6.2.1 Background

Historically, the traditional method of educating a resident in the practice of surgery has been centered on the hospital-based, apprenticeship model, initially described by William Halsted over 100 years ago [1]. Skill acquisition has been reliant on observation, assisting and subsequently performing the task [2]. This is what many trainees have come to understand as the classic “see one, do one, teach one” mentality. Within this template, residents learn principles and gain experience while caring for real patients, and are given increasing amounts of responsibility to prepare them to practice independently. The skills and knowledge acquired during their training is contingent on exposure to the disease conditions and procedures encountered by their faculty, rather than curricular needs [3]. Given the varied patient population and practice patterns of each program, experience-based training in surgery does not ensure standardization of skills [4].

Scrutiny of the conventional framework has caused a significant “paradigm shift” towards a more objective standardized approach to education. The progression of technology in surgery, demand for improving patient safety and decreasing medical errors has created a need for innovation in surgical education [5]. Attendance by way of case logs insufficiently comments on surgical competence [6]. A long-term study by Drake et al. demonstrated that while operative volumes have rebounded following the introduction of work hour restrictions, the diversity of operative experience has narrowed with changing disease processes, technological advancement, subspecialization, and reductions in trainee autonomy [7]. The shifting dynamics of surgical education are both challenging and exciting for trainees and educators alike, as it provides the foundation to alter the future of this craft.

6.2.2 Competency-Based Medical Education

Over the past decade, there has been a paradigm shift towards the model of competency-based medical education (CBME) , defined by the International CBME Collaborators as “an outcomes-based approach to the design, implementation, assessment, and evaluation of medical education programs, using an organizing framework of competencies” [8]. Their rationale for CBME has been summarized into four themes: (1) focusing on outcomes, (2) emphasizing abilities, (3) de-emphasizing time-based training, and (4) promoting greater learner-centeredness.

The Accreditation Council for Graduate Medical Education (ACGME) and Royal College of Physicians and Surgeons of Canada (RCPSC) are currently in the process of implementing CBME in residency programs. The ACGME began phased implementation of the Next Accreditation System in 2013, in which milestones are developed within each specialty that will provide data on performance that graduates must achieve before entering unsupervised practice [9]. Similarly, the RCPSC officially initiated Competence by Design in 2017, which will be introduced in seven cohorts, extended to all specialties by 2022 [10].

Moving forward there are tremendous opportunities for innovation in surgical education, and specialists in burn care must collaborate to develop and clarify the competencies relevant to our field. The initial process of defining core competencies related to burn care began with the ACGME Milestone Projects for plastic surgery and general surgery [11, 12]. For establishing a CBME curriculum in plastic surgery, Knox et al. describes the following: identifying important principles and procedures, modeling new teaching strategies, and developing assessment models [13]. This framework gives a structured and systematic approach to curriculum development and is currently being implemented for burn unit rotations.

6.2.3 Simulation

The learning curve associated with new procedures carries inherent patient morbidity, as they require a level of technical skill and confidence normally gained through practice [14]. For example, the donor site morbidity of an improperly harvested split thickness skin graft is significant, especially if a second site is eventually required. Simulators are an objective and reproducible medium that can allow technology to facilitate the transition from beginner to expert, while standardizing education, decreasing costs, reducing patient risk, and improving outcomes [4]. The efficacy of simulators has been reported in the literature [14, 15], and their widespread application is seen in general surgery [16], plastic surgery [17], urology [18], neurosurgery [19], gynecology [20], and endoscopy [21]. Increasing prevalence of simulation in medical training has prompted the Accreditation Council for Graduate Medical Education (ACGME) and the American College of Surgeons (ACS), to implement a phased approach to formally require their use in surgical education.

The advent of simulators has forged a new era of excellence in surgery. The low-stress environment alleviates the anxiety of the operating room and enhances trainee learning, while allowing for mistakes and improvement without compromising patient care. The skills gained in this practical learning atmosphere have been proven to enrich performance in live operative models and therefore can be transferable to the operating room [22]. The concept, “physical and mental skills are learned through a long process of persistent and dedicated efforts with repetition to reinforce the activity” [2], is fundamental to the development of a successful surgeon. Fitts and Posner described the three stages of skill acquisition in 1967. The student must first intellectualize the process, second develop the proper motor behavior, and third subsequently repeat the skill, resulting in smooth performance through muscle memory [23]. The notion of “practice before the game” holds true for musicians and athletes, and similarly, simulation has been shown to be effective in surgical motor skill acquisition [24].

Several simulation tools relevant to burn training have been recently described in the literature. Sadideen et al. devised “The Burns Suite,” a self-contained immersive simulation environment which guides trainees through a pediatric burn resuscitation [25]. Advantages of this learning tool include its low-cost and portability, as well as high face and content validity as judged by participants. Ur et al. developed and tested a biomimetic escharotomy trainer with discreet points of failure built in; their pilot study found that the model was considered realistic by participants and increased comfort levels in junior trainees [26]. Lastly, Gallagher et al. described and tested a simulator for tangential excision using a foam suture pad in novice, intermediate and expert subjects, who were prospectively assessed by blinded observers using an objective rating scale; all experts agreed that this tool would be useful prior to clinical performance of tangential excision [27].

Time is the key challenge faced by most programs establishing a skills lab. Trainee workload and responsibility is demanding and often prohibits dedication to practice. Similarly, the commitments of academic faculty limit their time to supervise and provide necessary feedback. For a skills curriculum to achieve optimal results, sufficient time allocation is imperative. Simulation training is a pivotal tool in surgical education, which should be adopted into the armamentarium of any residency program.

6.2.4 Education in the Internet Era

The widespread availability of online materials has permitted the shift of education away from the operating room. The issues of time constraints, patient safety, and geographical limitations have been greatly attenuated with the initiation of web-based learning. The Internet has also facilitated the development of global collaboration of medical education [5].

Currently, e-learning has been successfully integrated into surgical programs for instruction in areas including anatomy [28], course curriculum [29], procedural skills [30], and problem-based learning [31]. There are endless implementation strategies to supplement training. Individual programs can dictate the published content they wish to provide, ranging from links to journal articles and seminars, to modules and videos [5]. Online simulators are also becoming ubiquitous, creating a reusable, accurate, and self-directed model for the accession of knowledge and skills.

6.3.1 Peer Mentorship

Peer mentoring is defined as a relationship in which mentors and mentees are similar in professional status and they help each other and themselves through teaching and collaborative learning [42]. This model provides support in a non-evaluative environment [43], while promoting collegiality and a nurturing climate for personal and vocational growth [34]. It has been successfully applied in nursing, resulting in a less stressful and more comfortable environment [44, 45]. Students report increased self-confidence and social integration, mitigating much of the initial anxiety associated with a new rotation [34]. Mentors enjoy the satisfaction of service while honing their interpersonal and communication skills [46].

6.3.2 Hierarchical Mentorship

The classical model of mentorship involves a pupil learning skills and knowledge from a preceptor or established expert in the field. This allows for the transference of experience from one generation to the next. In addition to the obvious advantages to the trainee, hierarchical mentoring encompasses many benefits for the staff. Mentors develop a sense of pride and privilege in fulfilling their role of shaping the successors of their field. Medicine involves the pursuit of lifelong learning, and mentorship programs give the “lions” a chance to learn from the “cubs” in order to retool themselves in this progressively changing environment. This mutually beneficial relationship has also been shown to increase faculty retention [47].

6.3.3 What Is a Mentor?

A mentor is a trusted educator whose role extends far beyond the teaching of technical skills and clinical judgment in the clinics, operating room, and on the wards. They are role models who provide direction and instill values, while demonstrating effective communication, time management, and successful prioritization of multiple personal and professional commitments [48]. The relationship is dynamic and adapts over time to meet the needs of the mentee [49]. Although support is the primary principle, mentees need to be challenged and given both positive and negative feedback to enable professional development [50]. Successful execution of this role requires many important qualities that a mentor must possess. Competence, confidence, and commitment are three essential attributes vital to knowledgeable mentors who are respected in their field [51].

The ingredients that produce an outstanding mentor are rarely innate. “Mentorship has been a casually acquired trait with varying levels of success, but it is clear that the face of medicine and surgical training in the twenty-first century requires deliberate cultivation of mentors” [48]. It would be beneficial to implement staff development programs, highlighting effective mentoring skills and mentor responsibilities [47].

6.3.4 Implementation

Although informal mentoring occurs in the daily interactions with more senior surgeons, formal mentorship programs increase satisfaction and efficacy [36]. The success of the mentor relationship is significantly higher when mentees select their own mentors [36, 52]. Role preparation of both sides ensures a smooth introduction, as mentors need training, and mentees need objectives and reasonable expectations [33]. As with any new relationship, adequate meeting time is compulsory for the development of a trusting and fruitful alliance.

Mentorship primarily occurs because mentors consider it a rewarding feature of their profession. Increasing demands on faculty time and the current criteria for academic advancement have seriously threatened the future of mentorship. Scholarship over citizenship is currently the gauge for promotion in surgery; thus, mentoring descends to a lower priority being largely uncompensated and undervalued [38]. There is a need for novel ideas to enhance faculty participation in this cornerstone of surgical training. Institutional recognition and appreciation of mentors and publicly rewarding mentorship excellence will increase the prestige of the activity and faculty enrollment. Mentorship can also be adapted into the faculty evaluation process for promotion [38].

“Mentoring is a vital cog in the machinery of medical education” [50] and should be strongly considered in burn unit curricula.

6.4.1 What Is Interprofessional Education?

Health Canada defines interprofessional education (IPE) as “socializing health care providers in working together, in shared problem solving and decision making, towards enhancing the benefits for patients; developing mutual understanding of, and respect for, the contributions of various disciplines; and instilling the requisite competencies for collaborative practice.” The Centre for the Advancement of Interprofessional Education (CAIPE) similarly refers to IPE as instances when “two or more professions learn from and about each other to improve collaboration and the quality of care” [63]. IPE is a unique approach to learning, where knowledge is attained through social collaboration with other professions, and the learning process is equally as important as the content itself [53]. It improves the understanding of team member complementary skills and increases mutual accountability. The contact between professions is insufficient to build the communication, respect, and trust necessary for effective team performance [64]. Learning “as” a team, rather than simply “in” a team, enhances the collective capability [65].

6.4.2 Approaches to Interprofessional Education

There are numerous models to engage the members of the burn unit in interactive learning. These health professionals include students, surgical trainees at various levels of experience, occupational therapists, physiotherapists, social workers, nurses, respiratory therapists, dieticians, intensivists, surgeons, and any other specialists that are involved in the complex care of these patients. Exchange-based learning can be achieved through seminars, workshop discussions, and case study sessions, where members of the team can explore the realms of each other’s roles in the setting of collaborative care [66]. Problem-based learning is an effective example of the action-based educational approach, as the team is actively involved in working together to determine the most suitable course of action. Simulation not only has educational merit in technical skill acquisition, it is also useful in the teaching of IPE when feedback is given in small instructor led groups simulating a real situation [67]. The growth of online resources has allowed asynchronous communication to overcome collaborative time scheduling and geographic constraints, while permitting practicing health care workers to learn together [68–72]. This model has been shown to be effective in teaching IPE [73].

Student feedback reveals that interprofessional education, through learning outside one’s disciplinary boundaries, forges mutual respect [74, 75]. Interprofessional education provides the tools necessary to reduce the gaps in current practices by forming a profound comprehension of the patient care team.