Current concepts in teaching and learning in surgery

Current concepts in teaching and learning in surgery

PROFESSIONAL DEVELOPMENT Current concepts in teaching and learning in surgery advances in educational resources and new forms of assessment, both in...

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PROFESSIONAL DEVELOPMENT

Current concepts in teaching and learning in surgery

advances in educational resources and new forms of assessment, both in the workplace and in examinations, is proceeding apace. Not all surgical teaching is directed towards the qualified trainee. It is vital that medical students are exposed to the surgical specialties and receive good education in surgical disease and skills, if we are to recruit the brightest students to our discipline. The decline in application numbers to core and speciality training programmes illustrates the ongoing need to raise the profile of surgery. Increased tuition fees, the importance of ranking of medical schools on the basis of student perceptions in the National Student Survey and realization that student income plays a significant part of Faculty funding has encouraged universities to place more emphasis on quality teaching. Development of academic career pathways in teaching as well as research is driving forward new opportunities in surgical education.

Richard Bamford Frank CT Smith James Coulston

Abstract Modern surgical teaching is evolving at speed. The environment in which we learn and teach is subject to a number of extrinsic pressures. These are influencing ways in which medical students and trainees learn and are taught the discipline of surgery. As a surgical educator it is useful to understand the reasons for these changes and to acquire the skills necessary to provide effective teaching. This short article looks at reasons why one would wish to develop surgical teaching skills, covers basic principles associated with delivery of effective teaching sessions and briefly reviews other avenues that may enhance teaching practice.

Developing as a surgical teacher The General Medical Council (GMC) expects that all doctors will play some role in teaching and acknowledges that the example of the teacher is the most powerful influence upon the standards of conduct and practice of trainees, whether medical students or junior doctors. In Good Medical Practice, the GMC highlights that any doctor ‘should be prepared to contribute to teaching and training doctors and students’ and that those formally involved in teaching ‘must develop the skills, attitudes and practices of a competent teacher’.1 The attributes of the doctor with teaching responsibilities are shown in Box 1, and demonstrate why there is a need for surgeons to undergo educational training. However, there are reasons other than altruism as to why you might choose to develop your surgical teaching abilities. You might wish to include teaching as a formal component of your job plan or to enhance your curriculum vitae for career appointments (Box 2). Formal educational training opens up new opportunities with respect to educational management, organization of teaching and curriculum development. One way to improve teaching competence is to obtain a formal education in teaching methods.

Keywords Competencies; eLearning; human factors; learning; simulation; skills; surgical education; teaching; technology enhanced learning

Introduction Teaching and learning have always been integral to a career in surgery. Changes in modern surgical practice mean that the ways in which surgeons both learn and teach have had to evolve to cope with extrinsic pressures. Increasing patient turnover, refocussing patient care from inpatient to outpatient pathways, shorter hospital stays and increased public accountability means that exposure to clinical materials and operating opportunities are restricted. The European Working Time Directive (EWTD) reduces the number of hours available each week for training. These factors contribute to the long-term apprentice model (sometimes referred to as ‘see, do and then teach’) being replaced by tailored teaching and structured training programmes. If high calibre trainees are to be attracted and complete training, surgical units are obliged to provide quality education and training, rather than merely to acquiesce to service demands. At the same time, development of curricula for surgical specialties, technological

Frank CT Smith BSc MSc (Med Ed) MD FRCS FHEA is Professor of Vascular Surgery and Surgical Education at the University of Bristol, UK. Conflicts of interest: none.

Training the trainers course An excellent opportunity to obtain insight into educational techniques, with the added bonus of being able to practise teaching in a controlled situation, is to participate in a ‘Training the Trainers Course’, such as those run by the Royal College of Surgeons of England.2 Completion of this course is a mandatory requirement of Higher Surgical Training in the UK. Recognizing that much of surgical training takes place in situ, ‘train the trainers’ programmes have been developed in endoscopy and laparoscopic surgery (http://lapco.nhs.uk). The content of these courses includes small group teaching, techniques for facilitating group teaching, planning and structuring teaching sessions, staged approaches to teaching clinical skills, giving and receiving feedback and training without compromising patient safety. Each of these considers development of the individual’s approach to teaching.

James Coulston MSc MBBS FRCS is a Consultant Vascular Surgeon and Core Surgical Training Programme Director in the Severn Deanery; Honorary Senior Lecturer at the University of Bristol, UK. Conflicts of interest: none.

Higher degree If you are interested in developing your teaching abilities further, you may well choose to study for a higher teaching qualification.

Richard Bamford MBBS FRCS FHEA is a Surgical Registrar in the Severn Deanery and Honorary Senior Lecturer at the University of Bristol, UK. Conflicts of interest: none.

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Obtaining a master’s degree in medical or surgical education will generally involve some pedagogical research into educational themes and the writing of a dissertation. Acquisition of the Fellowship of the Higher Education Academy (FHEA) demonstrates that you have complied with criteria described by the UK Professional Standards Framework for teaching and supporting learning in higher education. This may be a valuable asset if contemplating a career in surgical education.

Personal attributes of the doctor with teaching responsibilities (GMC, 1999)1 C C C

C

C

C C C C C

C

An enthusiasm for his/her specialty A personal commitment to teaching and learning Sensitivity and responsiveness to the educational needs of students and junior doctors The capacity to promote development of the required professional attitudes and values An understanding of the principles of education as applied to medicine An understanding of research method Practical teaching skills A willingness to develop both as a doctor and as a teacher A commitment to audit and peer review of his/her teaching The ability to use formative assessment for the benefit of the student/trainee The ability to carry out formal appraisal of medical student progress/the performance of the trainee as a practising doctor

What makes a good teacher? A good teacher aims to be a role model, inspiring student learning. The good teacher encourages learning in an open atmosphere in which each student is at ease asking questions. Learning objectives are established early on in a teaching session, so that students know the boundaries within which they are expected to perform. Teaching is pitched at an appropriate level so that the student remains interested and challenged. The good teacher is organized, enthusiastic and incorporates adequate preparation into their teaching schedule. Teaching sessions should be clearly structured with a summary of the points learned at the end of the session after taking questions. Good preparation will extend to the use of appropriate resources and facilities, simulators, visual aids and provision of lecture notes or handouts. Where feasible, lecture notes or summary slides can be uploaded to a website which the student can access to recap important points or to obtain revision material. Lastly, good teachers don’t cancel sessions at the last minute and although sessions may not always run to time, the teacher will arrive punctually and will deliver teaching at advertised times.

Box 1

Many medical schools run part-time courses in medical education leading to a Certificate of Medical Education or at a higher level to a Diploma, or Masters. These courses tend to offer structured modules in various areas of education with core components such as teaching, learning, evaluation, assessment and course design. These are assessed by course work or written assignments. Modular components include topics such as educational research methods, use of information and communication technologies in education, ethics, mentoring and supervision, developing communication skills, simulation, developing professionalism and using the arts and humanities in medical education.

Preparation for a formal teaching session Ramsden has identified six principles of effective teaching:3  interest and explanation  concern and respect or students and student learning  appropriate assessment and feedback  clear goals and intellectual challenges  independence, control and active engagement  learning from students. If these principles are to be followed a formal teaching session needs to be thoughtfully planned and structured if it is to be effective.

Why should I develop my surgical teaching skills? Personal benefit C Satisfaction C To enhance curriculum vitae for job application, promotion or retention C As part of continuing professional development C Re-accreditation/revalidation C Change in career emphasis

Planning the session Two alternative approaches to session planning are described, the first is based around specifics and the second around competency-based training:

For benefit of students C Improve acquisition of knowledge, skills and behaviours C Improve attainment of learning aims and objectives C Improve performance in assessments C Promote interest in subject

Who am I teaching? You will need to consider this carefully. Are you teaching medical students or trainees and at what stage of their course are they? Is this a masterclass for consultants? How big is the group? What level of knowledge do they already have? Different techniques will be required to teach 4, 8, 24 or 250 students. Try to learn about your students’ backgrounds where feasible and determine whether they have specific problems (i.e. undertaking resit examinations).

For the benefit of the institution C Improve institutional results C Attract students and high quality staff C For quality assurance purposes Box 2

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Where am I teaching? Attention to the environment is an important factor in effective learning. Is the seminar room/ lecture theatre appropriate? Teaching space is increasingly difficult to access in both NHS Trusts and in medical schools. What about lighting, heating and ventilation? It is hard for your students to assimilate finer learning points if they are sitting shivering in a coat. Are flip charts, projectors, simulators and a laser pointer provided or do you need to take them? Are audiovisual facilities appropriate? Will the projector computer in the NHS Trust or university only read an encrypted USB stick? Where are the lecture theatre lighting controls and how do they operate?

Mnemonic for the introduction of a teaching session, MMOP4 Mood e ensure that students feel welcome and at ease Motivation e explaining the relevance of the session content to their future practice or assessments Objectives e outline session learning objectives and be prepared to negotiate these if students have specific learning needs Programme e to give students comprehension of what material will be covered and how this fits into the course curriculum Prior knowledge e establishing this is important so that time is not wasted with unnecessary detail and new knowledge is delivered at an appropriate level

When am I teaching? Arrange protected time, get someone to hold your bleep and remember to turn your phone off. Ensure that your session fits into the learners’ timetable and doesn’t clash with other important commitments or teaching on which the learners will miss out. Ensure the appropriate study leave required to allow adequate time and ensure no distractions has been arranged if possible.

Box 3

Less is more, it is better to teach three or four key concepts well than to cram in material that will be forgotten. Determine what the ‘need to know’ points are, rather than the ‘nice to know’. Vary the stimulus, particularly where learning is largely passive and students are prone to losing concentration. Changing pace or altering teaching technique may prevent attention decay. Interaction promotes active learning, but this takes longer than didactic teaching and additional time is necessary for a fully interactive teaching session and should be budgeted into the lesson plan.

What am I teaching? How does the topic you are teaching fit into the curriculum, what are the learning aims and objectives and how will the material be assessed? (An aim is the broad statement of a teaching session or programme; an objective, the detailed statement of what you expect the student to be able to achieve at completion of the session.) Students learn best if they know what they are setting out to do (aims) and how they are going to achieve this (objectives). Has the subject been addressed previously so that you can adapt existing teaching materials? Do you know the topic and are you prepared? An alternative approach to determining session content is to determine what a student should be able to do by the end of the course/session or what skills they should be able to perform to a requisite standard (competencies). Competencies may be specific (placement of an interrupted mattress suture in a simulated skin pad) or generic (communication skills). When determining learning objectives, one tends to work from a syllabus, whereas with competence or outcome-based teaching sessions planning is determined by what you want from the end product and can often be more focused on the individual learner.

Closing a session well Closing a session effectively is important since this capitalizes on a brief increase in the students’ attention span to reinforce key messages. Hartley et al. provide another useful mnemonic for the session closure (Box 4). Questions should be dealt with in the body of the session, rather than in closing, because there is the real risk that students will otherwise depart remembering the questions rather than key messages. Once the students have left make notes on your lesson plan. What went well and why? What didn’t go so well and why? What could you do to improve the session next time? Are any additional resources necessary? ‘Top tips’ for lesson planning The following eight points may help you as you start to plan teaching sessions:

The session structure Providing a semblance of structure to a teaching session is vital if it is to be effective. The use of a lesson plan will help you to work out session timings and emphasis and will enable you to improve planning for future sessions. A lesson plan should have a clear beginning, middle and end (‘introduction, set and closure’). Hartley et al. qualify important components of the introduction of a teaching session with a useful mnemonic (Box 3). You might use an initial session to outline the course and to set ground rules, for instance with respect to punctuality and questioning. In the middle or body of a session, the students’ interest and participation should be maintained. The body of the session is broken down into mini-topics in which key points are highlighted before moving on. Fluid links between topics should be established. Clinical examples are almost always welcome. You should determine the optimum pace for session delivery so that students remain challenged, but not at a pace at which you lose the slowest learners.

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Mnemonic for the closure of a teaching session, LASTT4 Leave out questions Achievement e let the students know the extent of the ground they have covered. This increases motivation Summarize e this allows repetition of key information and is especially effective if the students themselves summarize key points Think (for student) e encourage the student to practise new found skills soon to reinforce learning Think (for teacher) e reflect for a few minutes on the session Box 4

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learning how to hold the ties, how to cross the hands and how to perform the throw to lay down a square knot). Knowledge is translated into appropriate behaviour in the integrative phase as the student practises, with formative feedback. During this period the student is able to lay down the throws of a knot more fluidly, with fewer interruptions, but still has to think about where to place his hands and how to hold the ties. Finally, in the autonomous phase, practice results in smoother performance of the skill, wherein the student is no longer concentrating on the component parts and has the capacity to concentrate on other parts of the procedure. Once the skill has been learned and reinforced by practice and the student is at the autonomous phase, it is difficult to change habits (ask any golfer trying to correct his swing!). It is therefore important that initial teaching of a skill embeds correct and safe principles at an early stage. This model of teaching has obvious implications for surgical training. Early technical skills training should take place away from the operating theatre, for instance in skills laboratories. Practice is essential until the trainee can undertake the task automatically, allowing he/she to concentrate on the more complex technical and non-technical issues. Finally, once the student has mastered the skill, he/she will still have to practise regularly to maintain proficiency. This is especially important where the skill may be needed in an emergency, which is why, for instance, resuscitation competencies need regular revalidation.

No more than three key objectives for a one-hour lesson. Determine ‘need to know’ versus ‘nice to know’ content. Leave out most ‘nice to know’ content. Highlight ‘need to know’ content and organize session timings to ensure this material receives appropriate attention. Allocate time for introduction and closure this is often forgotten. Divide the body of the session into digestible chunks with appropriate links. Include clinical or other examples to keep students’ attention. Reflect following the session. Keep your lesson plan available for future sessions.

    

Teaching surgical skills Traditionally, teaching surgical skills has relied on the ‘see one, do one, teach one’ principle and volume of exposure has been a surrogate marker of surgical training. With diminishing opportunities for learning skills on ‘real patients’ and increasing emphasis on litigation, this approach is no longer ethically or medico-legally defensible. Considerable work has been undertaken on cognitive and intellectual aspects of surgical training. Surgical skills laboratories allow students to learn and practise on models and simulators and aim to provide them with better foundations for subsequent interaction with patients. Several models exist for teaching surgical skills. Peyton has described a four-stage approach,5 initially the skill is demonstrated to the student by the teacher, first without and then with commentary. The commentary explains and reinforces what is happening, providing the student with aural and visual input. This is followed by the student describing steps in the skill, while the exercise is undertaken by the teacher. Finally, the student undertakes supervised practice of the skill, with formative feedback from the teacher to improve performance. The teacher should try to provide feedback on completion of the exercise, unless the student gets stuck, since continuous feedback during performance of skills exercises inhibits learning. Hartley et al. have described a similar process (Box 5).

Simulation The use of simulation in medical education is an established method of teaching technical and non-technical skills. Recreating realistic environments allows for safe, reproducible and effective training method that is supported by the GMC.7 In surgery, simulation is a useful technique to safely improve procedural skills as well as a tool for assessment. Bench models to teach basic surgical skills are commonplace and may use either synthetic or animal tissue (Figure 1) and include high-fidelity models, such as those used to demonstrate saphenofemoral dissection and ligation and carotid artery stenting,8 however these models are generally more expensive. Simulators are available for laparoscopic and arthroscopic training. Low- and high-fidelity models allow for skill acquisition that can be transferred to the operating room. Task recognition, replication and assessment can all be performed (at medical student, trainee and consultant level) on cost effective low-cost

Motor skills acquisition Reznick and MacRae6 contend that this method of teaching maps onto Fitts and Posner’s three-stage theory of motor skills acquisition. In the cognitive stage, the student has to understand the mechanics of the skill, for instance tying a surgical knot. This may require task-analysis to break down the skill into its component parts and establishing links between the steps (i.e.

A process for teaching surgical skills.4 Activate prior student knowledge Teacher demonstrates skill without commentary Teacher demonstrates skill with commentary Teacher demonstrates skill with student commentary Supervised practise by student with formative feedback from trainer Figure 1 A low-fidelity cost-effective solution to develop a range of basic surgical skills.

Box 5

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Simulated trauma training can significantly reduce the errors associated within these highly stressful situations including medication and transfusion errors and significantly improve the efficiency of trauma management. High-fidelity manikins can be used as trauma patients during simulated in-situ trauma calls allowing for a realistic situation for the trauma team to manage. Adaptations can be made to the manikins to simulate the physical and physiological impact of trauma and the effect of treatment. This can occur as part of a normal working day in the resuscitation room of an emergency department, as part of a course or in the pre-hospital setting. Improvements in teamwork developed during in-situ multi-disciplinary simulated trauma cases have been shown to transfer to the real world setting and as such are a hugely valuable resource.14 More recently, there has been recognition that the surgical ward round is a highly important yet variable entity with increased morbidity if undertaken poorly. Simulation-based ward round training can assess and improve performance in this area and may therefore benefit patient outcomes.15 The development of non-technical skills is essential for surgical trainees. Many trainees will need to develop these skills rapidly and with limited experience while they attempt to simultaneously master technical skills. By introducing these components at an early stage of training and reinforcing their value, trainees will have long lasting tools at their disposal.

simulators. Virtual-reality simulators have been shown to offer valid, reliable and feasible assessments of a trainee’s skills level.9,10 Access to simulators alone is not the solution to developing surgical skills. Ericsson suggests that successfully learning a new skill requires a mechanism for feedback and repetition of the task.11 Regular repetition and aiming beyond basic levels of achievement are also important to prevent the deterioration of a skill. Surgical skills training must have well-defined, specific outcomes and aims and allow for feedback and repeated practice beyond that of the initial training opportunity.

Non-technical skills Technical skills are only one part of surgical training. Nontechnical skills such as clinical judgement, communication, decision making, patient interaction and teamwork are essential components required in trainee surgeons and considered the ‘critical cognitive and interpersonal skills that underpin technical proficiency’.12 Non-technical skills training should not be confused with clinical human factors training. Poor communication and team work issues increase risk of complications and mortality, accounting for up to 70% of adverse events, and are a contributing factor in 24% of malpractice claims.13 Simulation offers the opportunity to train individuals and teams in these skills and does not depend on expensive or complex models to reduce rates of surgical morbidity and increase efficiency. In-situ simulation (Figure 2), where training occurs within the normal working environment has been shown to be beneficial in reducing patient harm when compared to didactic training sessions.13 Figure 3 illustrates the hybrid approach of using a low-fidelity simulator assessing technical skills during a multidisciplinary scenario assessing team nontechnical skills.

Information and communication technology (ICT) and technology enhanced learning Education relies on rapidly emerging technology to a greater extent than ever before. We use computers for many aspects of teaching and teaching development. If you wish to employ ICT in your development as a teacher, then investigation of facilities available may be necessary. At a basic level, the use of computers and ICT

Figure 2 The debrief of a multidisciplinary in-situ training exercise is a valuable part of team training.

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Figure 3 The use of low-fidelity laparoscopic simulators can be used as part of complex simulations to enhance technical and multidisciplinary team training during in-situ exercises.

evidence of learning and achievement of competencies for job applications and in-training appraisals. As a trainer or educational supervisor in the NHS, it is likely that you will already have submitted trainee assessments or references using the NHS e-Portfolio (https://www.nhseportfolios.org/). Another example of an e-Portfolio of value to surgical educators is the revalidation portfolio adopted by the joint Royal Colleges of Surgeons (https://www.surgeonsportfolio.org/).

may be involved in your preparation of graphical slides for teaching, utilizing programs such as Microsoft PowerPoint. Courses, such as the Intercollegiate Basic Surgical Skills Course use a multimedia approach that (including slides, video, audio and text) allows communication of principles, provision of background context and enables close-up demonstration of procedures such as knot tying and suturing. Multiple online learning resources are available to trainees including http://www.surgical-tutor.org.uk, or specific examination programmes such as www.onexamination.com or www. eMRCS.com. If you are a current UK surgical trainee or trainer, working knowledge of the facilities provided by the web-based Intercollegiate Surgical Curriculum Programme (http://www. iscp.ac.uk/) is essential, and it is likely that you will be keeping an electronic log of your surgical procedures (http://www. elogbook.org/). Record keeping of learning objectives, workbased assessments and educational goals achieved in a placement form part of the ISCP electronic portfolio, aiding student reflection, which many Programme Directors use as part of the trainee appraisal process in annual ARCP assessments.

Virtual learning environments A virtual learning environment (VLE) consists of an integrated set of teaching and learning tools designed to enhance the students’ learning experience. Components of a VLE system may include curriculum mapping, student tracking, online support for student and teacher, electronic communication (email, threaded discussions, chat, blogs etc) and Internet links to external resources. Usually in a VLE, students and teacher are assigned an ID. The teacher sees what the student sees but has additional user rights to modify course and learning materials and to track student performance. Examples of commercially available VLE software packages include Moodle, Blackboard, Lotus Learning Space and WebCT. Technology enhanced learning (TEL) is the process of using technology to enhance the learning process. The aim is that the technology allows students to become active in their own learning and development. In this way it goes beyond the use of power point presentations and when used appropriately can enhance a learner’s experience and educational outcomes can be improved. This is particularly relevant as nearly all learners carry with them highly powered and functional computers in the form of their smart phones every day. The use of Apps can make accessing educational resources straightforward and opens a wealth of potential educational resources for the educator and learner. Examples of TEL include:

Electronic portfolios An e-Portfolio is essentially a personalized electronic repository for gathering evidence of learning. It allows the student to enter and store evidence, which may be used to facilitate reflection concerning academic progress and achievement of learning aims and objectives. The developing teacher may keep an e-Portfolio of evidence of teaching, lesson plans, student feedback and assessments, peer-review and appraisals. This will be essential if you want to submit evidence to the Higher Education Academy in application for the Fellowship (FHEA). The e-Portfolio can provide a vehicle for joint discussions between student and tutor, with tools to help the student plan their learning. It can also be used by the learner to present

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rewarding experience for the mentor and mentee and is advocated by the Royal College of Surgeons of England and the British Medical Association (BMA). Gaining training for both the mentors and the mentees can enhance this relationship and a host of training programmes are available.

E-Learning is the process by which learning is made possible through technology. This is a flexible learning tool that can be accessed at times and locations convenient to the learner and adapted to suit their needs. It incorporates but is not limited to web-based data resources, interactive online modules, virtual reality environments and virtual patients. When used as part of a blended learning experience (combining both face to face training and eLearning) these can be highly beneficial teaching tools. A number of free surgical specific modules are available to all trainees and can be used as part of a training programme (https://ecancer.org/education/education.php).

Conclusion This short article has looked at rationale behind improving one’s surgical teaching as well as practical tips on teaching delivery and the use of developing technologies in teaching and learning. It provides an introduction to ways to deliver effective teaching and how technology is changing the ways in which this is delivered. The reader who is keen to obtain up to date information with respect to current and future developments in medical and surgical education. A

WEB 2.0 programmes are tools that support the sharing and communication amongst users often by generating an online community. They encourage active participation, idea sharing and debate in an open or closed forum. These include Wikis that enable multiple users to edit the same web page, allowing on line collaborative learning and resource sharing. They are based on socio-constructivist educational principles. Blogs are basically journals available on the web, typically updated regularly with postings maintained in a chronological order. They are easy to use and personal to the author. Academics may use blogs for instance to generate content related to professional practice, for networking and knowledge sharing, for instructional tips for students, for course announcements and for annotated web-links. Students may use blogs for reflective writing, assignment submission and review, for knowledge management, to share course-related resources, for group work dialogue and for e-portfolios.

REFERENCES 1 GMC. Good medical practice, 2013. Available at https://www. gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/goodmedical-practice (accessed 15 April 2018). 2 https://www.rcseng.ac.uk/education-and-exams/courses/search/ training-the-trainers-developing-teaching-skills/ (accessed 15 April 2018). 3 Ramsden R. Learning to teach in higher education. London: Routledge; 1992. 4 Hartley S, Gill G, Walter K, Carter F, Bryant P. Teaching medical students in primary and secondary care. Oxford University Press; 2003. 5 Peyton JWR. Teaching and learning in medical practice. Rickmansworth, Herts: Manticore Europe Ltd; 1998. 6 Reznick RK, MacRae H. Teaching surgical skills - changes in the wind. N Engl J Med 2006; 355: 2664e9. 7 GMC. The trainee doctor, foundation and specialty, including GP training [online]. Web GMC, 2011. Available http://www.gmc-uk. org/education/postgraduate/standards_and_guidance.asp Feb 2011 (accessed 16 April 2018). 8 Gallagher AG, Cates CU. Approval of virtual reality training for carotid stenting: what this means for procedural-based medicine. J Am Med Assoc 2004; 292: 3024e6. 9 Grantcharov TP, Kristiansen VB, Bendix J, Bardram L, Rosenberg J, Funch-Jensen P. Randomized clinical trial of virtual reality simulation for laparoscopic skills training. Br J Surg 2004; 91: 146e50. 10 Dawe SR, Pena GN, Windsor JA, et al. Systematic review of skills transfer after surgical simulation-based training. Br J Surg 2014; 101: 1063e76. 11 Ericsson KA. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med 2004; 79(10 Suppl): S70e81. 12 Yule S, Flin R, Paterson-Brown S, Maran N, Rowley D. Development of a rating system for surgeons’ non-technical skills. Med Educ 2006; 40: 1098e104. 13 Young-Xu Y, Neily J, Mills Pd, et al. Association between implementation of a medical team training program and surgical morbidity. Arch Surg 2011; 146: 1368e73. 14 Steinemann S, Skinner A, Ditulio A, et al. In situ, multidisciplinary, simulation-based teamwork training improves early trauma care. J Surg Educ 2011; 68: 472e7.

Social media is a rapidly developing area of TEL that allows for sharing of ideas, publications and opinions (some of which are expert) to a large audience and has the affect of a flattening hierarchy. The development of visual abstracts on Twitter allows learners to quickly identify interesting and relevant new research and incorporates social acceptance to research and educational practices. Twitter and other sharing applications can be utilized in the classroom or larger audiences at conferences by displaying opinions, questions and ideas to progress debate. Educational gaming relies on interactive activities within a range of settings including lecture-based environments and audience participation devices, small groups, online modules and examination revision aids. Its aim is to increase engagement and have users commit to decisions and then be able to critically appraise the decisions they have made in a way that reflects reality. It utilizes trainees competitive nature and neuroscience studies have shown gaming with reward (no matter how small) can motivate learners, increase social interaction and drive learning. Many postgraduate centres and academies will have access to gaming software and power point presentations can be adapted to include its use with minimal training16

Mentoring Despite the apparent loss of the apprentice model of education in surgery, many trainees will still benefit from mentoring. This can be part of an official mentoring programme and revolves around guiding trainees through professional and personal development and is different to clinical supervision. It can be a beneficial and

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15 Pucher PH, Aggarwal R, Singh P, Srisatkunam T, Twaij A, Darzi A. Ward simulation to improve surgical ward round performance: a randomized controlled trial of a simulation-based curriculum. Ann Surg 2014; 260: 236e43. 16 Graafland M, Vollebergh Mf, Lagarde Sm, Van Haperen M, Bemelman Wa, Schijven Mp. A serious game can be a valid method to train clinical decision-making in surgery. World J Surg 2014; 38: 3056e62.

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FURTHER READING ASME: Association for the study of medical education (www.asme. org.uk). De Cossart L, Fish D. Cultivating a thinking surgeon. New perspectives on clinical teaching, learning and assessment. tfm Publishing; 2005. Swanwick T, ed. Understanding medical education: evidence theory and practice. 2nd edn. Wiley Blackwell; 2014.

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