Surgical Learners Do Not Teach Skills According to How They Were Taught

Background: Surgeons are expected to teach students, residents and colleagues about surgical skills. The critical assumption that a “first-learner” will default to teaching a “second-learner” what they were taught, in the way they were taught, was investigated. Methods: Thirty-six medical students without experience tying a locking, sliding knot were divided into 18 pairs of first- and second-learners. 4 pairs were assigned to the “traditional teaching” (T) protocol group, 5 pairs were assigned to the “operant-teaching” (O) group and 9 pairs were “informed of the importance of the operant teaching strategy” before instruction and assigned to the “operant-informed” (OI) group. First-learners were taught to tie the locking, sliding knot according to one teaching protocol (T, O, or OI). Successful first-learners were asked to teach a second-learner. For the first-learners, time from the start of their instruction to the first constructed knot, time to tie 10 consecutive knots, and accuracy of knots (number of incorrectly constructed knots) were recorded. For second-learners, time from start of instruction to the first constructed knot, time to tie 10 knots, and accuracy of knots were recorded. Results: All first-learners, in all groups, were able to accurately tie a locking, sliding knot. During self-practice, all T-group first-learners lost the ability to tie the knot. Between the 5 O- and 9 OI- first-learners, only one OI-group first-learner lost the ability to tie the knot. After instruction from the 16 successful first-learners, 16 second-learners were able to tie to the knot. The error rate for second learners was 93% for the T-group, 20% in O-group and 12.5% in OI-group. Time to tie the first knot were different between the three teaching groups for both the first and second-learners (p=0.007 and p=0.041, respectively). The average time to tie the 10 knots was similar between first-learner (p=0.336) and second-learner O- and OI-groups (p=0.788). Conclusion: Demonstration-based teaching results in incomplete skills which deteriorate. Contrary to the assumption that successful first-learners would teach the way they were taught, first-learners abandon the teaching strategy when tasked with teaching a second-learner. Our results emphasize the importance of incorporating teaching curriculums into surgical education.