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Anesthesiology Graduate Medical Education

Best Approaches for the Learner, Best Approaches for the Teacher

Fahy, Brenda G. MD, MCCM*; Brull, Sorin J. MD, FCARSCI (Hon); Schwartz, Alan Jay MD, MSEd‡§

doi: 10.1213/ANE.0000000000000994
Editorials: Editorial

From the *Department of Anesthesiology, University of Florida, College of Medicine, Gainesville, Florida; Department of Anesthesiology, Mayo Clinic College of Medicine, Jacksonville, Florida; Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and §Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.

Accepted for publication August 13, 2015.

Funding: None.

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Address correspondence to Brenda G. Fahy, MD, MCCM, Department of Anesthesiology, University of Florida, P.O. Box 100254, Gainesville, FL 32610. Address e-mail to

Educating the next generation of anesthesiologists presents many challenges. In this month’s Anesthesia & Analgesia, Weidman and Baker1 review principles of cognitive learning, providing examples pertinent to the field of anesthesiology with a goal of assisting learners and teachers as they confront these educational challenges. Educating the anesthesiologist of the future in the face of a variety of challenges presents an opportunity to improve graduate medical education by applying the principles discussed by Weidman and Baker.

Medical practice as a whole and anesthesia patient care in particular require practitioners to make clinical decisions and problem-solve, often during critical events when time is of the essence and the stakes are high. These decisions can mean the difference between patient survival and demise. A primary goal of graduate medical education is to provide residents and fellows with the necessary background, readily accessible for application when these situations arise; this goal requires that these future clinical anesthesiologists have key material readily accessible and available to be applied effectively and efficiently to crucial clinical decisions. The challenge for educators is to identify and implement optimal educational strategies that will assure that the patient care information is readily available and effectively and efficiently applied by the learners.

There is a variety of key principles of learning presented in the review by Weidman and Baker. To highlight these principles, this editorial focuses on how to enhance learning acquisition to facilitate retrieval of the clinical care information so that it can be applied during clinical scenarios to provide the best patient care.

Learning is a complex process involving the human memory system with initial steps establishing a basic foundation of knowledge. The brain has a remarkable capacity to store information. This complex process involves initial learning of the material, forgetting, and then remembering with the goal of retrieval of the information and its subsequent clinical application. Studies reveal that after initial learning, only one-third of the content is retained within a day.a Residents have significant forgetfulness over a 6- to 7-month period.2 So how do we apply the learning theories discussed in the review by Weidman and Baker1 to optimize learning so that this material is not “forgotten,” especially when its clinical application is needed?

One of the key aspects of learning is the retrieval process. Some of the processes that enhance learning and thus enable the retrieval process may appear counterintuitive. Some of these principles include varying the conditions of learning rather than having them be constant. It is no coincidence that an effective educational principle included in the review highlights the importance of spacing learning opportunities so that conducting multiple practice sessions will allow for repeated studying and additional opportunities for implementation of the learned techniques.1 Education is further enhanced by interweaving other learning opportunities that provide better conceptual frameworks that actually increase understanding, although to the learner, this may appear at first to be disruptive. Teachers and students must also recognize that tests, rather than being used solely as a performance metric, can be and should be recognized as learning events. Focusing on testing as a learning aid represents an area that is championed in cognitive psychology and that can be of benefit to the field of anesthesiology. Students who wish to be lifelong learners can gain more educational substance than those who wish to perform and stop learning once they prove their performance ability through passing the test. Interestingly, test-enhanced learning may prove to be most beneficial for novice learners who lack strong associative networks and thus may be particularly valuable for trainees who are in the process of acquiring strong associative networks during training.3

The 3 authors of this editorial remember well the principle that guided medical education in the past, that is, “see one, do one, teach one.” However, the past is still present when it comes to graduate medical education. Those entrusted with the future professional lives of clinical anesthesiologists still teach with little educational background to ground their activity. Many of these teachers, for example, walk into the operating room and decide to teach a high-level cognitive topic at the same time the resident is trying to focus on his or her patient’s altered physiology. The teachers have not recognized that the distraction of patient care results in cognitive overload, preventing the resident from grasping the depth and breadth of the intended teaching. In other educational settings, the teachers dive into the lesson without a clear understanding of the residents’ prior knowledge. All residents are not equal; they enter teaching activities with different backgrounds and different foundational understanding of the anesthesia and medical/surgical patient care that is taking place. These teachers, who do not really understand the educational background of their students, cannot offer, for example, the analogical similarities and differences that may already be known to the resident. Not knowing who the learners are diminishes the educator’s ability to capitalize on prior student comprehension. What results is less effective and less efficient teaching and learning.

These examples point out what we believe should be the obvious; teaching is a profession that requires the educator and the learner to be facile with the principles of learning to assure that the best education will result. The ability to apply principles learned in clinical situations will impact patient care and thus outcome is of paramount importance. We have known for many years that the best curricula are those that use residents’ actual clinical experiences and teach medical skills “in real time in existing clinical and educational venues.”4 Just as one would not risk a patient’s safety to a neurosurgeon who has never been taught (and thus has not learned) the principles of intracranial surgery, one should not put patients at risk because an anesthesiology resident or fellow was exposed to a clinical teacher who never learned the principles of education. We are all indebted to Weidman and Baker1 for their superb, timely, and useful review of the principles of cognitive learning; our residents need the best education we can offer, and our patients deserve the best care we can provide.

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Name: Brenda G. Fahy, MD, MCCM.

Contribution: This author helped write this manuscript.

Attestation: Brenda G. Fahy has read the review by Weidman and Baker.

Name: Sorin J. Brull, MD, FCARSCI (Hon).

Contribution: This author helped write this manuscript.

Attestation: Sorin J. Brull has read the review by Weidman and Baker.

Name: Alan Jay Schwartz, MD, MSEd.

Contribution: This author helped write this manuscript.

Attestation: Alan Jay Schwartz has read the review by Weidman and Baker.

RECUSE NOTEDr. Sorin J. Brull is the Section Editor for Patient Safety for Anesthesia & Analgesia, and Dr. Alan Jay Schwartz is the Editor-in-Chief of A&A Case Reports. This manuscript was handled by Dr. Steven L. Shafer, Editor-in-Chief, and Dr. Brull and Dr. Schwartz were not involved in any way with the editorial process or decision.

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a Ebbinghaus H. über das Gedächtniss. Leipzig 1885. Memory: A Contribution to Experimental Psychology. Ruger HA, Bussenius CE, trans-ed. 1913; section 29 & 34. Available at: Accessed June 26, 2015.
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1. Weidman J, Baker K. The cognitive science of learning: concepts and strategies for the educator and the learner. Anesth Analg. 2015;121:1586–99
2. Larsen DP, Butler AC, Roediger HL III. Repeated testing improves long-term retention relative to repeated study: a randomised controlled trial. Med Educ. 2009;43:1174–81
3. McConnell MM, Azzam K, Xenodemetropoulos T, Panju A. Effectiveness of test-enhanced learning in continuing health sciences education: a randomized controlled trial. J Contin Educ Health Prof. 2015;35:119–22
4. Green ML. Graduate medical education training in clinical epidemiology, critical appraisal, and evidence-based medicine: a critical review of curricula. Acad Med. 1999;74:686–94
© 2015 International Anesthesia Research Society