The old adage in medicine, “see one, do one, teach one,” has changed. It was thought to have served medicine, especially surgery, well over the last century of changes in medical care and medical education, especially when there was no specific or formalized medical training in this country. However, in the new era of American medical compliance (Health Insurance Portability and Accountability Act, patient safety concerns, and compliance oversight),1 from our various professional societies as well as at the state and federal levels, this adage needs to be looked at again and may actually have been detrimental to the patient and the physician’s overall well-being.
The days are long gone of residents being unsupervised and teaching other residents on a daily basis. This is certainly the case in plastic surgery and has been for years in lieu of the recent compliance era of faculty oversight, the patient safety act, and the 80-hour work rule.2 Many of these rules were enacted because of significant medical errors that were injurious to patients and resulted in patient deaths. Thus, the days of “see one, do one, teach one” are long gone and we are now in the era of evidence and outcome medicine, that is, “see many, learn from the outcome, do many with supervision and learn from the outcome, and finally teach many with supervision and learn from the outcome” (Fig. 1). The major differences today are the involvement of the mentor and the degree of supervision/oversight, which has changed radically from sporadic, episodic learning to the capability to learn from each outcome. This is vital to learning, because it is key to learn from each outcome of what you see, do, and teach, so you can be self-critical and learn at each phase of the new medical learning cycle (Fig. 1).
It is now time to look at how plastic surgery has performed in this venue. Plastic surgery, as well as other surgical subspecialties, has struggled to accommodate and now embrace the new changes in compliance and the 80-hour work rule that have been mandated by the Resident Review Committee for Plastic Surgery. Overall, these changes are good for patients and residents, but they have required a restructuring of how we train, teach, and educate residents.
Furthermore, it has forever changed how we do continuing medical education for the practicing, board-certified plastic surgeon. It is definitely an evolutionary process in which we are all held more accountable for our individual actions. We have to monitor our individual outcomes so that eventually we can compare them with the outcomes of our peers in plastic surgery.
The key to plastic surgery training is to develop and instill in all plastic surgeons a system of life-long learning as our ultimate goal in patient safety and optimal patient care, hence the rationale for Maintenance of Certification by the American Board of Plastic Surgery.3 Certainly, we want to provide and maintain excellent and safe patient care, but we also want to provide optimal education during training that will serve as life-long imprinting for continued learning throughout our careers. For instance, at The University of Texas Southwestern Medical Center, we are fortunate to have an excellent public hospital system—Parkland Health and Hospital System and Dallas Veterans Administration Regional Center—that not only allows us to directly supervise residents on every case but also allows residents to have a degree of independence, so that they can truly develop into plastic surgeons in an efficient and safe fashion. However, we must become even more outcome and data oriented, not only in the teaching of our residents but also in the application of how we recertify or maintain our certification in plastic surgery, as this will soon be enacted by the American Board of Plastic Surgery’s Maintenance of Certification program in 2007.3 The Journal is leading this trend as the major peer-review source of plastic surgery information on this issue. Our emphasis will be to publish only premier articles in the clinical area that will document outcomes data.4 The Journal plans to implement a new and easy method for our readers to delineate what type of article they are reading and whether it is outcomes based or merely an expert opinion article.
Tracking Operations and Outcomes for Plastic Surgeons (or TOPS) has been a good initial effort developed by the American Society of Plastic Surgeons and the Plastic Surgery Educational Foundation. It has helped us to focus on how accountable we are individually and how we compare with others in our peer group. In the future, when groups say they are better than other specialty groups in a specific arena, the burden will truly be on us to show these data in an evidenced-based fashion. In plastic surgery, there are several principles that we should abide by: (1) faculty teaching residents, and not residents teaching residents, is paramount; (2) the model of residents teaching residents is kept to a minimum, as good educators and supervisors who are faculty are the best role models; (3) role models lead by teaching, educating, and doing. We know that those who imitate or mimic excellent plastic surgeons and role models of integrity obviously establish a lifetime of good, safe, and competent behavior, which when internalized helps them become similar excellent physicians and caring plastic surgeons.
Plastic surgery education is a team sport, and that is why we have many interactive conferences and why we debate the pros and cons of plastic surgery diagnosis, care, and management in an open fashion with our residents and faculty, locally, regionally, and nationally. It is vital to the continuum of plastic surgery education to have an organized approach to learning, so that residents, faculty, and practicing plastic surgeons know what to expect and what is expected of them each day in the operating room, in conferences, and with their life-long home study program. Furthermore, these expectations and standards must be uniform and attainable. The continuation of life-long learning must be self-rewarding, critical self-analysis, but not punitive.
As program directors, we also know that adequate and constructive feedback between residents and faculty is critical to learning. There must be direct feedback not only in the operating room but also in the conference arena, so as to provide the foundation for proper learning and the learning of what is deemed good judgment and competent behavior. The in-depth involvement of all levels of our faculty with the residents amplifies the ability to identify those residents with sociopathic and borderline behavior. It is hoped that direct one-to-one observation will provide more immediate feedback, to derail or correct the problem, to place the resident on probation or ask for his or her resignation, and/or to allow for the resident to alter his or her behavior or perhaps pursue another career.
The bottom line is that the adage of “see one, do one, teach one” is no longer valid. Today it is “see many, learn from the outcome, do many with supervision, learn from the outcome, and then teach many with supervision, learn from the outcome, and then repeat the cycle” throughout one’s career, thus becoming better every day. The end result is improved patient care. The new learning cycle for medicine is better not only for the patient but also for our commitment to life-long learning as plastic surgeons. In the future, medical simulation, as with flight simulation, will greatly enhance and enrich this cycle of learning in medicine, especially in surgical specialties such as plastic surgery.
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