by Ara A. Salibian, M.D. (@AraSalibianMD)
The Halstedian residency was developed to provide graduated levels of resident learning and responsibility. From within this model arose the paradigm of “see one, do one, teach one”; a simple phrase for a not-so-simple task. The maxim strictly translates to learning a procedure by seeing it done once, then performing it, and finally, teaching it to others. In reality, the ability to advance so rapidly in learning a skill is near impossible, and likely dangerous.
As healthcare has changed since Halstead’s introduction of the residency program, so has the structure of surgical education. The traditional model of surgical training has been affected by work-hour restrictions, stricter oversight regulations and importantly, a critical appraisal of patient care and outcomes.1 The classic adage can therefore be adapted to fall more in line with today’s healthcare goals, as described by Dr. Rod Rohrich, in which one should strive to:
“see many [and] learn from the outcome, do many with supervision and learn from the outcome, and teach many with supervision and learn from the outcome”.2
In this revised model, emphasis is placed on learning through repetition under the guidance of experts, while constantly scrutinizing one’s outcomes to optimize results and patient safety. This becomes an intimidating task as the compendium of different procedures in the field of Plastic Surgery is staggeringly broad and dauntingly complex. However, breaking down each component of the cycle into practical points helps provide direction to develop the appropriate habits to learn efficiently and safely.
“Seeing one”, or observing in a case, can be prone to a detrimental cycle of loss of focus, perceived lack of interest, and absence of teaching. This cycle can be broken, however, by better understanding the value of observing others and what is needed to utilize these opportunities for self-development. Most critical is preparation. Preparing for a case as if you are the one performing it promotes familiarity with the basic steps of an operation. This foundation will inevitably make the case more interesting and also allow one to better assist the operating surgeon. In addition, this level of preparation provides the opportunity to glean more advanced information rather than just trying to keep up.
Retention of information learned from observing a case is also important for progress. Taking a few notes after seeing something new is a quick and easy method of forced review. There are several free note-taking apps such as Evernote® and OneNoteTM (Microsoft, Seattle, WA) that can efficiently organize and sync notes across different mobile and computer-based platforms. Along with this comes the importance of seeing not just “one”, but “many”.2 Repetition is key for familiarity, comprehension and mastery. Furthermore, critically observing many surgeons perform the same procedure provides the opportunity to witness variations in techniques. Combined with an analysis of results among different patients and surgeons, this habit allows one to formulate operative plans on outcomes-based data and choose the optimal techniques for completing each aspect of a procedure.
When it comes to “doing one”, preparation inherently becomes even more crucial. Multi-volume textbooks have long been the gold standard for learning and remain an important resource for foundational knowledge. Several other sources offer high-yield information including the Plastic & Reconstructive Surgery journal “Resident Reader Collection”, Continuing Medical Education (CME) articles, the Plastic Surgery Educational Network (PSEN) “Resident Education Center”, and the American Orthopaedic Surgery Reference application, among many others.3 The availability of high quality procedural videos, however, has revolutionized case preparation. The Also, Plastic & Reconstructive Surgery journal “Video Collection” and the American Society for Aesthetic Plastic Surgery RADAR Resource are invaluable libraries of countless in-depth instructional videos that are imperative to watch prior to cases.
A critical aspect of efficient execution of a case is appropriate supervision. Under expert supervision, residents can perform with graduated levels of responsibility while continuing to learn in an atmosphere that is still safe for the patient. However, it is still imperative to prepare for an operation as if it was your own. A very helpful question to ask is:
“What would I do if the attending had to leave the room and I had to finish the case alone?”
While not a practical situation, this question stimulates constant critical thinking and ownership of each move in the operation. As importantly, it prompts thinking ahead to major decision points in the case.
Again, practice really does make perfect. Improvements in technique for simple procedures such as epidural anesthesia do not occur until after 25 procedures have been performed, with at least 60 attempts needed to achieve a 90% success rate.4 The Accreditation Council for Graduate Medical Education (ACGME) has set requirements for minimum numbers of operative procedures, though the highest minimum for a particular procedure is 30.5 This emphasizes the constant cycle of learning that extends far beyond residency training in order to always improve upon and optimize results.
The concept of “teach one”, particularly with regards to resident responsibility, must be adapted to modern-day healthcare. Along these lines, the concept of teaching can be practically divided into teaching oneself and teaching others. The first simply expounds upon principles discussed earlier, in that constant reflection, scrutiny of one’s own technique and evolution are key. A former chief resident would always ask me 3 new things I learned from each case and one thing I would do differently. This became a valuable exercise to promote critical evaluation of one’s own techniques, regardless of stage in training, and is a question I continue to ask myself after each operation. Tracking outcomes is also very helpful, and a concerted effort to follow patients post-operatively, even with a simple chart check, can be an invaluable teaching tool.
Teaching residents is primarily the responsibility of faculty educators, experts in their own fields who have completed the learning cycle innumerous times to be able train others. Residents, however, can aid more junior housestaff in adopting the basic principles and skills to optimize their educational experience. Furthermore, residents can guide juniors in procedures under the supervision of attendings that allows for a controlled and safe, top-down flow of information. As years in training progress, one should aim to develop a familiarity and comfort with a procedure to be able to teach it to others, as that level of independence is not far away.
As surgical training continues to evolve, residents can strive to adhere to principles that involve conscious absorption of knowledge from experts, appropriate preparation for and reflection upon cases, and the goal of comfort with procedures to be able to eventually pass down knowledge. Most important to remember is that these tenets are not only useful in residency, but apply throughout one’s career. The ability to continually learn, evaluate and evolve will allow us to constantly improve ourselves as physicians, advance the field of Plastic Surgery forward, and most importantly, better serve our patients.
- Kotsis SV, Chung KC. Application of the “see one, do one, teach one” concept in surgical training. Plast Reconstr Surg. 2013;131(5):1194-1201.
- Rohrich RJ. “See one, do one, teach one”: an old adage with a new twist. Plast Reconstr Surg. 2006;118(1):257-258.
- Khansa I, Janis JE. Maximizing Technological Resources in Plastic Surgery Resident Education. J Craniofac Surg. 2015;26(8):2264-2269.
- Kopacz DJ, Neal JM, Pollock JE. The regional anesthesia “learning curve”. What is the minimum number of epidural and spinal blocks to reach consistency? Reg Anesth. 1996;21(3):182-190.
- Plastic Surgery. Accreditation Council for Graduate Medical Education. http://www.acgme.org/Specialties/Overview/pfcatid/19/Plastic-Surgery. Accessed July 1 2017.