Learning Processes and Mechanisms in the University of Utah Department of Surgery


As an academic medical center, the University of Utah is dedicated to "serv[ing] the people of Utah and beyond by continually improving individual and community health and quality of life" through "excellence in patient care, education, and research" (University of Utah Health, n.d.). The University's mission includes providing compassionate care, educating scientists and health care professionals, and engaging in research. These goals are evident in the Department of Surgery through formal learning programs and informal learning practices, the use of Senge's five disciplines, and the support of Smerek's thinking dispositions.


Formal Learning Programs

The University of Utah Department of Surgery currently offers 19 formal learning programs, including six residencies and 13 fellowships, with more in various stages of creation and accreditation. Though several sanctioning bodies exist, the majority of the programs offered by the department are accredited and overseen by the Accreditation Council for Graduate Medical Education (ACGME). Requirements may differ between programs depending on what type of program it is (e.g., residency vs. fellowship; the subspecialty being taught), but the ACGME issues similar "Common Program Requirements" for both residencies and fellowships that must be followed by all programs (2020a; 2020b). These general requirements include directives regarding oversight, personnel, trainee appointments, the educational program, evaluation, and the learning and working environment.


Core Competencies and Evaluations

The key measures of performance in the Department of Surgery's programs are portrayed by the ACGME's "Core Competencies" (often even in non-ACGME programs). These six core competencies provide a conceptual framework that is meant to measure a physician's ability to enter autonomous practice and administer a high level of care. Certain milestones in each competency must be met at different points throughout the program in order to officially complete a residency or fellowship. The ACGME (2020a; 2020b) describes the competencies as follows:

  • Patient Care - providing care that is "compassionate, appropriate, and effective for the treatment of health problems and the promotion of health (p. 19; p. 20)

  • Medical Knowledge - demonstrating knowledge of "established and evolving biomedical, clinical, epidemiological and social-behavioral sciences, as well as the application of this knowledge to patient care" (p. 19; p. 21)

  • Interpersonal and Communication Skills - demonstrating interpersonal and communication skills "that result in the effective exchange of information and collaboration with patients, their families, and health professionals" (p. 19; p. 22)

  • Professionalism - demonstrating "a commitment to professionalism and an adherence to ethical principles" (p. 18; p. 19)

  • Practice-Based Learning and Improvement - demonstrating the ability to "investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and lifelong learning" (p. 19; p. 21)

  • Systems-Based Practice - demonstrating an "awareness of and responsiveness to the larger context and system of health care, including the social determinants of health, as well as the ability to call effectively on other resources to provide optimal health care" (p. 20; p. 23)

In the Department of Surgery, learners and educators complete reciprocal evaluations, as well as evaluations on the rotation and overall program, either on a monthly basis or upon completion of a rotation (depending on the program), as well as quarterly, to ensure programs are effective. Additionally, trainees are evaluated on their progress through the milestones set forth by the ACGME at minimum every six months (but usually quarterly) based on faculty, peer, self-evaluations.


Informal Learning Practices

Within surgical education, and even medical education at large, informal learning often takes place in the form of self-directed learning. Incidentally, "self-directed learning" can be used to describe both a personal characteristic and a process. As a trait, it represents self-efficacy, initiative, independence, self-discipline, and strong sense of curiosity. In applying these attributes to education, self-directed learning becomes a process. Learners can rely on the constitution of formal learning while still "tak[ing] the initiative, with or without the help of others, in diagnosing their learning needs, formulating learning goals, identifying human and material resources for learning, choosing and implementing appropriate learning strategies, and evaluating those learning outcomes" (Knowles, 1975, p. 18).


Members of the medical community must, by nature of their professions, actively continue to learn throughout their careers. Medical school and the University of Utah Department of Surgery's formal training programs naturally provide structure to our learners' education, but the majority of their learning throughout their lives is expected to be self-directed. The Department of Surgery has adopted some of Towle and Cottrell's (1996) strategies and methods to support this objective and ensure the attainment of organizational goals:

  • Clear, advance information about tasks

  • Specific performance goals

  • Intrinsic rewards for task completion

  • Timetabling that allows sufficient time for task completion

  • Trust that learners will remain on task

  • Formative assessment and feedback that enables trainees to monitor and modify their own learning

  • Appropriate summative assessment, that is, that tests problem solving rather than rote repetition of facts (p. 358)

Finally, it should be noted that these basic tenets of self-directed learning fulfil one of the ACGME's (2020a; 2020b) practice-based learning and improvement goals to "continuously improve patient care based on constant self-evaluation and lifelong learning" (p. 19; p. 21) within the core competencies.


Use of Senge's Five Disciplines


Workforce development is a concept generally described as initiatives that create, sustain, and retain a viable workforce. Traditionally, this may have simply meant training employees to do their jobs, and while this is basically still true, the concept has become much more complex and involves provided employees opportunities and maximizing their potential. Current trends have made workforce development employee-led (and, in the case of the University of Utah's Department of Surgery specifically, trainee-led) and includes skills-based training, leadership development, interpersonal problem solving and relationship building, and continuing education programs amongst other factors. Besides the application of personal mastery and systems thinking already discussed, understanding mental models, building a shared vision, and team learning are disciplines that can positively cultivate workforce development.


According to Senge (2006), mental models are "deeply ingrained assumptions, generalizations, or even pictures and images that influence how we understand the world and how we take action" (p. 8). In essence, these models are the beliefs that motivate our behaviors. Employees should identify and recognize patterns of behaviors, both positive and negative, and address those that need to change in order to enhance almost all aspects of employee development (Diniz, 2018). Other qualities that have aided workforce development in the Department of Surgery are building a shared vision and team learning.


When members of an organization have a shared idea - a genuine vision - of what they want to accomplish as part of the organization, they "excel and learn, not because they are told to, but because they want to" (Senge, 2006, p. 9). The University of Utah Health's shared vision energizes and focuses trainees and employees, creating stakeholders interested in the organization's outcomes. Finally, when individuals come together to learn and work as a team, less energy is wasted, burnout is minimized or avoided, and duplication of effort is evaded. In 2020, Instructure identified "Rise of Teams (Collaboration Versus Competition)" as a key trend in the workplace, citing the need to innovate as driving a new organizational structure amongst high-performing organizations (p. 6). Within the Department of Surgery, and across the University of Utah, collaboration augments morale and makes it so that members' strengths are utilized. The dialogue that comes from team learning also leads to perceptive and useful free-flowing thoughts and insights not attainable otherwise.


Support of Smerek's Thinking Dispositions

A mindset is a collection of ideas and beliefs that shape one's worldview. According to Dweck (2006), when one believes that qualities are "carved in stone" they have a fixed mindset, creating "an urgency to prove [one]self over and over" (p. 6). In contrast, a growth mindset is based on the belief that effort is the "primary driver of success" (Smerek, 2018, p. 58). Those with a growth mindset believe that everyone can grow through application and experience. The University of Utah Department of Surgery supports a growth mindset by cultivating critical thinking and resilience, and by focusing on lessons learned from "failures" (for instance, by conducting Morbidity and Mortality [M&M] conferences).


While a growth mindset fosters a learning orientation, one's achievement striving is done in pursuit of performance goals. In this regard, McClelland (1961) proposed three achievement orientations: the Need for Achievement, the Need for Affiliation, and the Need for Power. Those high in Need for Achievement usually posses a strong need to set and accomplish challenging goals and like to receive regular feedback. Those with an affinity for Need for Affiliation prefer collaboration over competition but are so afraid of failure that they may avoid any high risk or uncertain situations. Finally, those with a Need for Power largely enjoy control, status, and recognition. Like any other organization, the University of Utah is comprised of individuals with varying degrees of each of these orientations; however, it would seem that a Need for Achievement is generally encouraged, though aspects of the other orientations are also favored and play a role in the University's success.


The last of Smerek's thinking dispositions, intellectual humility, is the "effective calibration of what you know and do not know" (Smerek, 2018, p. 69). Essentially, by admitting that (and what) we do not know, we are exposing ourselves to a desire to learn. Intellectual humility strikes a balance between intellectual arrogance (excessive confidence) and intellectual diffidence (excessive cautiousness). If one is too timid, or at the other end of the spectrum, certain that they know everything, it "affords little motivation to learn" (Smerek, 2018, p. 69). It may be that all physicians go through a phase of diffidence (likely early in their careers), then arrogance once they have gained some understanding in their fields, and hopefully finally humility, where they realize that the more one knows, the more there is that one does not know. I believe that the majority, if not all, of the attending physicians in the Department of Surgery practice intellectual humility, understanding that their actions directly affect the lives of their patients and the education of their trainees. In doing so, they ensure patient safety, encourage learners' curiosity, and discover opportunities for self-study.


Conclusion

Senge (2006) maintains that a learning organization is one where its members "continually expand their capacity to create the results they truly desire, where new and expansive patterns of thinking are nurtured, where collective aspiration is set free, and where people are continually learning how to learn together" (p. 3). At a basic level, organizational learning describes the creation, retention, and transfer of knowledge within an organization. This is achieved at the University of Utah's Department of Surgery via formal and informal learning, and through the use and support of Senge's five disciplines and Smerek's thinking dispositions. By creating this type of learning culture, the University of Utah benefits from increased efficiency, productivity, profit, and employee satisfaction; decreased turnover; and a culture of inquiry and sharing.


The state of the Department of Surgery's learning culture, much like those of organizations across the globe, has been extensively impacted by the Coronavirus. Elective surgeries have been cancelled or delayed, meetings and trainings moved to virtual settings, and in-person learning severely limited to adapted to be done electronically or independently. But with supportive leaders, a culture of continuous improvements, intuitive knowledge processes, and defined learning structures, the University of Utah Department of Surgery successfully continues in its mission.


References

Accreditation Council for Graduate Medical Education. (2020a). ACGME Common Program Requirements (Fellowship). Retrieved from https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/CPRFellowship2020.pdf

Accreditation Council for Graduate Medical Education. (2020b). ACGME Common Program Requirements (Residency). Retrieved from https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/CPRResidency2020.pdf

Diniz, A. (2018). Why start with mental models? Association for Talent Development. Retrieved from https://www.td.org/insights/why-start-with-mental-models

Dweck, C.S. (2006). Mindset: The new psychology of success. New York: Random House.

Instructure. (2020). 7 trends for workforce 2020: How to make today’s ever-changing workplace work for you. Retrieved from https://sewi-atd.org/resources/Pictures/7%20TRENDS%20FOR%20WORKFORCE%202020.pdf

Knowles, M.S. (1975). Self-directed learning: A guide for learners and teachers. New York: Association Free Press.

McClelland, D.C. (1961). The achieving society. New York: Free Press.

Senge, P.M. (2006). The fifth discipline: The art and practice of the learning organization (Rev. ed.). New York: Doubleday.

Smerek, R.E. (2018). Organizational learning and performance: The science and practice of building a learning culture. New York: Oxford University Press.

Towle, A., & Cottrell, D. (1996). Self-directed learning. Archives of Disease in Childhood, 74(4), 357-9. doi: 10.1136/adc.74.4.357

University of Utah Health. (n.d.). About University of Utah Health. Retrieved from https://uofuhealth.utah.edu/about.php

Anna Darelli-Anderson

University of Utah

Department of Surgery

Office of Surgical Education

30 N. 1900 E. 3B110 

Salt Lake City, UT 84132

annadarellianderson@gmail.com

anna.darelli-anderson@utah.edu

801.213.2598

© 2020 by Anna Darelli-Anderson