In My Opinion

Re-Engineering Resident
by Marion Couch, MD, PhD
Johns Hopkins University
Baltimore, MD, USA

In Otolaryngology – Head & Neck Surgery (OHNS), a high percentage of residency training program graduates pass the American Board of Otolaryngology exam, reinforcing the belief that the residency programs are succeeding in producing competent physicians (1). However, a number of factors suggest that we should be proactive in redesigning aspects of our residency educational systems. While this article is written with OHNS in mind, General Surgery training programs are addressing the same issues as well.

We are witnessing an explosion of new information in medicine with tremendous advances from the human genome project, molecular biology techniques, and gene therapy trials. As this translates into advances in our field, we cannot merely add hours to the day to learn this new knowledge. Indeed, as limitations on resident work hours appear to be imminent, more efficient ways to teach our residents must be developed and implemented. Unfortunately, the current economic environment for the practice of surgery places tremendous production pressure on faculty, which tends to reduce the time available for teaching. Residents also have time pressure upon them as they perform service roles for the hospitals and surgical departments.

When discussing surgical graduate level educational systems, it is important to note that 'training' residents is not the same as the 'education' of residents. Training refers to the technical surgical skills, patient management, and clinical judgment that occur in the operating room, in the clinics and offices, and at the patient's bedside. Education is the didactic teaching that occurs during Grand Rounds, conferences, journal clubs, regional or national courses, and by independent reading. Individual training programs will emphasize different aspects of surgical training, based upon their strengths. And training, with excellent patient care as its cornerstone, will be the responsibility of each program. But a uniform problem of virtually all training programs is the decreased time and resources available for educating residents. It is this component of surgical training that could be addressed at the national level.

Surgical education has lagged behind many other fields in implementing some of the innovations in education. Industry, especially the sales and manufacturing sectors, have proven that Internet learning and other forms of computer based learning results in higher retention, with less time spent learning. Indeed, online learning is 35 – 45 % more efficient than more traditional textbook-based learning (2). Chunks of information that are reusable forms of content allow the learner to delve into areas of interest without reading the entire chapter. This 'just-in-time learning' results in a higher level of learner retention, as the learner can search for just the information they want, when they want it. These chunks of information, often called Reusable Learning Objects (RLOs), can be shared with other online communities, allowing for scaleable programs and content. Since content is a precious resource, this sharing of information is very economical.

The evolution of computer languages will facilitate the ability to search for information and to share learning objects. XML (Extensible Markup Language) is a language for documents containing structured information. It is human-legible and XML links to objects, not just to web pages. Java programs have a modular structure that allows for parts of a program to be reused, which makes it an efficient programming language. Java applications can run on most computers and operating systems as well. Java Server Pages enable a high level of interactivity within a web site.

So, one way to begin to re-engineer resident education is to balance clinical experience (training) with an organized didactic educational program that provides state-of-the-art knowledge supplied by experts across the country (3). This curriculum, which could be developed for head and neck cancer education, would provide the framework for effective learning and the Internet would be the information conduit for the residents. An online curriculum might be used by residency program directors as an aide in planning instruction, but it would only be a guide. An online curriculum would not limit the flexibility of a teaching program nor would it interfere with educational innovation being developed at a teaching site. It should not be an attempt to standardize training programs, as this was not well received when another surgical field attempted this (4). The true curriculum represents the entire learning experience (training and education) while the curriculum document addresses the didactic teaching component. But new areas of importance need to be emphasized in all training programs: ethics, economics of health care, ambulatory surgery, practice administration, evidence-based medicine, patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. Content in these areas, as well as many others, could be shared by all interested training programs.

An online curriculum shouldn't be viewed as an electronic textbook but should be as interactive as possible, using small chunks of information to facilitate 'just-in-time learning.' By using educational innovations to present concepts in small chunks of information, content will be readily searchable. It should link to and complement existing textbooks and journals. Whenever possible, it should link to existing online content sources. Streaming video and audio would enhance the educational experience. Excellent graphic images are well suited for use in online learning. Ideally, the curriculum would be a dynamic document that's reviewed and revised every 3 – 5 years. Educators in the field should be encouraged to contribute to the curriculum and to share educational resources. Finally, it would be important to improve the educational experience with resident-directed surveys and pre- and post-test scores (collected in aggregate only, not individually) (5).

This is just one type of distance learning or e-learning that could be used by residents. Other modules of learning that could be designed for use include examples of virtual endoscopy, streaming videos of surgical procedures, and videos of lectures and conferences. Reusable modules of time-sensitive topics, such as the medical response to certain bioterrorism agents or the mechanism of action of new pharmaceutical agents, could be made available for residents online. If the online learning is of high quality, it will also serve as a way to update practitioners, and can be used as a form of continuing medical education.

For all these reasons, it is my opinion that we should invest in online education and strive to update educational products with the newest technology. Not only will we enhance the education of our residents but also we may instill in them the love of lifelong learning.

REFERENCES:

1. Miller RH: Otolaryngology residency and fellowship training. The resident's perspective. Arch Otolaryngol Head Neck Surg 1994;120;1057-61.
2. Walt AJ: The challenge and a vision for reform of graduate medical education. In: Walt A, Bashook P, Dockery J, Schneidman B, eds. The ecology of graduate medical education. Evanston: American Board of Medical Specialities, 1993:3.
3. Baumgartner WA: Retooling Thoracic Surgery Education for the 21st Century. Ann Thor Surg 1998;65;13-6.
4. Murray GF, Jones DR, Stritter FT: A comprehensive curriculum for thoracic surgery: survey of opinions from program directors and residents. Ann Thor Surg 1995;60;877-87.
5. Schirmer WJ, Galat JA, Morris JB, Persons ML, Shuck JM: The impact of a resident-directed survey on the education curriculum of a university surgical training program. Surgery 1991;110;405-10.