Surgery students 'losing dexterity to stitch patients'
bbc.com
bbc.com
What the surgeon wants is for lower level schools to provide him with students that are pre-trained for his specific needs.
If the Imperial College of London needs people who can cut-and-sew, then the Imperial College of London should teach them to cut-and-sew.
Or even better, the Imperial College of London can just institute a “cut-and-sew” entrance exam. Given the status and pay of a surgeon, it is likely that the exam prep industry will do the training job for them.
If they don’t, then some Youtubers surely will. Problem solved, no robots harmed and everyone got some extra plushies.
But the fact that they're complaining and they should be introducing remedial courses (or something) is something of a "canary in a coal mine", an indication that these skills aren't being learned, with implications beyond medicine.
We could do with more emphasis on knife use, carpentry, sewing/knitting, soldering, etc. among primary school students though.
https://en.wikipedia.org/wiki/Fine_motor_skill
I'd add that writing with a pen, playing musical instrument are important activities to develop fine motor skills. Just to buy toddles more toys would not work, without constant development later.
No, it assumes that if you make surgery and related specialties areas that one has to plan to enter when one starts medical school, the surgeons that result will have better manual dexterity.
Saying that if you change things, things will change, that is never a good argument against changing things. The real question is what the possible negatives would be of the change.
Tactile dexterity depends greatly on developing a 'feel' for what you are doing.
It means developing:
1) heightened sensitivity to the inputs of all the nerves, joints, and muscles,
2) delicate and highly tuned muscle activation, coordination among muscles, and hand-eye-object coordination,
3) refined expectations about the behavior of your materials,
4) deep and subtle integration of all those skills.
Neuroscience studies show that experts in a field can develop 10x the sensitivity of ordinary healthy people in relevant perceptual disciplines. E.g., if the ordinary person can distinguish a pressure difference of 1g on his fingertip, a pianist or surgeon would be able to distinguish 0.1g pressure.
This kind of tuned neuromuscular system does not develop from simply taking a set of courses. It takes years or decades of training. It may even be the case that if not developed during the more plastic stages of brain/neuromuscular development, it will be close to impossible, or at least substantially more difficult.
To obtain real professional-level dexterity takes decades of learning, understanding, & integrating many subtleties and sub-skills before fluency is achieved.
A closer analogy would be literacy. The professors certainly have a specific need that their students be literate. Yet I wouldn't expect anyone, even a highly intelligent person, who had not learned to read and developed extensive and solid note-taking skills to arrive at Med school and expect that the professors teach him/her to read, write, and take notes. This is because it takes decades of learning, understanding, & integrating many subtleties and sub-skills before fluency is achieved.
edit:clarity & #4
The article very much reads as an editorial "the next generation isn't ready" piece. It blames the lack of dexterity on smartphones, yet there is no research on this, just anecdotal accounts. I'm sure there is merit to the professor's claims, but the article does not back up the claims.
That being said and tying to OP's comment, expertise does take time; however, when improve skills that an individual is bad/inadequate at, then deliberate practice [1] can be used. This is what motivates my current research. Someone that is not technically literate is unable to write/debug problem-solving solutions, despite being competent in problem-solving. Therefore, require deliberate practice on where they struggle, in writing syntax.
All technical skills need to be ingrains to the point of having a "feeling". Whether total immersion or specific practice is better has not be really researched, though I'm sure it is a combination of the two (with specific practice being deliberate in nature).
[1] https://en.wikipedia.org/wiki/Practice_(learning_method)#Del...
OP casually shunts off the severely deficient students as an 'invalid concern' and "just [a] transfer of responsibility", as if the schools merely "should teach them". Or, perhaps add an exam that would be solved by some 3rd party exam-cram courses or YouTube videos.
OP is wrong in this by orders of magnitude.
The training that you propose with immersion and deliberate practice is more, but likely still drastically inadequate.
There's little doubt that the surgery professors are observing a new and serious deficiency, even though the article doesn't mention quantifying the observations or research that nails down the exact cause.
Moreover, the skill deficit is deceptively simple, and may require years to fix, or even be unfixable in those subjects. Several examples:
* A group of monkeys being raised in an indoor arboretum had some injuries, and the scientists installed much more stout sticks and secured the vegetation. No more injuries due to broken branches, but when the monkeys were introduced to the wild, instead of swinging & leaping through the leafy canopies like their wild brothers, they cowered at the trunks. They'd completely failed to learn while young the skills required, and so the release failed for that generation.
* Personal experience, in learning a physical skill to an internationally competitive level, starting from being already well-coordinated, it took close to a decade of full immersion & dedication to get to the national team level. Moreover, even having achieved this skill level in certain sports, I've tried to get good at things like juggling and piano, and I have no illusions that even making a similar level of dedication, I'd never get anywhere near a professional level in either -- I didn't build that kind of wiring earlier.
* I've made arguments like yours to concert-level musicians, i.e., that simply being dedicated enough and training hard enough would get one to a professional level. Instant response of "NOoooo..." -- they've each seen multiple people pour years of their lives into hard work with top teachers and never get to a professional level, and these weren't people starting with a deficit.
* In neuroscience there is observed a period of plasticity for some skills. While it is not absolute, it is phase in brain development where the brain is particularly suited to absorb & learn certain skills. With some skills and animals, it is absolute -- if not exposed during that time, the organism or person will have an unsurmountable lifetime deficit. Languages are like this, where picking up a language between the ages of 4-8yo is almost effortless, but after that... Even if it is a skill that can be overcome in a different period of life, it's much more difficult.
Serious professional level manual dexterity and physical skills are not something that can be picked up even with multiple dedicated courses.
I'd venture that putting in the courses of immersion & deliberate training you suggest, and at a level of intensity equal to med school itself, might recover 30% of the deficient students in several years, delaying their Med School by the same period. Seems out of scope to me.
But the OP's idea of a pre-screening exam is good, not because prep courses would solve it, but because the pre-med students could wash themselves out of contention if they lacked the skills to begin with.
Do you have a link about this one? Sounds interesting.
That's a longer term approach. I agree that if I'd started some of my current hobbies at a younger, more malleable age, I would have improved at a faster rate. But I also can't time travel, so should I simply give up my aspirations of learning? Hitting 35 soon, the skills I have are all I can have? If we assume the article is referring to young med students, they are still in their early twenties - is that too late to 'start'? What about any non-traditional student that goes to a community college for a vocational trade, are they SOL? As you mention, it is more difficult, but I'd argue not impossible through specialized training.
Pre-screening is a suggestion I'd be very careful towards. The reason being is that Computer Science saw a rapid spike in popularity in the 80s [2]. Unfortunately, academia could not match the demand and so they were faced with an issue of "whom to teach". One approach was to increase the difficulty of entrance exams. I'm sure this eliminated a lot of poor students just going where the money was; however as Roberts puts it, some students took this as a sign that they were "unwanted", causing a sharp decline in enrollment in the field. Interestingly enough, this drop is around the time women in CS took a nosedive [3] that we are only now recovering from. In addition, many underrepresented groups do not pursue CS at a young age, contrary to Caucasian males. Walking into their first CS courses, it's intimidating to be met with peers that have been modding Minecraft since they were 12. We're seeing a similar 'peak interest' in CS due to the dot-com/social media era and many of the same suggestions are getting thrown around. Coupled with the demand for future software developers [4], there is a need to figure out how to teach individuals starting out with an inadequate skill level.
Instead of pre-screening, I'd lean more towards placement tests, faded assistance, and teaching discipline (which I've called perseverance/'grit' in other posts). Not everyone enters the classroom at the same ability and so those that need additional work should be given time to hone those skills. Faded assistance (scaffolding) removes the crutches as a student's 'Zone of Proximal Development' increases [5]. The mistake learned from your monkey example is they failed to be properly integrate into real world scenarios where those crutches are nonexistent. Finally, discipline teaches students to continue, even after becoming skilled. Doctors that continued to practice after their time in school were better performers than those that did not [6]. In the martial arts I train, you typically have earned your blue belt after 2 years. By that time, you KNOW every technique; however, many students also quit around this time because they become frustrated they aren't as good as the people nearing 10-20 years of training.
Others have mentioned it, but in addition to their neuroplasticity, children are forced to learn because a) they have an empty cup (neuroplasticity), and b) they are forced to (early specialization by parent). It's harder for an adult to learn because of both age and they don't have the same time to devote to becoming skilled like they did as a child. This is why I like the idea of specialized courses and why I prefer academia to something like a MOOC. There is an implicit "forced learning" where the novice is devoting time toward progression.
If a student "can't learn CS", I'd say it is because they are ill equipped to learn it at that time. As such, the next step is to identify why they struggle (technical literacy, problem-solving, reasoning, or some combination of those) and seek to improve that skill before moving into CS. Similar to surgery, by identifying what basic skill a student struggles with and then improving it should be the first course of action. WHERE that basic skill should be taught is more political than I'd like to get into, since I've written enough.
[1] http://www.chrest.info/fg/Articles-2011-2015/Hambrick-2014-I... [2] https://cs.stanford.edu/people/eroberts/CSCapacity/ [3] https://www.npr.org/sections/money/2014/10/21/357629765/when... [4] https://fas.org/sgp/crs/misc/R43061.pdf [5] https://en.wikipedia.org/wiki/Zone_of_proximal_development [6] https://www.ncbi.nlm.nih.gov/pubmed/22141427
Don't you mean they should test for "real professional-level dexterity"?
> Many medical specialties don't require high dexterity. Most medical students don't decide whether to go into surgery until they've been in school for a while and assisted on some procedures.
The easy and obvious solution is to test everyone on entrance and only let people choose specialities if they have the necessary dexterity.
That's certainly an option.
On balance, I think the increased cost is worth giving people years of advanced notice about what their career options are. If someone really has their heart set on surgeon or nothing, they can go do something else rather than find out they won't make it 2 years into med school (with the associated debt).
While this generally increases acceptance odds, by no means do medical schools require this. I always recommend fact-checking tidbits of K-12 daycare lore. Once upon a time, I believed the 'impossible to enter unless perfect stats' rumors too until I looked at the actual data. Apply early in the cycle and broadly to many schools and the numbers quickly turn in your favor.
>t. 30-something who got into a US medical school with closer to a 3.0 (although a 4.0 in the prereqs), a ~50 percentile MCAT, and a soft science bachelors, focusing less than 2 years in late twenties to do so.
They do - my friends who were applying to medical school all had to bring some example of manual dexterity. My housemate brought some needlework she'd done.
They’ve got longitudinal studies over several decades with strong statistical methods.
If you are ever between jobs, or wondering what things you could be really good at or what careers might be a good choice for you, I highly recommend signing to take their extensive testing procedures, and then following up with them over the decades.
The human body and mind are highly dynamic system where minor changes make big differences. A good example is that learning a second language makes you better at learning, it doesn’t just teach you how to use different words. I would bet that lowered dexterity due to less hand usage would result in all kinds of weird developmental changes.
I’m a Level 2 CASI certified snowboard instructor. I taught hundreds of adult beginners over the years. I myself started as a never-ever when I was 35.
Season starting soon, come up (I’m at Vancouver/Grouse) it’s awesome!
Snow boarding is also done upright, so your spatial awareness is the same.
Try teaching adults with no gymnastics background how to handstand. Kids can pick this up in weeks. I know very few examples of adults managing it. And even then their skill level is not very high.
1) A fear of embarrassment while learning - because as an adult learner you're at the bottom of a far wider range of skill levels of people your own age than a child is when they're learning. When you've been working on your French for two years, and a five year-old French child speaks with a facility you don't have in your wildest dreams, well, remember that that five year-old has been working on their French for five years; and while they were learning, they never had to feel like they were too far behind every other under-five in the world.
2) The constant encouragement of adults to concentrate on improving the things that they're already good at, and not to waste too much time on the things they're not good at that aren't necessary for their jobs. I think part of this comes in the form of theories that it's impossible to learn things after you're the customary age for people to learn that thing. Or worse, that everybody who is good at a thing was anointed by god or genes to be good at it, therefore if you aren't good at it already you probably weren't chosen.
Ed: I found the link to the less skilled surgeon video. Could not find the more skilled one.
https://www.nytimes.com/video/health/100000002513726/the-bad...
If I may, it's "Imperial College London" - not "The Imperial College of London".
It's one of the top rated reasearch institutions, worldwide, for science and technology. That an Imperial professor is concerned about students' skills is cause for alarm.
Only on HN you can find such hubris that a comment arguing surgical skills can be provided by Youtubers is sitting at the top of a thread.
Anecdotally, this Professor believes that increased focus on exams and computer use is leading to a generalize dulling of dexterity and specifically tactile sense / fine motor skills.
This isn’t something that you can prep for like an exam. It’s specifically the exam focused mentality and the idea you can cram or prep for this that is the root of the problem.
The untested theory behind the article is that children and adolescents need long term and broad exposure to all sorts of varied tasks which challenge their fine motor skills to develop the pathways that will shift the bell curve back to where it was, and lead to a greater number of students who are ultimately capable of achieving an ‘elite’ level of surgical skill.
In the absence of these programs and with the arduous focus on exams/testing, that the nervous system development and motor pathways for an increasing number of otherwise perfectly qualified students are simply stunted. Those students will have a much harder time developing the necessary dexterity and fine motor skill required for even basic tasks like stitching and suturing. But more likely it’s not that they won’t get the basics, but an increasing percentage will never even be capable of approaching the skill level of an elite surgeon.
Now, the whole things smacks a bit of generational prejudice and seems totally anecdotal. It certainly seems like it is something quantifiable that could and should be more rigorously studied.
That being said, this is just one guy's opinion, not a true motor behavioral study. The impulse to blame the "kids these days" seems like an ever-present force, so I wouldn't place too much emphasis on this without a proper study of precision dextrous manipulation across age cohorts.
Lamenting a lack of experience with arts and crafts and similar sounds more like an "education these days"-complaint to me. If children do suffer from a lack of trained motor skills it is not their fault, but it is something to take seriously, for their sake more than anyone else.
Also, I dunno waiting for a proper study is worth the risk. It would take quite long, which means that if it is a problem we already screwed over a generation. Plus, people complaining about a lack of physical education these days is not something limited to surgery.
Taking physical education more seriously as being important for general development, and not something just for the people who want to continue in sports is probably beneficial for everyone in the long term anyway.
(tangent: I wonder if these students would perform better when handling robot arms with a control stick than previous generations)
Physical education is awful and it is not capable of not being awful. Even if it was not almost uniformly focused on team sports which some people hate to the point of faking illness and others love to the point of obsession, leading to massive capability gaps, it would still be irrelevant. Two or three hours a week of teacher directed exercise is nothing in the scheme of developing real skill.
If people were serious about this problem they could allow children ample time to play, learning about the world and their bodies as small animals are meant to, or if they insist on making everything into a subject, treat physical education as a core part of the curriculum, English public school style, where everyone plays team sports almost every day.
No one gets good at anything on two hours a week of practice. Absolutely nothing. Two hours a week will barely get you past novice in a year. It’s so little, so seldom that a substantial amount of each lesson has to be revision too but even if learning was instant and perfect 100 hours a year rounds to nothing.
> Unstructured play is great, but it's no substitute for targeting coaching when it comes to developing useful skills.
Tell it to the Chinese football team. Then tell it to the Brazilian football team.
You have never done any sports, have you?
> Tell it to the Chinese football team. Then tell it to the Brazilian football team.
Are you seriously going to use two professional teams with extensive professional coaching as an argument against the use of coaching?
Nobody is arguing against unstructured play, you are just trying to steer the conversation into a direction where it's an either/or situation where it is not.
For some, yes. And it is certainly taught in an inadequate way in most cases.
> and it is not capable of not being awful.
And this is where you basically close the door on any further discussion. I think the issue is more that you are too fixated on what Physical Education is than on what it could and should be.
As an example the Javelin anti Armour missile have playstation-esq aiming controls on them for this reason and most remote weapons systems have a thumb driven joystick config.
Sounds like presumably "USA" is not expending enough time and money on target practice - I would hope that UK still understand s the lesson taught by the Napoleonic wars that well trained and practiced troops are key to winning a firefight.
And crew served weapons is quite different to traditional marksmanship and that's where most of the killing is done these days.
The rant is about interaction design in computer screens, but the points made here are easily transferred if we treat the tools & the environment surgeons work in as a user interface.
I suspect those higher classes would have a fit if one of their kids got their ands dirty - quite keen on it for the lesser classes though.
For instance maybe in prior years applicants were more likely to have practical job experience: a summer job in retail, fast food, etc. Now maybe they only select students who have programmed existences.
Just seems odd to me that he would make this observation then suddenly jump to blaming it on “screens”.
[0] Hard to say if it was weeks, months or a full year, because everything more than a day away is long when you're five.
[1] The answer, as always, is budget cuts: trying to spend less money on teachers and material and time. I find this especially infuriating because our centrist/right-wing politicians always claim that the progressive ones don't have a clue about economics, yet somehow are blind to the fact that good, accessible education as early as possible is one of the best long term ROIs a country can make.
But surely, we can be selecting for people who are better rounded as opposed to human robots. You actually see the same thing in engineering interviews. Regurgitating leetcode answers etc but ask them a question that's not exactly what they studied for and it all falls apart.
As you said:
> being selected for their memorization skills, not for critical thinking
A physician's "subject area" is "all" areas, and they too will refer to Google or other resources to confirm to themselves - similarly with medical advertising rampant in the US, it's often the patients who put ideas into the doctors' minds. Do they need 12 years of schooling to "know" everything - which will likely be outdated knowledge by the time they learn it? Or should we be training people to become experts at navigating systems of learning and specifics protocols to follow, so they are efficient and fluid?
Specialization is valuable for many reasons, though we don't seem to leverage or engage with that properly, yet.
If we or his kids ever got any wounds that needed stitching he would do it instead of the hospital as we knew he would do a better job.
Zeitels succeeded in part because of his leatherwork in college: It made him ambidextrous, a necessary skill for a procedure in which a cut a millimeter too deep would damage the vocal cords, but where one too shallow would leave some of the lesion intact, and therefore able to grow back. The problem with Zeitels’s surgery, however, was that no one else could repeat it. No one else in the field could be as precise. As he looked to publish his findings in an atlas on the larynx, one editor told him, “You can’t write that! People can’t do that!” His findings were published anyway, but the editor was right.
[0] https://www.bostonmagazine.com/2008/09/22/voicebox-hero/
I would expect that selection for surgeons is above and beyond the test scores.
Then a couple months later I was the student on service suiting up and I understood the truth: they're aerosolizing bone dust with those shrieking saws when they're implanting the new joint. The room was actually foggy with the stuff. The suits were to protect us!
It's a gritty specialty.
Ehhh, not so sure about that. I was really good at FPS games (played counter strike for some 10 years), and I can't stitch for the life of me. My mother who is in her late 60s however, oh boy can she stitch and stitch fast. She can thread things well too - Last thanksgiving, we were doing some threading with the turkey, and I was amazed at her threading skills. I tried to imitate her but just couldn't.
Not sure. Don't game use only 2 of 5 fingers on each hand excessively ? ( Thumb and Index)
Suturing is not the only thing a Surgeon does...
But given the way games also tend to be addicting, I wonder if it hurts people's drive/motivation (on aggregate, not per individual) as much as it helps people's finger dexterity.
I often wonder if certain sports actually do a better job training dexterity, short of focused practice on specific tasks. Or knitting, or juggling, or... heck, even cooking.
To think of it now: I think boy scouts really are a great organization, to be teaching kids how to tie knots and survive in the outdoors.
I wish such a thing existed for me to attend as an adult!
But you'd expect that to be increasing on average, given how video games keep getting more popular. It seems like, perhaps, operating buttons and joysticks doesn't train the same sort of dexterity as sewing does.
https://www.ncbi.nlm.nih.gov/pubmed/17309970
And, if you don't want to read the paper, here's a piece about it and some related studies (2013):
https://www.medicalbag.com/lifestyle/gamers-make-good-surgeo...
My mom had what we thought might be a stroke, but without the typical symptoms of a stroke. We wound up in the ER on a Saturday in a medium-sized metropolitan area (maybe 250k people). They wheeled her back for a head CT, and at the same time wheeled in a telepresence cart, with a computer screen and a video camera. Within a minute or so, a remote neurologist was on the screen talking to me. Before my mom was even wheeled back to the exam room, he had viewed the images and identified the bleed in her brain that was causing her vision problems.
I was fascinated by all of this, so I asked the ER doctor and nurse about it, and they told me that with specialties like neurology, on a weekend they’d have to page someone to come in. It would likely be 30 minutes before they even walked in the door of the hospital. With the telepresence neurologist, the SLA was something like 5 minutes. That’s a huge difference when dealing with serious medical problems, and it’s not hyperbole to say that it will save lives.
Another thing I learned that day: Not all strokes look like strokes, and any sudden-onset vision problem is a stroke until it’s been ruled out.
The problem with these rotations is you do them and then move on to the other ones. More than one year passed before I got the chance to stitch something up again. The results were not as good...
I believe that if you want to be a surgeon you need to be constantly practicing and honing your manual skills. It's probably much easier to do this in residency where you're 100% focused on surgery and won't have to switch to a pediatrics or gynecology rotation after some time.
On a phone call, all you have is your voice. So if you get uncomfortable and start stuttering or stumbling and you don't have the confidence to recover, you're not going to recover.
You've also only got your voice to give impressions of your attitude and emotions, as well. People who are good on the phone tend to be animated, tend to use body language even if the other person can't see it, smile when they're happy, and furrow their brow when they're not. All of this impacts your speech, and a bit of over-acting goes a long way. They also know how to break into someone else's conversation to get a chance to speak.
These are all things learned over time, and someone who just started using a phone isn't going to have the skills or the confidence to pull it off.
Meanwhile, all the phones at my office have attached cameras and displays. We can see each other on the phone. Except most of use keep the camera turned off because we want to retain our private eye rolling.
Business have landlines and/or low latency internet to handle quality voice communication. Most families these days don't.
Show some scientific integrity Kneebone, it would be easy to do an actual unbiased study instead of ranting to the BBC.
A half decent gel pen will work almost as well, combining the best parts of a fountain pen with the best parts of a ballpoint. I can write for hours with a fountain pen or a gel pen, but I really struggle with those $1 Biro pens.
Taking those classes in high school instead would have required me to give up AP classes, or my independent study of Computer Networking class.
In relation to the article, we have plenty of opportunities to do suture clinics as a second year and even practice with box trainers. Perhaps training is different outside the United States.
"Doctor"
Having children also tinker with electronics (and anything else modular for that matter) is also a great way to gain accuracy needed for minute and subtle movements.
These have added benefits over simple handwriting -- in that writing is a prolonged contraction of the muscle whereas playing an instrument and doing small scale work involves contraction-release and learning of pressure sensitivity.
Neither playing the piano or typing on a keyboard will alone build good manual dexterity. Precision and strength are also needed.
Just writing or drawing with a pen would be a great help.
I'm currently learning the piano, and was very surprised how quickly my Left hand fingers pick up on notes, chords and rhythms, and how unrhythmic and clumsy my Right hand fingers are in comparison!
Also, it's pretty depressing to hear the response to deskilling be more deskilling.
I would separately guess that "tactile feedback and response" is harder to find and more important for a surgeon than "fine motor control", though obviously they do need both.
Next time I am intoxicated, I should (unscientifically) test this by comparing the difficulty of threading a needle with that of sending an accurate and correct text message
Skills and neural pathways have training and use specificity. Even (or especially) slightly different practices can have surprisingly little transfer, or even interference.