Reflections of a Surgical Educator

Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg

Published in "The Healing Cut", November, 1999

My life as a general surgeon has been a continual learning and teaching of the science and art of general surgery while practicing it and periodically, by conducting formal research. This piece focuses on my experience as a surgical educator.

In 1981, I completed my general surgery residency at the Philippine General Hospital.

In 1982, I joined the Department of Surgery of the Philippine General Hospital as a part-time consultant. This began my career as a surgical educator.

By the end of 1997, I had spent sixteen years of my life teaching surgery as well as administering surgical education programs in various institutions in the Philippines. In the process I took part in the training of surgeons at the Philippine General Hospital, Manila Doctors Hospital, Medical Center Manila, Ospital ng Maynila, Tondo Medical Center, Zamboanga City Medical Center, and other hospitals.

All through those sixteen years I was in a constant search for the most effective and most efficient way of teaching surgical residents.

When I started my career as a surgical educator in 1982, my goal was simply to teach. My concept of teaching then was merely to impart to my students whatever I knew about general surgery as a discipline, using presentation and lectures. This is essentially a teacher's attempt to transfer knowledge to the students and may be expressed in the following equation:

where T stands for teacher, K, knowledge, and S, student.

Starting in 1985, frustrated with the ineffectiveness of the presentation-and-lecture methods in ensuring comprehension among my students, I shifted to the inquiry approach. This method of teaching is expressed in the following equation:

Where the teacher (T) acts not as a content expert spoonfeeding information to students but as a coach and adviser on the following: (1) what competencies are needed by the students; (2) where the needed information can be found; (3) how best the students can acquire the competencies, etc. In other words, my function as a teacher is to guide and enhance my students' genuine learning.

I refrained as much as I could from lecturing. I encouraged active student participation in learning through small group discussions, problem-solving, exercises, etc.

After sixteen years of searching, I think I have found a truly effective and efficient way of teaching aspiring general surgeons or students of any discipline for that matter. The three elements of the method which I now use are the following:

1. Motivation

A motivation to learn must be present in the student before teaching/learning can begin. It is the teacher's role to reinforce this motivation - with the aid of relevant teaching materials, by giving encouragement, and by using learning methods that are enjoyable and facilitate learning. Whatever these methods are, it is well to remember that effective and efficient teaching-learning can only take place when students are properly motivated.

2. Teaching Students How to Study

Students should be taught how to study using the problem-based learning and self-directed learning approaches.


IIA. Problem-based Learning

The problem-based learning (PBL) approach consists in learning the science and art of medicine and surgery by solving actual or simulated cases. It is akin to rehearsing for the actual practice of medicine and surgery after graduation.

The student is presented with a health problem, either simulated or actual, a study of which the teacher has not previously assigned or lectured on.

The student is asked to analyze and try to solve the problem. In the process, the student invariably encounters questions, doubts and gaps in his competencies. These constitute the "learning issues."

The student then decides how to go about settling the "learning issues." He implements his plan of action, after which he applies what he learns to the problem on hand as well as to future problems or patients.

A comparison of results in terms of learning retention, easy recall, problem-solving, and critical thinking convinces me that PBL has an edge over the lecture method. When used with a small group of students, PBL can help develop communication and interpersonal skills. It also develops skills in cooperative learning and self-directed learning.


IIB. Self-directed Learning

In self-directed learning, the student takes the following steps:

1. Determines the competencies he must acquire to practice the profession of his choice.

2. Determines the competencies he already has and those he has yet to develop.

3. Formulates a study plan that will help him acquire the competencies he still does not have.

4. Implements the study plan.

5. Evaluates his performance against the goals set in his study plan.

Self-directed learning is important because the teacher cannot teach everything. Remember that learning is defined as change in behavior or disposition that persists over a long period of time. Students must, therefore, play an active part in learning.

Learning goes on from the cradle to the grave. This is a universal fact of life. Everyone is therefore called upon to develop the skill to learn new knowledge and skills even outside the traditional teacher-led system.


III. Framework of Knowledge

Students should be taught a learning framework to guide them in the eventual practice of their profession.

The framework that I have come up with consists of maxims, rules, and guidelines on the management of a patient. It spells out the goals, main objectives, steps and processes in the management of any patient , whether requiring surgery or note. It can, in fact, be applied to any kind of problem-solving and decision-making situations in the medical profession. Students are expected to develop and master this framework during the training period.

Employing the three elements of the teaching method I have described, I have witnessed the development of students and graduates who have genuinely learned and who did not merely pass the examination but who acquired skills in and practiced self-directed learning. I have come to realize that the ultimate criterion by which I can assess my effectiveness as a teacher is whether I have inculcated self-directed learning habits in my students, not the amount of knowledge and skills the students have acquired.

In 1989, I took a new step forward in my journey as a surgical educator: I drew up the General Surgery Course in Zamboanga City Medical Center (ZCMC) using distance education.

The course filled a deficiency in the ZCMC general surgery program: it lacked resident trainors and it was not accredited by the Philippine College of Surgeons.

The course ran from 1991 to 1995. What was most gratifying about the course was that it produced nine general surgeons for Western Mindanao (population: three million): one practicing in Jolo; another in Pagadian, there outside Zamboanga City, and four in Zamboanga City. The last four also teach at the Zamboanga City Medical Center and are carrying on the structured program which I drew up.

The other beautiful thing about the course was that it allowed me to try out innovative teaching-learning strategies such as debate and teleconferencing. Debate has become one of the regular teaching-learning activities in the Division of Head and Neck, breast, Esophagus, and Soft Tissue Surgery at the Philippine General Hospital since 1992. Teleconferencing in surgery has been adopted by the University of the Philippines Open University since 1998.

Looking back, I can say that my sixteen years' experience as a surgical educator has been truly fruitful and instructive. But much more remains to be explored and to learn.

I thank my wife, Jackie, and my children, Lance and Therese, and colleagues and friends for their support and encouragement.

They tell me: "Rey, what you are doing is extremely difficult and entails a lot of sacrifices. It sometimes seems to interfere with your practice. It would be all right as long as you are happy with what you are doing.

I am.

Health Profession Education