- Email: [email protected]
Visual Learning: Harnessing Images To Educate Residents Optimally
ASE OUT OF THE BOX
Visual Learning: Harnessing Images To Educate Residents Optimally Kenneth W. Gow, MD Department of General and Thoracic Surgery, Seattle Children’s Hospital and the University of Washington, Seattle, Washington Surgical educators are confronted with outdated models of education and less time for teaching. Digital images present an opportunity for a new method of education. In this method, students are presented with a series of key images, each representing an important teaching point (radiographs, patient external images, operative images, and histopathology images) and asked to construct a corresponding case presentation. In this fashion, the traditional presentation is disassembled and the learner is responsible for teaching his or her colleagues. By incorporating surgical images into the teaching process, the teacher enhances insight and learning. In addition, by prompting the students to add creative elements to the thought process for diagnosis and management, the teaching format can be a dynamic and interactive process. (J Surg 66:392-394. © 2009 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: education, resident, surgery, visual COMPETENCY: Patient Care, Medical Knowledge, Practice
Based Learning and Improvement
BACKGROUND The clinical and administrative responsibilities of the educator and the duty-hour restrictions on learners lead to challenges for surgical resident education.1,2 However, the technologic advancements in digital imaging provide surgical educators with a wealth of educational resources.3-7 By harnessing images to educate residents optimally (HIERO), the surgeon can use a timeefficient and effective method for promoting and integrating the learner’s knowledge base.
METHOD AND MATERIALS For defined topics, the educator determines the important teaching points and selects the images that illustrate these points (Fig. 1).
Correspondence: Inquiries to Kenneth W. Gow, MD, General and Thoracic Surgery, Seattle Children’s Hospital, 4800 Sand Point Way NE, M/S W-7729, P.O. Box 5371, Seattle, WA 98105; fax: (206) 987-3925; e-mail: [email protected]
392
Images may include but are not limited to surface anatomy or anomalies, diagnostic images (radiographs, ultrasounds, computed tomography [CT], and positron emission tomography), intraoperative images, and histopathology. Sources for high-quality digital images are plentiful: high-resolution digital cameras8; picture archiving and communication systems;9,10 high-definition laparoscopic cameras; headlight cameras; intraoperative light-mounted cameras; scanned images from textbooks and journals; images clipped from portable document format articles; and the Internet.11 The selected images may be edited even more using digital photographic tools (eg, Adobe Photoshop; Adobe Systems Incorporated, San Jose, California).12,13 Each image is placed in a format the student can access, either printed on paper or placed into a digital presentation (eg, Microsoft PowerPoint; Microsoft Corporation, Redmond, Washington) either for liquid crystal display (LCD) screens (laptop, computer screens, personal digital assistant, or smart phone) or for LCD projection. Each group of images represents 1 “patient.” If the class size is large, then students are grouped into teams, each handling 1 set of images. To enhance the educational experience, students should be provided reading materials before the date of the planned educational session.14 During the group educational session, the educator instructs the learners on the format and informs them of specific features on which they should focus (eg, signs, symptoms, anatomy, radiologic findings, surgical steps, and/or histologic findings). Within the time frame that has been allocated, the first 5 minutes will be used for the student or student teams to review their images and assemble them into a plausible case scenario (Fig. 2). The learner(s) will then present their “patient” to the group. They may add creative flourishes to the story. The educator will guide the presentations and will highlight important teaching points. If the students are off track, it will be an opportunity for the teacher to redirect and clarify. A short summary slide or handout after the cases can be used to reinforce teaching points.
EXAMPLE—TOPIC: SURGERY AND THE SPLEEN The educator provides learners with a review article on the topic. Four cases with the following key images are presented:
Journal of Surgical Education • © 2009 Association of Program Directors in Surgery Published by Elsevier Inc. All rights reserved.
1931-7204/09/$30.00 doi:10.1016/j.jsurg.2009.07.012
FIGURE 1. Educator putting together the cases.
case 1— happy fourth birthday card, family tree depicting autosomal dominant inheritance, examination blood smear demonstrating spherocytes, and operative image showing laparoscopic splenectomy ⫽ herediatry spherocytosis; case 2—picture of an antibody, bruises, bottle of methylprednisolone, dose of intravenous immunoglobulin, and accessory spleen ⫽ idiopathic thrombocytopenic purpura; case 3—ruptured spleen, bottle of penicillin, microscopic view of meningococcus, and patient in intensive care unit ⫽ overwhelming post-splenic infection; case 4 —football player being hit on the left side of the abdomen, abdominal ultrasound showing blood around spleen, CT scan image of shattered spleen, and splenectomy ⫽ grade V splenic laceration.
DISCUSSION The surgical educator is faced with many challenges, the most important of which is the lack of time to put together and present educational sessions.2 However, the current student has been educated mainly through case-based education, and most have grown up in a visual and digital age. Taken together, the HIERO method addresses many of the current challenges in an educational, engaging, and fun manner. Surgeons know the pertinent points that need to be passed onto the learner. For the educator, HIERO is an efficient means to educate because it only requires the educator to assemble the images. In most situations, surgeons already possess many of the images, often already in digital format. Therefore, preparation for an educational session will be abbreviated. For the learner, a teaching session should encompass the pertinent topics in an easily absorbed and integrated fashion. In what has been deemed “Death by Powerpoint,”15 traditional didactic lectures are considered the least effective method to deliver information because students become disengaged in the learning process.16 Unlike passive learners, active learners are more engaged and more likely to absorb the information.17
HIERO actively prompts the learner to assemble the information and present a “story.” Such creation of virtual cases has been shown to be a useful format for education18 because residents learn best with problem-based learning.19 Also, using images for learning has been found to be an effective tool for adult learning.20 Furthermore, HIERO promotes student engagement and taps into their inherently competitive nature. Studies also have shown that residents serving as educators leads to an increased acquisition of knowledge.21 Also, when students work together, the value of teamwork is promoted, which has also been shown to enhance learning.22,23 Finally, HIERO lends itself to speaking in front of a group of peers; this skill improves only with practice. Podium-based lectures require the proper setup, including the room, computer, projector, and screen, thus creating a formal setting that discourages participation by the students because they are clearly relegated to the role of the passive “audience.” The current method removes the need for such formal settings as the digital photos can be shown to the students in a variety of ways, such as printed, projected, laptop, or handheld devices.24 The method works equally well in a small or large group setting. If the teacher encourages the students to add creative embellishments to the case, it can become a fun event. Because cases can be enhanced with many details and possibilities and because our culture is permeated with medical shows and movies, students find creating stories to support their presentations, which is a natural and enjoyable process. By providing educational materials for reading before the educational image session, the teacher will most effectively maximize the educational experience. This promotes learner reading and will then inspire rapid application of their readings around cases. Something that may be viewed as “practice” for patient care can take on an aura of reality as the images they view are from patients and, when assembled, can be observed as a complete patient presentation. This leads to the integration and processing of information and makes it relevant in a way that a
FIGURE 2. Learners using the cases to discuss points.
Journal of Surgical Education • Volume 66/Number 6 • November/December 2009
393
simple lecture cannot. Even if the students are off track, it may still be an important teaching moment. In conclusion, HIERO is a rapid method for assembling and administering education materials. It is a flexible method that engages the student in a fun and time-efficient manner. Because it makes what the student read relevant, real, and memorable, the author would encourage the educator to try this novel tool for future educational endeavors.
11. Candler CS, Uijtdehaage SH, Dennis SE. Introducing
HEAL: the Health Education Assets Library. Acad Med. 2003;78:249-253. 12. Kirsch J, Geller BS. Using Photoshop filters to create an-
atomic line-art medical images. Acad Radiol. 2006;13: 1035-1037. 13. Corl FM, Garland MR, Lawler LP, Fishman EK. A five-
step approach to digital image manipulation for the radiologist. Radiographics. 2002;22:981-992.
REFERENCES
14. Southwick FS, Theodore E. Woodward award: Spare me
1. Mittal V, Salem M, Tyburski J, et al. Residents’ working
hours in a consortium-wide surgical education program. Am Surg. 2004;70:127-131. 2. Mathis BR, Diers T, Hornung R, Ho M, Rouan GW.
the PowerPoint and bring back the medical textbook. Trans Am Clin Climatol Assoc. 2007;118:115-122. 15. Harden RM. Death by PowerPoint—The need for a
“fidget index”. Med Teach. 2008;30:833-835.
Implementing duty-hour restrictions without diminishing patient care or education: can it be done? Acad Med. 2006;81:68-75.
16. Richardson D. Don’t dump the didactic lecture; fix it.
3. Riley RS, Ben-Ezra JM, Massey D, Slyter RL, Romagnoli
G. Digital photography: a primer for pathologists. J Clin Lab Anal. 2004;18:91-128.
BF. A controlled trial of active versus passive learning strategies in a large group setting. Adv Health Sci Educ Theory Pract. 2004;9:15-27.
4. Pritt B, Gibson P, Cooper K, Hardin N. What is a picture
18. Demichelis F, Barbareschi M, Dalla Palma P, Forti S. The
worth? Digital imaging applications in autopsy reports. Arch Pathol Lab Med. 2004;128:1247-1250.
virtual case: a new method to completely digitize cytological and histological slides. Virchows Arch. 2002;441:159164.
5. Durfee SM, Jain S, Shaffer K. Incorporating electro-
Adv Physiol Educ. 2008;32:23-24. 17. Haidet P, Morgan RO, O’Malley K, Moran BJ, Richards
nic media into medical student education: a survey of AMSER members on computer and web use in radiology courses. Alliance of medical student educators in radiology. Acad Radiol. 2003;10:205-210.
19. Ozuah PO, Curtis J, Stein RE. Impact of problem-based
6. Dumery B. Digital image archiving: challenges and
strategies for teaching adults: using visual media to engage the adult learner. Gerontol Geriatr Educ. 2008;29:234238.
choices. Radiol Manage. 2002;24:30-38. 7. Tran TH, Roach NA, O’Kane PL, Thune M. Creating a
digital radiographic teaching file and database using a PC and common software. AJR Am J Roentgenol. 2000;175: 325-327. 8. Elbeshbeshy B, Trepman E. Digital photography in or-
thopaedic surgery. Foot Ankle Int. 2001;22:67-74.
learning on residents’ self-directed learning. Arch Pediatr Adolesc Med. 2001;155:669-672. 20. Myers DR, Sykes C, Myers S. Effective learner-centered
21. Weiss V, Needlman R. To teach is to learn twice. Resident
teachers learn more. Arch Pediatr Adolesc Med. 1998;152: 190-192. 22. Haidet P, O’Malley KJ, Richards B. An initial experience
with “team learning” in medical education. Acad Med. 2002;77:40-44.
9. Lim CC, Yang GL, Nowinski WL, Hui F. Medical image
23. Kuhne-Eversmann L, Eversmann T, Fischer MR. Team-
resource center—Making electronic teaching files from PACS. J Digit Imaging. 2003;16:331-336.
and case-based learning to activate participants and enhance knowledge: an evaluation of seminars in Germany. J Contin Educ Health Prof. 2008;28:165-171.
10. Rosset A, Ratib O, Geissbuhler A, Vallee JP. Integration
of a multimedia teaching and reference database in a PACS environment. Radiographics. 2002;22:1567-1577.
394
24. Yam CS. Projecting PowerPoint presentations with a
PDA. AJR Am J Roentgenol. 2005;184:1356-1359.
Journal of Surgical Education • Volume 66/Number 6 • November/December 2009
Visual Learning: Harnessing Images To Educate Residents Optimally Kenneth W. Gow, MD Department of General and Thoracic Surgery, Seattle Children’s Hospital and the University of Washington, Seattle, Washington Surgical educators are confronted with outdated models of education and less time for teaching. Digital images present an opportunity for a new method of education. In this method, students are presented with a series of key images, each representing an important teaching point (radiographs, patient external images, operative images, and histopathology images) and asked to construct a corresponding case presentation. In this fashion, the traditional presentation is disassembled and the learner is responsible for teaching his or her colleagues. By incorporating surgical images into the teaching process, the teacher enhances insight and learning. In addition, by prompting the students to add creative elements to the thought process for diagnosis and management, the teaching format can be a dynamic and interactive process. (J Surg 66:392-394. © 2009 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: education, resident, surgery, visual COMPETENCY: Patient Care, Medical Knowledge, Practice
Based Learning and Improvement
BACKGROUND The clinical and administrative responsibilities of the educator and the duty-hour restrictions on learners lead to challenges for surgical resident education.1,2 However, the technologic advancements in digital imaging provide surgical educators with a wealth of educational resources.3-7 By harnessing images to educate residents optimally (HIERO), the surgeon can use a timeefficient and effective method for promoting and integrating the learner’s knowledge base.
METHOD AND MATERIALS For defined topics, the educator determines the important teaching points and selects the images that illustrate these points (Fig. 1).
Correspondence: Inquiries to Kenneth W. Gow, MD, General and Thoracic Surgery, Seattle Children’s Hospital, 4800 Sand Point Way NE, M/S W-7729, P.O. Box 5371, Seattle, WA 98105; fax: (206) 987-3925; e-mail: [email protected]
392
Images may include but are not limited to surface anatomy or anomalies, diagnostic images (radiographs, ultrasounds, computed tomography [CT], and positron emission tomography), intraoperative images, and histopathology. Sources for high-quality digital images are plentiful: high-resolution digital cameras8; picture archiving and communication systems;9,10 high-definition laparoscopic cameras; headlight cameras; intraoperative light-mounted cameras; scanned images from textbooks and journals; images clipped from portable document format articles; and the Internet.11 The selected images may be edited even more using digital photographic tools (eg, Adobe Photoshop; Adobe Systems Incorporated, San Jose, California).12,13 Each image is placed in a format the student can access, either printed on paper or placed into a digital presentation (eg, Microsoft PowerPoint; Microsoft Corporation, Redmond, Washington) either for liquid crystal display (LCD) screens (laptop, computer screens, personal digital assistant, or smart phone) or for LCD projection. Each group of images represents 1 “patient.” If the class size is large, then students are grouped into teams, each handling 1 set of images. To enhance the educational experience, students should be provided reading materials before the date of the planned educational session.14 During the group educational session, the educator instructs the learners on the format and informs them of specific features on which they should focus (eg, signs, symptoms, anatomy, radiologic findings, surgical steps, and/or histologic findings). Within the time frame that has been allocated, the first 5 minutes will be used for the student or student teams to review their images and assemble them into a plausible case scenario (Fig. 2). The learner(s) will then present their “patient” to the group. They may add creative flourishes to the story. The educator will guide the presentations and will highlight important teaching points. If the students are off track, it will be an opportunity for the teacher to redirect and clarify. A short summary slide or handout after the cases can be used to reinforce teaching points.
EXAMPLE—TOPIC: SURGERY AND THE SPLEEN The educator provides learners with a review article on the topic. Four cases with the following key images are presented:
Journal of Surgical Education • © 2009 Association of Program Directors in Surgery Published by Elsevier Inc. All rights reserved.
1931-7204/09/$30.00 doi:10.1016/j.jsurg.2009.07.012
FIGURE 1. Educator putting together the cases.
case 1— happy fourth birthday card, family tree depicting autosomal dominant inheritance, examination blood smear demonstrating spherocytes, and operative image showing laparoscopic splenectomy ⫽ herediatry spherocytosis; case 2—picture of an antibody, bruises, bottle of methylprednisolone, dose of intravenous immunoglobulin, and accessory spleen ⫽ idiopathic thrombocytopenic purpura; case 3—ruptured spleen, bottle of penicillin, microscopic view of meningococcus, and patient in intensive care unit ⫽ overwhelming post-splenic infection; case 4 —football player being hit on the left side of the abdomen, abdominal ultrasound showing blood around spleen, CT scan image of shattered spleen, and splenectomy ⫽ grade V splenic laceration.
DISCUSSION The surgical educator is faced with many challenges, the most important of which is the lack of time to put together and present educational sessions.2 However, the current student has been educated mainly through case-based education, and most have grown up in a visual and digital age. Taken together, the HIERO method addresses many of the current challenges in an educational, engaging, and fun manner. Surgeons know the pertinent points that need to be passed onto the learner. For the educator, HIERO is an efficient means to educate because it only requires the educator to assemble the images. In most situations, surgeons already possess many of the images, often already in digital format. Therefore, preparation for an educational session will be abbreviated. For the learner, a teaching session should encompass the pertinent topics in an easily absorbed and integrated fashion. In what has been deemed “Death by Powerpoint,”15 traditional didactic lectures are considered the least effective method to deliver information because students become disengaged in the learning process.16 Unlike passive learners, active learners are more engaged and more likely to absorb the information.17
HIERO actively prompts the learner to assemble the information and present a “story.” Such creation of virtual cases has been shown to be a useful format for education18 because residents learn best with problem-based learning.19 Also, using images for learning has been found to be an effective tool for adult learning.20 Furthermore, HIERO promotes student engagement and taps into their inherently competitive nature. Studies also have shown that residents serving as educators leads to an increased acquisition of knowledge.21 Also, when students work together, the value of teamwork is promoted, which has also been shown to enhance learning.22,23 Finally, HIERO lends itself to speaking in front of a group of peers; this skill improves only with practice. Podium-based lectures require the proper setup, including the room, computer, projector, and screen, thus creating a formal setting that discourages participation by the students because they are clearly relegated to the role of the passive “audience.” The current method removes the need for such formal settings as the digital photos can be shown to the students in a variety of ways, such as printed, projected, laptop, or handheld devices.24 The method works equally well in a small or large group setting. If the teacher encourages the students to add creative embellishments to the case, it can become a fun event. Because cases can be enhanced with many details and possibilities and because our culture is permeated with medical shows and movies, students find creating stories to support their presentations, which is a natural and enjoyable process. By providing educational materials for reading before the educational image session, the teacher will most effectively maximize the educational experience. This promotes learner reading and will then inspire rapid application of their readings around cases. Something that may be viewed as “practice” for patient care can take on an aura of reality as the images they view are from patients and, when assembled, can be observed as a complete patient presentation. This leads to the integration and processing of information and makes it relevant in a way that a
FIGURE 2. Learners using the cases to discuss points.
Journal of Surgical Education • Volume 66/Number 6 • November/December 2009
393
simple lecture cannot. Even if the students are off track, it may still be an important teaching moment. In conclusion, HIERO is a rapid method for assembling and administering education materials. It is a flexible method that engages the student in a fun and time-efficient manner. Because it makes what the student read relevant, real, and memorable, the author would encourage the educator to try this novel tool for future educational endeavors.
11. Candler CS, Uijtdehaage SH, Dennis SE. Introducing
HEAL: the Health Education Assets Library. Acad Med. 2003;78:249-253. 12. Kirsch J, Geller BS. Using Photoshop filters to create an-
atomic line-art medical images. Acad Radiol. 2006;13: 1035-1037. 13. Corl FM, Garland MR, Lawler LP, Fishman EK. A five-
step approach to digital image manipulation for the radiologist. Radiographics. 2002;22:981-992.
REFERENCES
14. Southwick FS, Theodore E. Woodward award: Spare me
1. Mittal V, Salem M, Tyburski J, et al. Residents’ working
hours in a consortium-wide surgical education program. Am Surg. 2004;70:127-131. 2. Mathis BR, Diers T, Hornung R, Ho M, Rouan GW.
the PowerPoint and bring back the medical textbook. Trans Am Clin Climatol Assoc. 2007;118:115-122. 15. Harden RM. Death by PowerPoint—The need for a
“fidget index”. Med Teach. 2008;30:833-835.
Implementing duty-hour restrictions without diminishing patient care or education: can it be done? Acad Med. 2006;81:68-75.
16. Richardson D. Don’t dump the didactic lecture; fix it.
3. Riley RS, Ben-Ezra JM, Massey D, Slyter RL, Romagnoli
G. Digital photography: a primer for pathologists. J Clin Lab Anal. 2004;18:91-128.
BF. A controlled trial of active versus passive learning strategies in a large group setting. Adv Health Sci Educ Theory Pract. 2004;9:15-27.
4. Pritt B, Gibson P, Cooper K, Hardin N. What is a picture
18. Demichelis F, Barbareschi M, Dalla Palma P, Forti S. The
worth? Digital imaging applications in autopsy reports. Arch Pathol Lab Med. 2004;128:1247-1250.
virtual case: a new method to completely digitize cytological and histological slides. Virchows Arch. 2002;441:159164.
5. Durfee SM, Jain S, Shaffer K. Incorporating electro-
Adv Physiol Educ. 2008;32:23-24. 17. Haidet P, Morgan RO, O’Malley K, Moran BJ, Richards
nic media into medical student education: a survey of AMSER members on computer and web use in radiology courses. Alliance of medical student educators in radiology. Acad Radiol. 2003;10:205-210.
19. Ozuah PO, Curtis J, Stein RE. Impact of problem-based
6. Dumery B. Digital image archiving: challenges and
strategies for teaching adults: using visual media to engage the adult learner. Gerontol Geriatr Educ. 2008;29:234238.
choices. Radiol Manage. 2002;24:30-38. 7. Tran TH, Roach NA, O’Kane PL, Thune M. Creating a
digital radiographic teaching file and database using a PC and common software. AJR Am J Roentgenol. 2000;175: 325-327. 8. Elbeshbeshy B, Trepman E. Digital photography in or-
thopaedic surgery. Foot Ankle Int. 2001;22:67-74.
learning on residents’ self-directed learning. Arch Pediatr Adolesc Med. 2001;155:669-672. 20. Myers DR, Sykes C, Myers S. Effective learner-centered
21. Weiss V, Needlman R. To teach is to learn twice. Resident
teachers learn more. Arch Pediatr Adolesc Med. 1998;152: 190-192. 22. Haidet P, O’Malley KJ, Richards B. An initial experience
with “team learning” in medical education. Acad Med. 2002;77:40-44.
9. Lim CC, Yang GL, Nowinski WL, Hui F. Medical image
23. Kuhne-Eversmann L, Eversmann T, Fischer MR. Team-
resource center—Making electronic teaching files from PACS. J Digit Imaging. 2003;16:331-336.
and case-based learning to activate participants and enhance knowledge: an evaluation of seminars in Germany. J Contin Educ Health Prof. 2008;28:165-171.
10. Rosset A, Ratib O, Geissbuhler A, Vallee JP. Integration
of a multimedia teaching and reference database in a PACS environment. Radiographics. 2002;22:1567-1577.
394
24. Yam CS. Projecting PowerPoint presentations with a
PDA. AJR Am J Roentgenol. 2005;184:1356-1359.
Journal of Surgical Education • Volume 66/Number 6 • November/December 2009