Time and practice are necessary for an orthopaedic resident to master the technical skills required to perform musculoskeletal surgery. Learning those skills is challenged by time constraints from work hour regulations, time pressures on both surgeon-teachers and resident-learners, and the limited tool-skills brought to the program by junior residents. The classical (apprentice) learning models used now, especially those that teach technical skills, are procedure oriented, involve emulation and self-shaping (learning) of complex activities and extend over the duration of the residency. These models can be tedious, discouraging and result in slow progress. In contrast, learning methods that employ positive operant learning can be reliable, quick, and motivating.
Operant learning is based on the fact that a behavior is more likely to occur if it is reinforced. Reinforcers used to mark the achievement of a task include acoustic stimuli or judgment-free communication and have been successfully used in a variety of human endeavors. Reinforcement, deliberate practice, and repetition let the learner rapidly progress from cognitive awareness of a skill to fluency of performance. For the learner, repetition is tolerated because the process is motivating (not unlike video games). Key to the success of this method is that complex skills (in this case the tool-skills) are analyzed and broken up into simpler skills, or “tasks,” and when learned to fluency, can be linked back together to form the complex skill. The skill can then be performed in any environment with an expectation of success.
However, to accomplish this, learning platforms need to be available that: 1) emulate the tool-skill to be learned, 2) tolerate high repetition learning and failure and 3) are available at a cost that is not prohibitive. Increasingly, surgical skills education is moving to the laboratory where residents can practice on models, cadavers and/or simulators to better prepare them for their OR experience. Unfortunately, the models used are often complex, procedurally based, and expensive, making it difficult to achieve individual learning goals and allow for the degree of repetition and deliberate practice necessary to achieve fluency.
For a skill to be fluent it must be able to be executed at the speed required by the environment it is to be used in. To build a fluent, complex skill, fluent, component (foundation) skills must be built first. This means, teach the tool-skills before you teach the procedures. It was our goal to design an innovative and inexpensive modular teaching program that allowed for meaningful repetition to achieve fluency with critical orthopaedic tools. This meant we needed to design and validate creative and challenging learning platforms that allowed for: 1) detailed task analysis, 2) use of positive operant learning methodologies, 3) meaningful repetition because they were cost sensitive, and 4) could be tolerated by both the learner and teacher, ultimately resulting in fluent tool-skills acquired by the learner.
This presentation describes why we designed it, the design details, and how we assessed our results so that these methods could be used in a variety of teaching environments.