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CSurgeries: An International Perspective with Dr. Juliana Bonilla-Velez

CSurgeries: An International Perspective

Dr. Juliana Bonilla-Velez

PGY 4 – Otolaryngology – Head and Neck Surgery, University of Arkansas for Medical Sciences

 

Tell me a little bit about yourself.

My name is Juliana Bonilla-Velez, and I’m a 4th year resident at the University of Arkansas for Medical Sciences. I’m originally from Colombia, and that’s where I did my medical training. I was very fortunate to work with Dr. Rocco at Mass Eye & Ear Institute as a postdoctoral research fellow on oropharyngeal cancer, and then I came to do my residency training at UAMS. Here, I was also very fortunate to be able to work with Dr. Richter – who is not only one of the founders but an avid promoter of CSurgeries.

He introduced me to CSurgeries very early on in my training. It really is an amazing tool, especially for residents to be able to easily visualize all the things that you are reading!  At times, it can be difficult to put all the aspects of a surgery together (especially if you haven’t seen that type of surgery before) or to learn how different people [surgeons] do things. There are so many different techniques for each type of surgery, so I feel like it’s a great avenue that enriches resident education.

 

Dr. Bonilla-Velez, I understand you published with CSurgeries in June 2016.  What can you tell me about your experience? Was it easy? Difficult?

It was my first experience making a video, so that was a little challenging. I was working together with a medical student and we made a really good team.  She worked a bit more on the media aspect of helping to put the video together, but then we were able to work together and incorporate some of the more technical aspects of the surgery, and important steps and findings to highlight.

In fact, the recording of the procedure was not difficult at all. It did not interfere with the clinical aspect of what we were doing. The surgery went great, and recording did not obstruct it, make it slower or impose any impediment to the completion of the surgery. At the same time, it was very insightful to be able to review all of it and to put it together in a format that would be easy to teach others what was going on. Not only was it a great experience…it was fun!

 

It’s very interesting that as a resident you were able to partner with a medical student to take over the technical aspect of video recording and editing while you were able to oversee and supervise the surgical content. Having recently partnered with the International Association of Student Surgical Societies, it confirms that we’re going in the right direction. 

Absolutely. Even as a medical student, I was very involved in research and publication. I was actually one of the founders of the International Journal of Medical Students which was an amazing experience, but also gave me a better understanding of the other side of making science. From a medical student’s perspective, it is such an enriching and fulfilling experience to be able to participate in all of these avenues for publishing – participate in research projects, writing manuscripts or making videos – just learning how to think in that way, getting your feet wet and learning all of these skills are so important for the rest of your career as a physician, especially now with evidence-based medicine.

 

How has publishing with CSurgeries contributed to education as a surgical resident?

As an author, it was very interesting to be able to go through the process of putting the video together, thinking through all the technical aspects of what we were doing and summarizing it in a short format that would be easy to show others.

As a viewer and user of CSurgeries, it allows you to be able to see different techniques for different types of surgeries. Perhaps the Attending at your institution is doing the procedure one way, but seeing how others are doing it in other places certainly enriches your education. In preparation for surgery, CSurgeries publications allow you to see what the steps are, so you can get a more visual understanding of what it is you are going to be doing and what you’re reading in the books. In surgery, even more so than other specialties, this is critical. Learning in 2D in one thing.  Being able to see in 3D what it is you’re actually going to be seeing in surgery is quite another. For that reason, CSurgeries is definitely a very valuable tool – especially for people in training.

 

As a user of CSurgeries, is there a particular CSurgeries publication you recommend (either within or outside of your specialty) you recommend for our members to view and why?

As a 4th year resident, at least in my program, we haven’t started our otology rotation, so I feel like I struggle a little bit more trying to imagine and put together all the otologic surgeries. I haven’t been exposed to them nor have I seen them before. For that reason, one video that was very useful to me that I really enjoyed was Right Stapedotomy that was published by Dr. Babu at the Michigan Ear Institute. Just seeing the video, especially with the ear (it’s such intricate anatomy) was extremely useful. Having access to such a high-quality video that walks you through the surgery, seeing all the steps clearly, was really great.

Of course, there are going to be personal circumstances for which you would find a video more educational than others- depending on what your institution does or your prior experiences. One of the really neat things about CSurgeries is that there’s so much variety- not only within otolaryngology, but among all the other specialties. It’s got something for everyone.

 

You mentioned you are also a founder of the International Journal of Medical Students. What can you tell me about the IJMS?

Our vision was to create a space that would be made by medical students for medical students to promote research and to provide an avenue for publication that would include all specialties. We aim to speak to medical students who are in a unique part of their training. Not only do we offer a window for them to show their publications, but we are able to help get them to that high-quality level of having a paper that is amenable for publication.

It was also a very exciting to build a team of people that would be able to represent all  – not only from around the globe but also those in different stages of their training. We have mentors who have guided us from the beginning, taught us to put all these pieces together and to provide not only an avenue but a service for medical students worldwide where they can publish their work and learn. Especially nowadays where medicine is guided by the paradigm of Evidence-Based Medicine, it’s critical for physicians to be able not only to do research but to understand the research that is published. It serves to train both the authors and the students who are learning to be the editors about all the different aspects of the publication process.  It’s been a really very rewarding experience knowing we’ve been able to contribute to medical students’ education worldwide.

 

How is publishing with CSurgeries different from publishing with IJMS? How are they similar?

It’s different in the sense that the CSurgeries is a video peer-reviewed journal. It’s very visually perfect for the surgical field because it takes you through the novel of each surgery by  showing what the key structures are and the key steps you need to be doing. It’s very educational, especially for people in training. In terms of similarities, both aim to educate physicians, students and other surgeons. IJMS provides an avenue for written publication of research along with the more traditional strategies while CSurgeries provides an avenue for video publication. Both share a common mission of education.

 

What advice do you have for international medical graduates looking to pursue surgical residency in the United States?

It’s certainly a very difficult task, but at the same time, it can be immensely rewarding. You have to be very passionate about what you want to do, what you want to accomplish, and what you want for your life. If your goals are clear and you can translate all that passion into hard work and dedication to your specialty, that goes a long way. It’s certainly hard but not impossible. I’d highly encourage you to push through the difficulties if you feel that’s your life mission. Don’t give up on your dreams.

 

What would you be doing if you were not a surgeon?

Oh gosh! There is nothing else I would rather be doing! I wish I could have a parallel life to be able to do all the things I want to do, but all at the same time. But certainly the life I would not give up is being a future pediatric otolaryngologist and be able to continue to participate in academics, in research and education, and in clinical practice and leadership.  I look forward to playing a part in furthering the field.

Watch Dr. Juliana Bonilla-Velez’s video Excision of Thyroglossal Duct Cyst here.

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The Great Divide: Bringing educational theory to practice in surgical education

by Dr. Eric Gantwerker, Vice President of Education, CSurgeries

This post originally appeared in the Harvard Macy Community Blog

 

This time last year I was sitting in a classroom at the school of education, learning about metacognition, reflection, and deep understanding.  It had only been 18 short years since I graduated high school and I couldn’t help but wonder – How did I get here?  I had finished my ear, nose, and throat (ENT) surgical training and quickly went from learning about resecting cancer and performing airway reconstruction to learning about teaching for understanding.

Over the previous 6 months I went from reading books from ENT legendaries like Dr. Charles Cummings and Dr. Jonas Johnson, to readings by education legendaries Edward Thorndike, Jean Piaget, Howard Gardner, and Carol Dweck.  I asked myself, what am I doing here and why do I keep pursuing more graduate education?

I realized that I was in this classroom to learn about learning and somehow parlay it into improving my own teaching, and hopefully, that of those around me.  I felt somewhat disenfranchised with the state of surgical education today.  Advances in the cognitive theory of learning were spreading like wildfire through K-12 and secondary education that, traditionally, have been missing in medical training.  As I sat there, I contemplated ways to adapt the lessons learned and bring cognitive theory to surgical education.

I preface this all with the fact that many of my instructors along my educational journey are excellent teachers, as are many people reading this post.  I also realize that everyone is a teacher and a learner everyday in their lives; whether to patients, friends, relatives, or peers, everyone teaches someone something sometime.  My goal with this post is to deconstruct our own teaching experiences and to connect them to underlying cognitive learning principles, so that we may adapt and magnify them to make ourselves more efficient and efficacious educators.

Novice-Expert Shift, Zone of Proximal Development (ZPD), and Desirable Difficulty

Theory:  The novice-expert shift is the journey our trainees take as they go from not knowing what they don’t know (true novice) to becoming experts in their field.  During this journey, they follow a path that is domain-specific and different for every student.  For example, they may develop laparoscopic skills much more swiftly than soft tissue skills, or vice versa.  The importance of this in surgical education is that no student’s growth in every domain will follow a straight line corresponding to his or her year in training.  [See Pusic et al. for more on learning curves in health professions education].  This is the principle behind competencies and milestones rapidly making their way into medical education.  Despite the recent implementation of these principles, I still hear attending surgeons say, “I never let a third year resident insert a cochlear implant or let 2nd year residents do X”.  I still see colleagues lecturing students with the same talk they gave at conferences in years past without ascertaining where their level of understanding of their audience or leveraging their base knowledge on the subject.

The Zone of Proximal Development (ZPD) essentially lies on either side of the student growth curve and delineates the boundaries of tasks that will result in positive student learning  [See Vygotsky (1978) for more on ZPD or DiSessa (2000) on Regime of Competence].  Tasks too far below this zone are too simple and will not result in moving students much along their growth curve.  Too far above and the task is too difficult to complete, leading to learner frustration and stagnation.  The sweet spot, or what I call the Goldilocks zone, is where the student will be maximally challenged and advance furthest along their learning continuum. If you target the zone above the curve, for both cognitive and practical skills, you will maximize their growth.

Application to Practice:  In my teaching, I try to remain agnostic to residents’ training year and gauge their skill in each domain based on their own insight into their abilities, and what they demonstrate in the operating room.  Intuitively, we all probably give trainees graduated responsibilities that will stretch their capabilities.  I try to take this further and ask every individual trainee, before a case, where they are along their continuum of learning for that particular case and where they want to be after.  This requires the instructor to meet with the resident before the case or before the day starts to assess their base knowledge or skill.  Often, due to time constraints, this isn’t practical but, again, if we want to be the most efficient at teaching our residents we need to keep these concepts in mind.  During the case I give them more and more difficult tasks in a sort of game to figure out where the limit of their zone is and we stay right at that level until the case is over.  I then ask them three simple questions after each case:  “What could I have done better as an instructor?  What are areas you would like to improve on as a surgeon?  What could have everyone done better as a team?”  I try to engage the OR staff and anesthesiology team in the last question as often our cases employ the shared airway principle between our two teams.  This reflection and metacognition on our experience is another principle that we will cover another time, but is vital to their learning.  Here is where, as the expert, we can assess their insight and get a gauge of their progression on their learning continuum.

Implicit knowledge to Explicit knowledge, Context, and Schema Formation

Theory:  When I get a first-year medical student in my clinic in OR, it is extremely difficult, dare I say impossible, to imagine what it was like to be at that level.  One major barrier is that as an expert, you have highly refined and streamlined information storage in your head, and have automatized many cognitive tasks.  This organizational strategy or ‘schema’ is very individualized and content-specific.  In deciding which bookshelf to store information in your head, you have made it the most efficient for retrieval when needed and attached to other similar nuggets of information.  Along with this, as an expert, you have cleared space on the shelves by pushing out elements of information that are no longer needed because they are implicit.  You no longer need to remember that the right pedal makes the car go forward and the left one makes the car slow down.  These assumptions and automations you have introduced into practice are very difficult to unpack for the novice learner.  Imagine explaining how to drive to the grocery store to someone who has never driven a car before.  As a teacher it is very difficult to unpack every little important detail needed and make them explicit for the learner.  Master teachers are able to take their schema for a particular topic, fully deconstruct it into its component parts and transfer that knowledge in a sensible fashion to their students.

Application to Practice:  I try to imagine myself trying to learn something for the first time.  Last year I learned the basics of how to write code for websites.  I realized that a major barrier to learning anything was that you had to get the basic words that people use and understand the context in which they are used.  I had to start out by understanding what ‘h1’ meant and why it mattered.  James Paul Gee in his book What Video Games Have to Teach Us About Learning and Literacy discusses ‘situated cognition’ and ‘situated meaning.’  He explains that words are context- and domain specific and uses the term ‘work’ as an example.  This word means something totally different to human resources versus a physics professor.  We must think about the efficacy of the message if the true novice doesn’t know the words or context, especially in the context of surgery, the operating room, or even medicine.  This is the same principle we must remember when explaining surgery to our patients or families.

As I go through the surgery I try to unpack things in my own head before describing it piecemeal to the trainee.  I encourage the resident to call me out when I skip over something or they feel I made an assumption.  Residents often feel apprehensive to point out weak knowledge areas so it is essential I set up a safe learning environment.  This is also exemplified during our post procedure feedback session where we undergo a frank discussion of what went well, what needs work and how to proceed.

Cognitive Load and Chunking

Theory: Cognitive load is familiar to most.  It is essentially the mental capacity of someone to absorb information in a given learning experience.  This is traditionally split into intrinsic, extrinsic, and germane load.  These loosely can be seen as the complexity of the learning content itself, the complexity of how the content is delivered, and the mental energy needed to internalize the information.   Chunking is one technique to lower the intrinsic cognitive load by only including smaller, digestible pieces of information.  The cognitive load of any learning experience, cognitive or procedural, can be managed this way.

Application to Practice:  My attending in fellowship, David Roberson, had a great way to put this into practice.  When he taught tonsillectomy, he would do the first 90% of the surgery and then allow the trainee to finish the surgery.  The next time he would do 60% and so on until the resident was doing the whole case.  Without him knowing, he was chunking the information and managing the cognitive load so residents could focus on the task at hand.  It was also backwards design in some sense as the resident saw what the finished product looked like and could just focus on getting to the next point in the case.  They also focused on the easiest part of the case first and repeated completing the case a multitude of times instead of messing with putting the mouth gag in, initially grasping the tonsil, and finding the capsule (often the harder parts of the procedure).  When I start cases with residents I think about what they want to focus on so I can manage the cognitive load and move them along their learning curve and not dwell on things they have already mastered.

Conclusion

Over the last year and a half I have come to realize that the cognitive psychology of learning is not as scary as I had originally thought.  It underpins what many of us know as good teaching strategies.  I realize for many of us bringing theory to practice can seem overwhelming.  I found that starting with just one strategy, i.e. managing my own cognitive load, made a huge impact on my teaching.  Over time I have instituted many other cognitive principles and continue to look for ways to incorporate them into my every day teaching of students, residents, and fellows.  Which of these principles do you intend to include in your practice?   Comment on the blog to share specific strategies with our community!

 

Have a question you would like to ask Dr. Gantwerker? Feel free to post a comment or send him an email at Eric.Gantwerker@csurgeries.com