Improving procedural memory

[epsilonprodigy]

I'm finding that I'm a REALLY slow learner when it comes to procedures. I do best when I see a lot of the same thing in quick sequence, when I can explain it back to someone soon after doing it, and when I can talk through steps in a "safe" environment beforehand. I don't really learn all that well by watching unless I can take detailed notes. Also, it's very rare in my program for anyone to actually walk us through a case with verbal descriptions to go along with each step. I try to watch as many videos as possible, but this is of limited usefulness because a) they usually don't say "aim your needle this way," etc., they just outline the steps and b) they're all a little different- from each other as well as my attendings.

Say I scrub something rare-ish, then 2 weeks later there's another. If, after the first time, I had to rush off to the next case or whatever, I can guarantee that I'll forget the miniscule details, even if I can outline the "gross" steps. Things such as whether to bury a knot, whether to start "outside in" or vise versa, whether to use an Allis or a Babcock leave my mind REALLY quickly, especially when I'm trying to concentrate on my actual technique. This inevitably leads to attendings screaming, throwing retractors and other unsavory behaviors which do not supplement learning. Worst of all, the second you take a bite that's not the "right" size, you get kicked aside. So you never learn to do it right, just that you were totally wrong.

This is a huge problem, because at my program, you are basically supposed to walk in knowing not only the steps, but exactly how to perform them. I'm not sure how some people are able to memorize every attending's differences in technique, instrument preferences for all the steps, etc. after only 1-2 passes- or 20, for that matter, if no one ever walks you through it. How to solve this issue and become a faster learner?

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[vhawk]

There isn't really an easy answer, you arent unique in this, you are describing a central challenge in surgical resident education. I think your approach of taking detailed notes after the case is a very good idea. I know of one attending who has his fellows bring a notebook to every case and scrub out multiple times to write down specific details. That's a bit extreme but the issues with retention you describe are universal. Operations are a serious of HUNDREDS (or more) steps depending on your chunking ability and it's impossible to simply memorize them in that way. Or at least, as you say, it takes dozens and dozens of repetitions.

No experienced surgeons think of them this way, however. We do what experts in all fields do, which is chunk the information. You didn't say what level of training you are at, but assuming you are a junior resident, you need to approach the problem from the top down and the bottom up at the same time. What I mean by that is that from the top down, a gallbladder operation consists of getting in, getting exposure, dissecting critical view, taking gb off, and closing. From the bottom up, a gallbladder operation consists of holding the knife correctly, holding the lap instrument correctly, having depth perception and instrument control, etc. It would be great if I could just say start bottom up and work until you understand it all but unfortunately this won't work because you can't really participate in an operation unless you have SOME big picture sense of the conduct of the procedure. So you have to find some way of keeping these two things in your head at once, and be aware of which approach you are being asked to use for any given step. A good attending will recognize when you are struggling with a bottom up issue and when it's a top down issue. If I ask you what's the next step, that's a top down question. If I ask you to describe how to do the anastomosis that's a bottom up problem.

Both of these approaches can be facilitated by study outside the OR but the top down is easier. The bottom up primarily requires practice and time. Mastery can be defined as the ability to move up and down the levels of complexity of the procedure effortlessly...dont expect that from yourself at this point. But the case becomes disorienting and bewildering when you don't know where to put the information you are getting.

And the more prepared you are ahead of time for a given case the more mental energy and focus you will have to dedicate to taking in the finer details.

I wish I had a better solution for you, hopefully someone else does, but you should try being candid about this with some of your attendings it's unfortunate that they don't routinely talk through the operation in this way with you. That's how I like to teach anyway.

 

[epsilonprodigy]

Thanks! These are great ideas. I've never been a good auditory learner, and now I'm actually pretty sure I'd meet criteria for auditory processing disorder. Ultimately, I'm going to have to throw out my concerns about looking silly and just do what I need to do to learn the info (like watching cases not scrubbed and taking notes, or getting someone to talk through steps with me.) Bring on the hellfire, attendings- at least I'm actively trying to self correct.

Not sure where this giant set of (proverbial) PGY-2 balls came from, but this year, I'm like "screw it, if I read the book and still don't know the answer, I'm asking!"


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[epsilonprodigy]

Yep, bumping my own thread. But there's another piece to this puzzle, and I KNOW I'm not alone here:

It's well proven that fear and learning are mutually exclusive. So, what are you supposed to do when your attending or chief is over your shoulder, telling you that LITERALLY EVERYTHING about you is wrong? I'm talking about more that just surgical technique here. Crap like, "quit standing like that." (Like WHAT, we're not even doing anything at the moment.) this kind of stuff naturally makes a person hesitate, and one hesitation is all it takes to trigger a really explosive reaction. Frankly, it's like operating with a gun to my head for how terrifying I find it. Even though I'm trying to focus, a good part of my mind is taken up by "oh my God, does he approve of how I'm holding this instrument? He's going to start screaming at me any minute, I just know it..." At times, this causes me to shake a little, which is its own problem. I get plenty of compliments on my technical skills from those I'm comfortable with, but put me in a room with a really malignant upper level and I'm an all-thumbs chimp.

I know I'm not alone here- how to remind your brain that your chief/attending is in fact, not a hungry saber toothed tiger?


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[armybound]

Do you think you're taking it to an unhealthy level? I used to get so nervous around some staff I couldn't function. Had to get on an antidepressant for it, and now I'm doing much better.

I don't know what to tell you other than to just keep working on it. You focus on what you're doing and try to do it well. Staying calm under pressure will get you far in surgery, and this could be one way to get experience with that.

 

[epsilonprodigy]

YES I think it's reached an unhealthy level! Here's the funny part: I walk out of the OR and think, "geez, I don't even like these people. So why again do I give two hoots about what they think or say?" I'm sorry to hear that this drove you to the point of needing medication, but glad to hear you got through it. I'm told that pretty much everyone in my program is on an AD, an anxiolytic or both. Maybe I'm missing the boat, lol. If you don't mind my asking, what medication did you try?


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[TraumaLlamaMD]

There's a balance to be struck between tuning out the anxiety of someone's advice while also listening to the core message. If someone is telling you you're standing wrong, take a deep breath and evaluate. Maybe you are in fact putting yourself in a position that is mechanically disadvantageous - it's something I've become acutely aware of as a senior now supervising interns doing central lines and other procedures. Good positioning can be half the battle sometimes, and you often don't realize you're doing it inefficiently until you try it a better way. Maybe your supervisors could educate you in a calmer manner, but I wouldn't write the statements off as "crap" just because you're not sure yet how they are relevant.

 

[armybound]

YES I think it's reached an unhealthy level! Here's the funny part: I walk out of the OR and think, "geez, I don't even like these people. So why again do I give two hoots about what they think or say?" I'm sorry to hear that this drove you to the point of needing medication, but glad to hear you got through it. I'm told that pretty much everyone in my program is on an AD, an anxiolytic or both. Maybe I'm missing the boat, lol. If you don't mind my asking, what medication did you try?


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citalopram

 

[Winged Scapula]

There's a balance to be struck between tuning out the anxiety of someone's advice while also listening to the core message. If someone is telling you you're standing wrong, take a deep breath and evaluate. Maybe you are in fact putting yourself in a position that is mechanically disadvantageous - it's something I've become acutely aware of as a senior now supervising interns doing central lines and other procedures. Good positioning can be half the battle sometimes, and you often don't realize you're doing it inefficiently until you try it a better way. Maybe your supervisors could educate you in a calmer manner, but I wouldn't write the statements off as "crap" just because you're not sure yet how they are relevant.

I'm not at the OP's program but I'd be wiling to bet that the comment about "standing wrong" was related to this; some mechanical disadvantage she was placing herself at.

Otherwise being angry with someone because of how they're standing is crazy.

 

[Buzz Me]

During fellowship I kept a notebook (also used Evernote when I didn't have a chance to write things down) and wrote down the key steps of each operation, and how each attending did things. As I got more experienced I expanded the notes and made them more detailed, down to the exact suture used, needle angle, etc. I had over 10 different attendings and each one did things a little differently. But I was expected to know each one's preferences so when given a chance, I could take over the case or keep going when they scrubbed out.