you prefer? What are you actually after in a podcast?

Rob:-

In a podcast, thinking about visual learning and videos, one of the things that I've started doing as well is in preparation for a bigger case or something that I haven't done for a while is use things like YouTube. So that's something that's happened just in the last few years and there's more and more resources online. And I think that what I want in a good YouTube video is clear picture and commentary as well as you go along, because that helps you to work out the important steps because it's the same sort of thing that you do. You're sort of learning when you're learning an operation, then you want to revise it and make sure you don't miss important things. For a podcast, I suppose structure is useful and we talked about this before, but having a lesson plan and goal, learning objectives is helpful for the learner as well as for the teacher.

Gavin:-

Yeah, I certainly use a video as well to go back through an operation and just review it. Gaya, would you like to make a comment as well?

Gayatri:-

I think the most valuable thing about the use of podcasts is the convenience of it all. I think generally as surgeons or as trainees, we are fairly time poor. There are so many demands, both in professional life, personal life, work life balance, all of that. I think now as trainees, we're empowered to not just think about our operative experience that we gain, but also academia, teaching, education, all of that. And I think that means there's a lot of demands. And so the convenience of a podcast that you can just listen to, tailor your learning, have flexibility when it suits you is awesome. It's really, really good. So going between hospital to hospital, during oncalls, other states have quite long drives to get to their work, waiting for cases. In my personal life, being at the gym and listening to a podcast if I'm on the treadmill, that kind of thing. So there's so much flexibility with when you can use that resource, which I think is really valuable. So yeah, I think from that perspective, I really enjoyed using that for my fellowship exams. But from the format perspective, I personally really like the kind of case-based learning type format, as opposed to the more didactic podcast that might be out there. So that question answering, especially for fellowship exams, because I found that it was really useful, again, to stop and start, answer the question myself. And then I have immediate feedback with the answer. And so that also helps with not just learning, but also technique. So yeah, I think there's a lot to gain with podcasts.

Gavin:-

We've got a question from the audience again.

Matt (Audience)

Yeah, I've got a question that Matthew, General Surgeon from New Zealand. I've got an assumption, and I want to test it with you guys. I think with a lot of podcasts that I listen to, it takes me two or three episodes to get into the feel of it, and then to start to recognize the underlying themes. One of the concerns I have with episodic or bits and pieces learning is that you never get the integrated sort of view of that. And I wonder if one of the goals of a podcast should be to have an overlying theme that becomes clearer after repeated listening.

Gavin:-

The type of chapters of a book sort of scenario and actually having an approach to working your way through a system is a good idea. I think part of the problem with having this one theme, though, for like, if we just went through orthopaedics, which is obviously the natural one for me, then it's going to only pick up a small section of the audience. So you've got to balance that between those aspects. But what does everyone else think?

Peter:-

So I remember actually my learning being dyslexic, I actually read my notes into a cassette record and then sort of listened to them in bedtime and stuff like this from 16. I think hearing any voice over a repeated time gets a bit annoying, particularly your own. And similarly, you know, I don't want to drink coffee for every drink for the rest of my life. I like variety. So I think, yes, themes help sometimes. But I also think sometimes I want something I'm just going to listen and then throw away, get that one fact and move on. You want that variation, I think. And I think actually having a variation almost means that you'll listen to that podcast more because otherwise you'll just end up going, I've had enough of that and I'm moving on. And so in terms of if you want a long gravity of a system like a podcast that Gavin does, having a variety helps with maybe interspersed with a few themes that can then piggyback on. And I think as you expand what you'll have is you'll have themes that people can package together but also not if they don't want to. Move on to Lisa, Lisa, would you like to say something on that topic?

Lisa:-

Yes, because this might be to do with where you're pitching. Matt, you are an expert in your field. So you know what you're looking for. Coming to this Congress, using a podcast, a webinar, your knowledge foundations are there so you can pick and choose what you're looking for. Medical students and core surgical trainees, very basic trainees, don't have the same foundations. So we'll need more of the guidance that you were talking about, Guy. So if you are trying to make podcasts that are going for a wide audience, that's going to make it quite difficult unless you provide guidance maybe through the website, maybe in the blurb, so you're crystal clear about what you're offering and what you, Matt, as an expert, can get from it, what June medical student can go in and get from it. The problem is if you go very, very narrow and you just aim at somebody of your level, the audience is small. If you go for much wider, that makes the appeal, all your potential audience much greater, but it's really then difficult to focus on very specific things that will meet a need. And that's what we're talking about, a need, not what we fancy doing as teachers or what we like or what we find interesting, but what is needed out there. And it can sometimes be difficult to keep sight of that.

Gavin

Okay, another question asked to me in the audience previously was, "How do you actually verify that the information being provided to us is actually accurate?" Well, perhaps the panel can answer this. Let's start with Rob.

Rob

You're really relying on the expertise of the person that you get along, particularly if you're interviewing someone about a topic of which you have less detailed knowledge. As a listener, though, how would you find when you're listening to a podcast that you actually think, "Oh, this is appropriate information and I'm happy with this information we've provided"?

Peter

I think it's really hard because we often, what we do is we trust a sort of unit as a whole and think, "Oh, if it comes from that, it must be truthful." But equally, as you say, Rob, it really depends on who your audience is and they can have a throwaway comment that can completely skew a podcast on a different view, which may not even be your view, but may not be the view that you're trying to portray. I think the best way is just trying to use multiple sources and hopefully if multiple sources link together and then that sort of corroborates what you're thinking.

Rob

I just wondered, Gavin, whether the other issue is if there are areas of difference of opinion within a field, maybe having two people in a podcast bouncing ideas of each other would be another way of capturing the diversity of opinions on whatever you're talking about.

Gavin

I've got a question from Adrian who would like to ask a question.

Adrian (Audience)

Thank you, Gavin. Adrian Anthony, general surgeon from Adelaide. My question is about artificial intelligence and part of our traditional biomedical educational process is to show that our learners learn effective ways of learning. That is, they can actually look at accessing reliable information and evaluate that. So I'd be interested in the panel's view about the emergence of artificial intelligence in this space and whether accessing artificial intelligence to get that information actually detracts or somehow influences how learners are learning how to learn.

Gavin

Looks like Pete wants to have a go at this one. So I might get Peter to give us an answer towards this question.

Peter

Well, I'm not sure I'll answer, but I'll give him my opinion, which said the whole beauty of a panel is you can have different people's opinions. AI is here and it's not going to change and we are going to have to adapt like we've adapted to everything else. So I think it's something that we're just going to have to accommodate. It has advantages and can be used. And I mean, I was at the American Academy for orthopaedics a few weeks ago and they're using it actually to give patient information back to the patients as text messages. They ask how's your pain by the chatbot in the background, sort of then modifies their answers depending on what they get. And it's all automated into the system and that's freed up the service for them spending more time with the patients that really needed the help or need things. So like all these things, there's going to be speed bumps and problems in the way. But I think the beauty of humans generally has been that we're such an adaptive species we've managed to sort of modify our ways to make it work.

Gavin

\Well, lastly, to make a special comment at the end here, and perhaps we'll start closing things up for this podcast. What do you think, Lisa, about the whole process of audio visual equipment being used and resources being used for education and how do we control it, particularly with the advances of AI?

Lisa

Control is an interesting term and maybe when it comes to education, we need to be a little bit careful about how much energy we put into controlling. Curating, yes. I think that probably is important. I think that there will be all kinds of changes. All of this is so desperately new to me in a lot of ways and I would love to be lectures, books, because that's what I've been brought up with. That's what I'm really good at. But it is changing and if I try and stay in my own space, everybody else will move on. So I think this may be a great way of leveling things out. I have to learn from people who are not just the generation down, but the generation after that. And I have to proactively engage with them as an adult, which is different from my generation. My generation was elders, purveying information down, purl to swine. You pick it up and be really grateful. Thanks so much. It's different. I have to learn how to relate to the two generations down differently and I have to be really aware that the more anxious and out of my depth I feel, the more I have a desire to control things. So I have to pick myself up with that, stop and consider my job as perhaps curating. I will make an observation about your culture as surgeons all over the world. I think you're very good at expressing your opinions as fact. And that can be difficult at very junior level. At your level, Matt, it's fine. You know the difference between whether it's opinion and fact, but for more junior inexperienced people don't, we all have a responsibility to watch out for that.

Gavin

And on that note, I think we'll finish up and thank everyone on the panel for attending this live podcast and also those in the audience for asking questions. This has been my first live podcast and it's been recorded directly at the College of Surgeons annual scientific meeting. And I would like to thank those on the panel and those listening. I'd like to thank you very much for listening to our podcast. I'd like to remind you that the information provided today is just for general medical advice and does not pertain to one particular medical condition or one way of treating a particular condition. If you have any concerns about information raised today, please do not hesitate to contact your general practitioner for further information. We hope you've enjoyed the podcast and please don't hesitate to give us a like or tell your friends about it or give us a positive review. We look forward to presenting another podcast to you in the near future on a different topic. Until then, stay safe. Thank you very much.