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Teaching and Evaluating Surgical Skills

Helen MacRae
Helen MacRae

When Helen MacRae completed her ten year term as Director of the Surgical Skills Lab recently, she was given a whimsical fur-lined lab coat created by her appreciative staff. She always feels cold in the air conditioned environment of the lab. “The most fun has been working with the people - the staff, residents and faculty who I get to know across all the divisions and would not ordinarily meet in my general surgery and colorectal practice at Mount Sinai Hospital.” The combination of learning, teaching and informal conversation has been an enriching experience. The medical students have also been active in the lab thanks to a program set up by David Backstein and continuing now under George Christakis.

Helen has been primarily involved in the PGY1 group. She enjoys getting to know the surgery residents and then following them later when they come on her service. In the future, she anticipates that the Skills Lab will become more integrated into the residency in the way that the orthopaedic Curriculum Based Competency program integrates laboratory skill building into the residents’ clinical work (see also: http://www.surgicalspotlight.ca/ Article.aspx?ver=Summer_2010&f=ResidentsCorner).

Teamwork training in the lab has been a focus of study of the Obstetrics Department. This program will be moved into other Surgical Divisions. Ara Darzi’s program at Imperial College, London is studying team communication during simulated crises (1). “We will need expansion of our facilities, especially of the virtual operating room, to strengthen this program. Our former colleague, Lorelei Lingard videotaped interactions in the operating room to show how easily surgeons’ “clear” communication has been misinterpreted. Video feedback has been explored to teach surgical technique. “It did not enhance performance significantly the way it does in sports. This may be related to the scale of the movements in surgery. Deconstruction of skills into building blocks such as instrument handling and knot tying are extremely effective, however, and residents learn how to automate these skills.”

Helen has been interested in the attention resources of learners. “Residents need to use more of their attention resources than faculty, for whom many things have become automatic. Faculty are better able to operate while having conversations. It is not as easy for a less experienced resident. The team showed that residents who are trained in

technical skills are able to attend to other learning in the operating room, whereas novice residents were less able to retain information from a script read to them while closing an abdomen (2). There is an important lesson here regarding operating room teaching of novice surgeons. Carol-anne Molton has written (3) about the importance of slowing down when required by the situation. For example, music in the operating room can be a distraction, occupying the attention resources of the personnel. “That’s why you turn the radio off when a crisis arises”.

“Teaching fundamental skills should be done without pressure. For example, my son is a basketball player - you don’t teach him to shoot during a game, but during practice in a less stressful situation. In surgery, we usually do the opposite.” Helen is leaving a busy lab that many members of the department have accepted enthusiastically. “Richard Reznick and Zane Cohen got it started, and Carol Hutchinson was the first director for 18 months. Luckily, Lisa Satterthwaite was here when I took over.” Helen relates her success to her husband Brent, to Lisa and the staff in the laboratory, and to her clinical secretary, Firdeza, who was a family doctor in Yugoslavia. Their help has made it possible for her to raise her two children ages 13 and 15, keep up a busy practice and have a successful academic career.

Helen is working with Master’s in Education students - developing technical skill certification as a potential component of Board Exams, which currently test only knowledge and judgment. “There is only one point on the ITER for technique. We need to develop skill assessment for certification.” She is working on this with the American Board of Colorectal Surgeons and has run a pilot study, unique in Surgery, in which she compared the technical skill of general surgeons and colorectal surgeons in an eight station examination. She will continue to work on this project and will stay in touch with the laboratory as well as work with the American College of Surgeons.


1. Aggarwal, R.; Ward, J.; Balasundaram, I.; Sains, P.; Athanasiou, T.; Darzi, A. Proving the Effectiveness of Virtual Reality Simulation for Training in Laparoscopic Surgery. Annals of Surgery. 246 (5):771-779, 2007

2. Palter, V., Grantcharov, T.,Harvey, A., MacRae, H. Ex Vivo Technical Skills Training Transfers to the Operating Room and Enhances Cognitive Learning: A Randomized Controlled Trial. Annals of Surgery, 253 (5): 886-889,2011

3. Moulton, C., Regehr, G, Lingard, L., Merritt C., Macrae, H. Slowing down When You Should’: Initiators and Influences of the Transition from the Routine to the Effortful. Journal of Gastrointestinal Surgery, 14.6: 1019-1026, 2010.

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