Poster2-03: COGNITIVE APPRENTICESHIP: MAKING BLIND STEPS “VISIBLE”
Eliza B Littleton, PhD¹, Mary Ackenbom, MD¹, Gary Sutkin, MD, MBA², Fizza Mahmud²; ¹University of Pittsburgh, ²University of Missouri Kansas City

A cognitive apprenticeship (CA) is an approach to help learners on the job to acquire the intellectual skills of a discipline. Intellectual skills like surgical judgment and reasoning are abstractions. These skills are processes that a teacher can make “visible,” thinking out loud for example, so the learner can try them out. Intraoperative teaching is intensely cognitive and visual, especially teaching about blind steps. Consider that in teaching learners a blind step, the teacher has to make (1) their own mental thinking and visualizations (2) which are about blind, invisible steps to be somehow “visible” for the learner. Further, sometimes that thinking is tacit for the expert. Blind steps in a surgery increase the risk of injury to a patient and force the attending surgeon and trainee to jointly imagine the relative positions of anatomy and instruments. We propose that education researchers can discover expert visualizations that could improve instruction in high stakes, complex procedures. We present tacit visual knowledge for a urogynecologic surgery that includes two blind steps: blind local anesthetic injection and passage of a sharp trocar past the bladder, bowel, and pelvic vascular system. A cognitive psychologist (EL) led experienced urogynecology surgeon educators (MA; GS) in a discussion of how they visualize these steps. By verbalizing, gesturing, illustrating with objects, and sketching, MA and GS discovered information about how to teach the steps they had not thought of before: 3 angles for mentally visualizing the pelvic anatomy; 5 visualizations of hand position for holding, moving, and checking the needle and the trocar during blind passage; 2 mental strategies in which the surgeon must imagine “space” in the pelvis that is not actually empty space; and 1 instance recalled by GS of learning that stemmed from residency in which he learned a different, open procedure no longer recommended and so he could not reference when teaching residents. We will suggest that intraoperative teaching has elements of a cognitive apprenticeship because of the mental tasks involved in performing and teaching it. Questions raised might be how a cognitive apprenticeship fits into competency based surgical education.