I read an interesting question on Quora the other day – What is the most effective way to learn?

The majority of answers were related to learning by doing. Whether you call it practice, rehearsal, experience or some other name – the majority of people believe that the best way of learning is by actually doing what you are trying to learn.

This is supported by academia as well – take a look at the learning pyramid. It essentially describes what we all know well – that we retain most knowledge when we interact with it in some way, whether that be by writing it out, saying it out loud, practicing it, or teaching it to others.

This method of learning is absolutely perfect for the majority of things that we wish to learn.

So to learn how to ride a bike, you need to get on the bike and ride it. To learn how to speak mandarin, you need to either do some classes or go to Beijing and practice speaking. To learn how to do algebra, you need to do algebra exercises and problems.

I’d like to add a little more detail to this. I think the best way of learning is by applying knowledge. Although its easy to say that learning by doing is the best way, you can often only do something when you have some knowledge about the topic first.

So for example, to learn how to ride a bike, you need to know the purpose of the bicycle, where to sit, what the handlebars are for, how to use the pedals etc. Otherwise if you gave a bike to a guy who had never heard of or seen cycling before, they would have no idea what to do. In the same way when you learn math, you do require some explanation of the concepts first, before you get thrown some algebra equations. In this fashion we can see that the way in which we all really learn, is by gaining a varying amount of background knowledge, and then using that knowledge over and over again – thats the learning by doing part.

Both of these parts are essential to learning – the background knowledge and the practice by doing. If you miss out either of these steps, you will most probably fail to learn in a spectacular fashion.

For example, you can teach someone the theory of how to ride a bicycle. You can show them videos, make them read books about cycling, balance and so forth. They could study this for years. Then you would put them on a bicycle and promptly watch them fall off and scrape their knees. They need to be able to apply their knowledge and practice before they can be judged to have learned something well.

When you think about it, this combined method of learning makes sense. Its what we do all the time whenever we learn anything new. We get some basic knowledge and then jump into doing it. How much basic knowledge we attain before practicing does however depend greatly on the topic you are trying to learn.

Where things become more tricky however, is with subject matters that are more complex, and higher risk.

Surgery is a topic like this. Medical students and junior surgeons spend years and countless hours reading around the topic of surgery. We learn anatomy, physiology, pathology, clinical symptoms and signs of disease. We attend lectures, read books, watch videos, observe in the operating theatre. And then we get handed a scalpel and told to cut from point A to point B. Its at that point when approximately 100% of training surgeons realise that they haven’t learned nearly as well as they thought they had.

Its true that in the current system, surgeons will get to learn by doing – thats the only method we know. We read, watch and then really learn by doing, with our hands inside a living breathing (mostly ventilated) patient.

However this system is deeply flawed.

Firstly comes the problem of: is it really ethical or safe to practice on real patients? Should you allow a trainee surgeon who is at the bottom of the learning curve to do an operation? Furthermore, is that the best training and learning environment for them? Given that the operative situation is by nature high risk – a wrong movement could mean disaster – are trainers right in letting their trainees operate before proving that they know what they are doing? What happens most of the time is that as soon as a trainee looks like they don’t know what they are doing, or they make a mistake, they get eased to the side by the trainer who takes over the case. The trainee has now lost that entire practicing opportunity and is relegated again to the watching and observing category of learning with its associated drop in retention rates. We think that this basic level of learning – understanding what the operation involves, and what to do next – should be taught outside of the operating theatre, and a trainee should prove their knowledge before being allowed to operate on a real human being.

The second problem comes with how a trainee at present learns and gains their basic operative knowledge. Any surgeon will tell you, although knowledge of anatomy is important, reading an anatomy book will not teach you how to apply that knowledge to the operative situation. The same goes for physiology, pathology, embryology, and every other -ology we learn in medical school.

So how do we learn how to operate? The amazing thing is that there is still no formalised or accredited method to teach someone an operation beyond getting stuck in and doing it on a real patient under the watchful (and sometimes nervous) eye of a more senior trainee. As a trainee we are never taught an operation step by step. All the important points and decisions made during an operation are never explained explicitly to us. We are all just expected to learn by osmosis and pick things up as we go along.

Doesn’t this sound like the most inefficient and potentially dangerous way of learning to you?

With Touch Surgery we have aimed to address both of these issues – gaining the appropriate basic knowledge and being able to apply that knowledge and practice in a safe and risk free environment.

By breaking down complex operations using Cognitive Task Analysis we ensure that every important step and decision point in an operation is explicitly explained and taught to trainees. Furthermore by presenting these steps and decision points as an interactive learning experience through Cognitive Task Simulation we engage a different part of the learning pyramid that enhances knowledge retention.

Further more by allowing trainees to test themselves and go through an operation in an ‘unsupervised’ manner, we allow them to actually make every single decision during the course of that operation. This allows them to practice, practice, practice – and thus maximise their learning BEFORE getting into the operating theatre. It also allows them to prove their knowledge to their trainer. This allows them to maximise their theatre training opportunity, improve their surgical training overall, and shorten their learning curve.

Our aim is simple – to make surgeons better at doing what they do best.

AC