Photographs by Jon Rentschler
Craftsmanship is a fusion of knowledge into skill. The equation may read simply, but creative mastery requires commitment, ambition and resilience. The process is a relentless cycle of adopting new knowledge, working and reworking methodology, succeeding and failing countless times, and continuing to learn and grow along the way. It is task that can be brutal and demanding. Obsessive hours, weeks, months, and even years of concentrated effort are devoted towards reaching perfection. At the Pediatric Endoscopic Surgery Training & Advancement Laboratory (PEDESTAL) located in the operating complex at the Children’s Hospital of Philadelphia (CHOP), Dr. Thane Blinman and his team of colleagues understand and implement this process in their approach to training surgeons. Although PEDESTAL is lauded as an advanced facility with cutting edge resources, it is Blinman and his team’s tenacious approach to educating medical students that makes PEDESTAL an effective learning space.
“One of our chief ways of learning is to check out what the other guy is doing. Neurologists know that if we watch somebody doing an action, our motor cortex and our cerebellum will pre-fire in order to make those same moves. Because we learn like that, a surgical education became a process of soaking in the environment, seeing 10,000 examples of how it is that something should be done, or not done.”
Medical training is notoriously grueling and no field is more demanding than surgery. Therefore, Blinman’s training strategy centers on deliberate practice, an appreciation for the challenging process of creative development. It is an acknowledgement of the fact that adopting any complex skill requires determined focus, hard work, and patience. There are no plastic cover-ups, no superficial gimmicks, novelty schemes, or fancy shortcuts applied. In order to be great, a surgeon must be intensely devoted to the challenge of mastering their craft. In the construction of PEDESTAL, Dr. Blinman and his collaborators strategically blueprinted their lab as a design intensive workshop. Recognizing the hands-on, tacit knowledge vital for every surgeon to understand, the curriculum for students at PEDESTAL centers on tactile experimentation. With a mixture of high-tech and low-tech gadgetry in place (equipment taken directly from the operating room or designed by Blinman’s students themselves), trainees utilize the workspace to exercise their surgical fundamentals. Learners are introduced to the basic design aspects of their tools, instructed on their functionalities, and enabled with creative liberty for experimentation.
“If you think about what surgery really is, it’s mechanical interventions for medical problems – we close holes that are not supposed to be there, we open holes that are missing, we put stuff in that’s missing, and we take things out that shouldn’t be there - so the curriculum here is on the design aspects of the tools and how to wield them to maximum mechanical advantage.”
The space is a training zone, a batting cage as Dr. Blinman describes it, for surgeons to hone their skillsets. Black countertops provide surface area for instructive conversation and hands-on exercise. It is here that students are introduced to their tools and provided a repertoire of techniques to study, execute, and internalize. Rather than parroting information back on written exams, residents are challenged to demonstrate their comprehension through application. They begin a habitual training regiment of drilling in-and-out maneuvers – lacing stitches, tying knots, and cutting incisions – into synthetic bodies. Below the tables, boxes are stashed with prosthetic limbs, rubber torsos, and other loose appendages battered from practice sessions of the past. Ink-smudged whiteboards are posted on each wall of the laboratory, a design school rip-off as Dr. Blinman admits. The boards encourage students to jot spontaneous notes, ask questions, break things apart, engage in creative discourse, analyze approaches, share ideas, and develop collaboratively. After lessons, trainees can immediately apply their insights on state-of-the-art equipment, monitors, and apparatus that directly simulate the experience of a live operating room. A self-contained space, PEDESTAL is a quiet testing ground secured for trial-and-error learning, a haven where mistakes are acceptable. Together surgeons, new and established, work cohesively to learn from one another and better their skills.
"We have pressure to create the kind of learner who says, 'Is that going to be on the test? Oh well, my shift’s up,' rather than the one who runs towards the blood and stays until their job is done."
Over the past decade-and-a-half, the culture around surgical education has experienced rapid evolution. Traditionally, the training of surgeons has been dependent on a dogged, hard-nosed apprenticeship approach. Young surgeons would work round-the-clock (120-130 hours per week) relentlessly immersing themselves into their discipline. Intensive time was spent observing a mentor and mirroring their knowledge through practice. Skills were cultivated through active lessons and situational schooling. This was the trusted strategy, assured to breed confident and capable surgeons into the field. But such a model has fallen under scrutiny from outside critics concerned that the exhaustive training process, particularly the long hours, was a major cause of an increase in serious medical errors. The perspective is reasonable: 120+ hour workweeks are taxing requirements for residents to endure. Few tasks could be more potentially dangerous to perform under the drained and dizzied state of extreme mental fatigue than surgery. The Accreditation Council for Graduate Medical Education (ACGME) implemented restrictions on medical training institutions in response, that capped the number of hours student-surgeons could work per week to 80. Yet these regulations infringed on the educational rite of passage that creates great surgeons, a 30% reduction in weekly hours could not but impact the process of training and mentorship. Drawing focus away from the apprenticeship model, intensive operational training learned by observing and doing was augmented with ‘softer’ skills – modules like team dynamics, Systems Based Practice, Interpersonal Skills & Communication, and professionalism, that could be taught in less time-intensive ways. The ACGME began to decree a system of generalized metrics, coined core competencies, to certify new surgeons.
“Training was replaced by a crude anatomization of what is needed to become a ‘good doctor.’ You have a sick patient, and through some magical group dynamic you’re supposed to figure out what’s wrong with the patient and what the plan of action is. That kind of thinking doesn’t help you with a gunshot wound or stabbing. You need one person who knows what to do and has the moral authority to do it."
"We need more educators who understand what the real nature of medical problem solving is, what the real nature of surgical intervention is, how it is that we learn, and teach."
As Dr. Blinman sees it, such evaluations are insufficient for assessing the true measure of a quality surgeon. He fears that the reduced practice hours, test-oriented curriculum, and quasi-credible metrics system may shift the focus of young surgeons away from where it needs to be, and from the information they need to know. Even worse, the shiftwork mentality and uniform curriculum may reduce that tenacious appetite for studying, practicing, and enhancing their craft that sets apart the best young surgeons-in-training. While Dr. Blinman does not seem critical of the current generation of surgical trainees, he is critical of the type of learner that is being sculpted. Operation is as deeply complex and sophisticated as any creative undertaking ever attempted by humans, and the literal life-and-death stakes of the work could not be higher. Technological transformation continues to expand the abundance of knowledge that new surgeons must possess. These advancements are continuously being integrated into the field and, as this occurs, so too are new approaches and techniques that must be honed. Thus, student surgeons must absorb an increasingly intricate and widening crescendo of tactical knowledge in an abridged timeframe. Since the installation of the ACGME’s time restraints, rates of surgical complications have actually climbed dramatically and, as educator groups such as the American College of Surgeons contend, these alarming numbers are likely to escalate. In Dr. Blinman’s eyes, no quick fix or cleverly devised shortcuts will ever outwit the natural process of hard work and mastery. While the recent regulatory changes have created a crisis within surgical training, it seems that Dr. Blinman and his team at PEDESTAL have been able to innovate the pedagogy in a much more central and profound way. They recognize that updated educational models are now essential to train new surgical residents efficiently and effectively. It is, ironically, precisely the negative consequences of the new regulations that have enabled PEDESTAL to become a radical new model for surgical trainees.