1. Kyla Terhune, MD

2.  None financial  Recognize that I am still in a learning phase  Technically capable– want to be better  Advantage: I am “teachable”  Spent many years thinking about thinking

4.  Almost as a hobby…  have enjoyed thinking about how people think  First teaching: 8 years old… Montessori  Lunch sessions in the locker room  Went to teach high school because…  Enjoy it… and by default, teaching skills

5.  “Know your audience”– here and there  Surgeon-Educators:  What I think you need, +  What you think you need  Sometimes congruent, sometimes not.  OBJECTIVE:  My model (my perspective)  Having thought about this  Currently experiencing it  Thinking about how to enact it

6.  Exposure (numbers and breadth)  Repetition (in close temporal content)  Feedback (constructive– verbal first)  Are some residents not teachable?  Focus  Persistence  Ability to take feedback

7. WIZARDS RADIOLOGISTS

8.  When you study, you learn more.  When you practice, you get better.

9.  Interview with a resident:  “doing the same operation with the same people”  “when I began to imagine what I would do next”  “when I began thinking in planes”  After that: accrue experience  No longer focusing on routine

10.  What we THINK surgery is (interns):  Technical– working with hands  Team– working in the OR  What surgery actually is (R4/R5 year):  Knowing when to operate  Knowing how to operate  Accruing the experience to be creative ▪ Ability to recognize and adapt to the unexpected

11.  Patient outcome  Preoperatively (in clinic)  Operatively (good judgment, avoid errors)  Postoperatively  Technical skills:  should be routine and universal

12. “Seeing the planes” BEFORE ACCRUE EXPERIENCE: operative decision-making (No longer focusing on the routine)

13. “Seeing the planes” BEFORE ACCRUE EXPERIENCE: operative decision-making (No longer focusing on the routine) What skills need to be in place? How soon can we get them there?

14. “Seeing the floor” BEFORE AFTER Strategy Decision-making Dribbling Passing 1-on-1 defense GAMES (12) GAMES (30) Tournaments

15.  R1:  Instruments  Knot-tying, suturing  Tissue Handling  R2:  Steps of procedure  R3:  Exposure, dissection  R4, R5:  Attending modeling  R1:  Recognizing the sick  Roles within acute care  R2:  Acute decision making  R3:  When/who to operate on  R4, R5:  Attending modeling TECHNICALPATIENT-CARE

16.  R1: Basics  R2: Steps  R3: Exposing  R4, R5: Modeling  R1: Basics  R2: Steps  R3: Deciding  R4, R5: Modeling TECHNICALPATIENT-CARE

17.  When you study, you learn more.  When you practice, you get better.  How to get there faster  So that I can spend more time on…  Accruing experiences  Operative decision making Being intentional

18.  Example  Intern Orientation: Central Line  What is routine?  Assessment

19.  Montessori School  Sweeping up Styrofoam peanuts  Cleaning already-clean sinks  Basketball  Free-throws, drills (creating simulated setting)  Progression drill:game ratio (practice: operation)  College:  Chemistry lab  Teacher and Coach:  Lab skills  Skills on the court (tennis)  Junior Resident:  Working on my own skills  Critical Care Fellow:  First experience: simulated code  Partial task trainers/simulation to gen surg  Senior Resident:  Translating those skills into operative technique

20.  Availability  Proximity  Cost  Realism  Protected Time  Rotations  Time out of rotations  Qualified instructors  Attending buy-in  Departmental buy-in (financial support)  Overcome apprehension (fear of observation)

21.  10/14 residents : ATTENDINGS  “many attendings think that it is bogus”  “lot of people (especially older attendings) do not feel it is useful”  “we need more attending input”  “I think any resident can do this stuff independently but they may be teaching themselves to do things the wrong way because no one is watching.”

22.  Buy-in  Supplementation not substitution  Reminding people that they have used simulation their entire lives ▪ Athletics ▪ Oral board questions (low fidelity system)  Question: would you rather have a resident who shows up knowing how to tie knots, suture?

23.  I want to have skills  Why? Obligations:  Patients  Operating room staff  Partners  Timing of Simulation as tool (perceived need)

24. “Seeing the planes” BEFORE ACCRUE EXPERIENCE: operative decision-making (No longer focusing on the routine)

25.  Julia Shelton, MD  Kevin Sexton, MD  Surgical Residents of VUMC  John Tarpley, MD