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EDUCATIONAL BACKGROUND OF THE KULEUVEN OPCAB TRAINING AND RE-TRAINING

Classicial didactic methods are avoided.

Didactive methods improve attitude and skills and knowledge but failed to achieve success in changing performance or patient care outcomes
Impact of formal continuing medical education, O'Brien Davis D, Freemantle N, Wolf FM, Mazmanian P, Taylor-Vaisey A, JAMA 1999, Sept 1;282(9):867-74
 
Knowledge is clearly necessary but not in and of itself sufficient to bring about change in physician behavior and patient outcome.
Impact of formal continuing medical education, Davis Dave,O'Brien Mary Ann, Freemantle Nick, Wolf Frederic M, Mazmanian Paul, Taylor-Vaisey Anne, JAMA 1999, Sept 1;282(9):867-74

The didactic approach consist in lectures and presentations without interaction.  These are extremely inefficient.


1. THEORY OF ADULT LEARNING


1.1 BEHAVIOURIST APPROACH

Technical drills are used to develop psychomotor skills.
Skil acquisition and assessment for laparascopic surgery, Rosser JC, Rosser LE, Savalgi RS, Archives of Surgery 1997;132:200-204


 

1.2 COGNITIVE APPROACH

Cognitive approaches have an impact on patient care and physician's performance.
Sucesssful adult education should be learner-centered, active rather than passive, relevant to the learner's needs, engaging and reinforcing.
Impact of formal continuing medical education, O'Brien Davis D, Freemantle N, Wolf FM, Mazmanian P, Taylor-Vaisey A, JAMA 1999, Sept 1;282(9):867-74.

The cognitive approach focuses on internal mental processes that are within the learner's control, highlighting importance of perception meaning and insight.  The locus of control rests with the learner and learner involves reorganising experiences in order to amke sense of stimuli from the environment.
Issue in cognitive psychology: implications for professional education, Regehr G, Norman GR, Acad Med 1996;71:988-1001


1.2.1 TRANSFERT OF TACIT INTO CODIFIED KNOWLEDGE

 


1.2.2 DECONSTRUCTION OF PROCEDURE INTO TEACHABLE COMPONENTS Kirk has pointed out that it is necessary to deconstruct skills so that can be taught to others.
Teaching the craft of operative surgery, Kirk RM, Ann R Coll Surg Engl 1996;78 (suppl I):25-28


1.3 HUMANIST / INDIVIDUALISED APPROACH

The humanist approach assumes that human beings are self-determining and responsible and that they have an innate urge to develop their potentialities.  The process of adult learning is about developing each learner as an individual, rather than the acquisition of individual competencies

The adult learner: a neglected species, Knowles M;, Houston Gulf 1984

The shape of the learning curve varies for each learner and each task.  Courses therefore need to be individualised

Skill acquisition rates and patterns, issues and training implications, Lane NE, New York:Springer Verlag; 1987


1.3.1 INTERACTIVE APPROACH

Interactive sessions that provide the opportunity for practice are more effective than didactic sessions.
Davis Dave,O'Brien Mary Ann, Freemantle Nick, Wolf Frederic M, Mazmanian Paul, Taylor-Vaisey Anne, JAMA 1999, Sept 1;282(9):867-74


 

1.3.2 ERROR RECONGITION AND CORRECTION


1.3.3 RECALIBRATION OF THE LEUVEN OPCAB CMEST PREDICTIVE MODEL by reciprocal influences.
The interaction with the visiting teams, from the uinitial contacts, if done by the CMEST experience expert, can induce a recalibration of the Leuven performance model by stressing on specific issues during the training, as well in technical as in cognitive skills.


2. NATURE OF KNOWLEDGE

The accumulation of experience in an activity leads to the facility to communicate and understand the relevant knowledge.

Knowledge and the speed of the transfer and imitation of organizational capabilities: an empirical test. Zanker Udo, Kogut Bruce. Organization Science 1995;6:76-92


2.1 CODIFIABILITY

Variance in improvement rates across organisations will be greater for aspects of performance that rely on tacit knowledge than on aspects of performance that rely on codified knowledge.
Learning how and learning what: effect of tacit and codified knowledge on performance improvement following technology adoption, Edmondson Amy C, Winslow Ann B, Bohmer Richard M J, Pisano Gary P, Decision Sciences, 2003;vol 34 nr 2:197-222

Codified knowledge refers to knowledge that is transmittable in formal, symbolic language, whereas  tacit knowledge is hard to articulate and is acquired through experience.  Tacit knowledge is often rooted in action or is context specific.
Tacit and codified knowledge exist along a spectrum and are not mutually exclusive.
Tacit knowledge is characterised by the absence of an agreed-upon language, but may not be inherently or permanently tacit.
The Tacit Dimension, Polanyi M, 1966, Garden City NY Doubleday


2.2 TEACHABILITY

Teachability captures the extent to which individuals can be trained. In contrary to codifiablity, which captures the degree to which knowledge can be encoded, regardless if the individual operator does not have the facility to understand it, teachability reflects the training of individual skills.
Knowledge and the speed of the transfer and imitation of organizational capabilities: an empirical test. Zanker Udo, Kogut Bruce. Organization Science 1995;6:76-92


 

2.3 COMPLEXITY

Complexity picks up the inherent variations in combining different kinds of competencies.
Knowledge and the speed of the transfer and imitation of organizational capabilities: an empirical test. Zanker Udo, Kogut Bruce. Organization Science 1995;6:76-92


 

2.4 SYSTEM DEPENDENCE

System dependence captures the degree to which a capability is dependent on many experienced groups. Knowledge and the speed of the transfer and imitation of organizational capabilities: an empirical test. Zanker Udo, Kogut Bruce. Organization Science 1995;6:76-92

transactive social memory of the team

The more institutionalized preexisting knowledge is, the higher the effort required to dismantle it, i.e., the higher the unlearning barrier.There may be a natural pace for organizational knowledge transfer to occur. if the pace is too fast, changes may never get fully implemented. However, if the pace is too slow, practices may become institutionalized and more difficult to replace.
The process of knowledge transfer: a diachronic analysis of stickiness. Szulanski Gabriel. organizational behaviour and human decision processes 2000;82:9-27


2.5 OBVERSABILITY

Captures the degree to which capable competitors can copy the manufactoring capability, because they are able to manufacture the innovation once they have understood the functions of the product.
Knowledge and the speed of the transfer and imitation of organizational capabilities: an empirical test. Zanker Udo, Kogut Bruce. Organization Science 1995;6:76-92


 

3. TAXONOMY OF LEARNING OBJECTIVES

Taxonomy of educational objectives: the classification of educational goals, Bloom BS Engelhart MD, Furst EJ, Hill WJ, Krathwohl DR, New York: David Mc Kay Company Inc


 

3.1 KNOWLEDGE

Knowledge is gained by the digestion of information and its transformation through the process of learning.  In order for this transformation to take place effectively, information must be reliable, readily accessible and able to be processed with a maximum of efficiency.
Simulation in surgical training: educational issue and practical implications Kneebone Roger, Medical Education 2003;37:267-277


 

3.2 SKILLS

Skills require the development of psychomotor competencies, a process based on regular practice.
1⁄ Expertise
Expertise can only be gained by sustained deliberate practice.  This must be complemented by expert feedback within a supportive learner centered environment.  The role of deliberate practice in the acquisition of expert performance, Ericsson KA, Krampe RT, Tesch-Römer C, Psychol Rev 1993;100:363-406
2⁄ Motivation.
Repeated performance on the job is insufficient unless underpinned by a conscious determination to improve.
The lifelong challenge of expertise, Guest CB, Regehr G, Tiberius RG, Med Educ, 2001;35:78-81
3⁄ Ongoing training
Ongoing training is required of recently learned skills, if they are not to disappear.
Simulation in surgical training: educational issue and practical implications
Factors that influence skill decay and retention. A quantitative review and analysis, Arthur W, Bennett W, Stanush PL, Mc Nelly TL, Human Performance 1998;11:57-101
4⁄ training in simulation
Simulation in surgical training: educational issues and practical implications, Kneebone Roger, Medical Education 2003;37:267-277


 

3.3 ATTITUDE

Attitude refers to how knowledge and skill are combined in the care of patients, including clinical judgement, decision making, the values of professional behaviour and all the components of the competent clinician.  The task of integrating knowledge and technical skills with these attitude components is a crucial challenge for surgical training.
Simulation in surgical training: educational issue and practical implications Kneebone Roger, Medical Education 2003;37:267-277


 

4. MULTIMODAL APPROACH

Multifaceted trainings are more efective at producing change than are simple interventions
Impact of formal continuing medical education, Davis Dave,O'Brien Mary Ann, Freemantle Nick, Wolf Frederic M, Mazmanian Paul, Taylor-Vaisey Anne, JAMA 1999, Sept 1;282(9):867-74


 

5. TEAM APPROACH

The K.U.Leuven will only allow a team of scholars: surgeon, anesthetist, scrub nurse, and of course the teaching is also done as a team by surgeons, anesthetists and nurses.

Group membership stability will predict improvement rates for dimensions of performance that rely on tacit knowledge
Learning how and learning what: effect of tacit and codified knowledge on performance improvement following technology adoption, Edmondson Amy C, Winslow Ann B, Bohmer Richard M J, Pisano Gary P, Decision Sciences, 2003;vol 34 nr 2:197-222

To bring an assistant or a partner (anesthetists) to the CMEST has been shown to reduce the incidence of complications during the initial experience
Predictors of Laparscopic complications after formal training in Laparascopic surgery, See WA, Cooper CS, Fisher RJ, JAMA 1993;270:2689-2692

Social knowledge is more likely to remain tacit Learning how and learning what: effect of tacit and codified knowledge on performance improvement following technology adoption, Edmondson Amy C, Winslow Ann B, Bohmer Richard M J, Pisano Gary P, Decision Sciences, 2003;vol 34 nr 2:197-222.  It includes enacting reciprocal coordination, intuitive assessments of whom to trust and awareness of who knows what (easier to codify).

Conventional surgery could be described as modular process whereby task boundaries are well established and fairly independent: the new procedure is a far more integral process in which task boundaries are more blurred and tasks are interdependent. Thus the technology disrupted the smooth flow of the operative routine and required the development of new routines to enable the execution of more interdependent ste of processes.


 

6. SEQUENTIAL APPROACH

The learn-work-learn opportunities, afforded by sequential sessions and reinforced at a further learning session, may explain the succes of sequential sessions
Impact of formal continuing medical education, O'Brien Davis D, Freemantle N, Wolf FM, Mazmanian P, Taylor-Vaisey A, JAMA 1999, Sept 1;282(9):867-74

Communication theory suggests that communication sustained over time may enable ideas to converge across gaps such as those that exist between CME (continous medical education) teachers and learner-participants. The process of communication: An introduction to theory and practice. New York, NY: Holt, Rinehart, & Winston; 1960

Repetitive performance of a specific task results in a much better performance of tasks than  does general training in a variety of skills
Acquisition of pursuit tracking skill under extended training as a joint function of sex and initial ability. Noble CE, Journal of Experimental Psychology 1970;86:360-373

The Leuven approach:
1⁄ pre-modeling interactive discussion
Improves declarative (knowing what to do) and procedural (knowing how to do)l knowledge
Little, if anything is known about the possible effects of narration prior to versus during modeling. It may be assumed that verbal instructions prior to modeling can prepare observers for whatever they are about to see, while comments during modeling serve to direct attentions to the proper cues or key features of the learning material.
Motoric Modeling: Theory and Research, Williams JG,  Journal of Human Movements Studies 1993;24:237-279

2⁄ expert cognitive modeling
According to Bandura's observational learning theory, a model influences four processes: attention, motivation, production and retention.
Multiple exposures provide observers with opportunities to discern the structure of the modeled actions, to organize and verify what they know, and to give special attention to problematic aspects in subsequent exposures.
Social Foundations of Thought and Actions: A social cognitive Theory, Bandura A., Englewoods Cliffs, NJ: Prentice-Hall 1986

A "perceptual blueprint" of the modeled action is represented in the memory of the observer when an expert model is observed. The blueprint serves as a perceptual referent against which the perception of concurrent action could be compared and corrected.
Theoretical considerations in the learning of complex sequential tasks for demonstrations and practice. Sheffield FN  In Lumsdaine AA (ed.) Student response in programmed instruction, 13-32. Washington DC: national Academy of Sciences, national research Council 1961

Subjects observing a correct model were able to perform better on a retention test than subjects who observed the correct model and viewed a videotape of their own performance. Subjects who were presented with videotape feedback only exhibited a poor performance on both the transfer task and retention task.
Effects of modeling and video feedback with knowledge of results on motor performance. Ross D, Bird AM, Doody SG, Zoeller M. Human Movement Science 1985;4:149-157

The amount of additional benefit that can be derived from multiple observations to amodel is affected by the ease with which the information conveyed in the demonstration. It can be incorporated into the cognitive (symbolic) representation of the skill: very complicated and subtle task may require many more demonstrations before a mental representation can be developed.
An additional factor is the isomorphism of the various demonstrations. Repetition of identical demonstrations may be of limited utility, whereas extremely diverse demonstrations may generate conflict or confusion.
The effect of modeling on learning a simple surgical proceudre: see one, do one or see many, do one? Custers EJFM, Regehr G, McCulloch W, Peniston C, Reznick R. Advances in health sciences education 1999;4:123-143

Even a single observation of an expert model performing a simple surgical task cab have important influence on the subsequent performance. This effect is immediate and is maintained or even accumulated across repeated efforts at the task, at least in the absence of explicit external feedback.
The effect of modeling on learning a simple surgical proceudre: see one, do one or see many, do one? Custers EJFM, Regehr G, McCulloch W, Peniston C, Reznick R. Advances in health sciences education 1999;4:123-143

3⁄ non-expert modeling (by resident or scholar), corrected by expert
After the cognitive phase, the scholar is allowed to perform the tasks.  The teacher provides feedback, identifies errors and provides explanations for corrective action.
This consitutes phase 2 (integration Kopka).
An approach to the evaluation of operative skills, Koptka JA Surgery 1971;70:297-303

Correction feedback needs to be given after each step of a complex motor task, and not after the complete task.
Frequent feedback enhances complex motor skill learning, Wulf G, Shea CH, Matschiner S, J Mot Beh 1998;30:180-192

The interactions should focus on providing feedback about the sequence of movements, movement kinematics and the apparent discrepancies between the expert and the scholar
Teaching and testing technical skills, Reznick RK, Am J Surg 1993;165:358-361

Observers who watch a model that does not display full mastery of a skill but is engaged in learning process show higher skill and training performance than observers of an expert model.
Modeling considerations in motor skill acquisition and performance: An integrated approach. McCullagh P, Weiss MR, Ross D. In pandolf KB (ed.) Exercise and sport sciences review, Vol. 17, 475-513. Baltimore MD: Williams and Wilkins 1961

4⁄ practice by scholar, corrected by expert
After the cognitive phase, the scholar is allowed to perform the tasks.  The teacher provides feedback, identifies errors and provides explanations for corrective action.
This consitutes phase 2 (integration Kopka).
An approach to the evaluation of operative skills, Koptka JA Surgery 1971;70:297-303

Correction feedback needs to be given after each step of a complex motor task, and not after the complete task.
Frequent feedback enhances complex motor skill learning, Wulf G, Shea CH, Matschiner S, J Mot Beh 1998;30:180-192

The interactions should focus on providing feedback about the sequence of movements, movement kinematics and the apparent discrepancies between the expert and the scholar
Teaching and testing technical skills, Reznick RK, Am J Surg 1993;165:358-361

Observers who watch a model that does not display full mastery of a skill but is engaged in learning process show higher skill and training performance than observers of an expert model.
Modeling considerations in motor skill acquisition and performance: An integrated approach. McCullagh P, Weiss MR, Ross D. In pandolf KB (ed.) Exercise and sport sciences review, Vol. 17, 475-513. Baltimore MD: Williams and Wilkins 1961


 

7. ENABLING MATERIAL APPROACH

CD-Rom is given after each training to allow review of educational material, distribution of knowledge locally to non-participants and to candidates for later participation.  This is now been replaced by the webproject http://www.opcab-training.eu.

Enabling methods facilitate adapting to changes in the practice site, and to the understanding of the environment in which change is to occur.
Impact of formal continuing medical education, O'Brien Davis D, Freemantle N, Wolf FM, Mazmanian P, Taylor-Vaisey A, JAMA 1999, Sept 1;282(9):867-74


 

8. MOTOR SKILL TRAINING


9. EVALUATION APPROACH

1⁄ Completeness
Under the Royal College of Surgeons of England comparative audit system, hundred of surgeons who initially registered as doing laparascopic cholecystectomy did not send any returns in under a voluntary system
New interventional procedures: efficacy, safety and training, Johnson A.G., Aust.N.Z. J. Surg. 1998;68:3-5

2⁄ Validity
Self reports of behavior change by physicians as a result of a CME course are accurate when compared with observation of changes.
Validity of self-reports of behavior changes by participants after a CME course, Curry Lynn, Purkis Ian, Journal of Medical Education 1986;61:579-584

3⁄ Early and Late after training process

4⁄ Scholar feedback during course
Koptka stressed the fact that deficiencies in the teaching and learning of motor skills are unlikely to be corrected unless there is a mechjanism to provide reliable and systematic feedback.  This is opposed to summative assessment, used to award a grade.  In addition fedback from students is an important ingredient when evaluating courses.

An approach to the evaluation of operative skills, Koptka JA Surgery 1971;70:297-303