Debate as a Teaching-learning Activity in General Surgery
Reynaldo O. Joson, MD, MHA, MHPEd*
Marissa M. Lim, MD**
*Associate Professor, College of Medicine, Philippine General Hospital, University of the Philippines Manila; Consultant, Zamboanga City Medical Center
**Faculty, Zamboanga Medical School Foundation; Consultant, Zamboanga City MedicalCenter
Text || Proceedings of a Debate
Debate as a Teaching-learning Activity in General Surgery
Reynaldo O. Joson,
MD, MHA, MHPEd
Marissa M. Lim, MD
Introduction
In the practice of medicine, physicians will invariably be confronted with the so-called "controversial issues." The setting can be during actual management of patients, conferences, and for the trainees, examinations.
With this reality, training on how to deal with "controversial issues" should be included in the medical and surgical curricula. There are various ways to achieve this objective (1). One possible way is through a debate.
Debate has been tried by the authors in the General Surgery Course (1991-1995) in Zamboanga City Medical Center (ZCMC). It has also been tried by the senior author in the curriculum of the Division of Head and Neck, Breast, Esophagus, and Soft Tissue Surgery in the Philippine General Hospital (PGH) from 1994 to 1996.
This paper describes the experience of the authors with the use of debate as a teaching-learning method in dealing with "controversial issues" in surgery. It presents a proceeding of a debate that was part of the General Surgery Course in ZCMC for illustration purpose.
Methodology
1. Using recall and records, the events surrounding the use of debates by the senior author from 1993 to 1996 were reviewed.
2. The proceeding of a debate was recorded to serve as an illustration.
3. Analysis and reflection were done on the benefits and problems of the debate as conducted.
4. Resolutions were then made.
Debate as a Teaching-learning Activity in the Surgical Curriculum
In 1991, upon request, the senior author decided to help improve the general surgery training program of ZCMC using a distance education mode, he being based in Manila. There were about a dozen surgical trainees. The quarterly tutorials in ZCMC were in the form of a small group discussion and learning. After about three tutorials, the surgical trainees had changed from passive to active participants in the small group learning primarily because of the inquiry approach and encouragement by the senior author. The trainees were frequently arguing with each other searching for correct answers to questions posed or raised. One day, the senior author thought of debate to formalize a training in argumentation. Thus, the inclusion of debate as one of the learning activities in the General Surgery Course of ZCMC.
From 1992 to 1995, the authors had witnessed three debates by surgical trainees of ZCMC. The topics consisted of the following:
In 1993, when the senior author was appointed acting chief of the Division of Head and Neck, Breast, Esophagus, and Soft Tissue Surgery (Division). he structured the training program of the quarterly rotating general surgical trainees. Debate was included as one of the teaching-learning activities at least once every three months. Beside training in argumentation, the debate was intended to be part of the research training program of the Division in which the trainees learned how to critically appraise journal articles.
From 1993 to 1996, the senior author had witnessed 10 debates by the trainees of the Division. The topics consisted of the following:
Mechanics of the Debate
A month prior -
1. The trainees were told of the objectives and format of the debate.
2. A debate issue would be decided upon by the trainees with the help of the faculty.
3. The trainees usually about 8 to 10 would be divided into two teams, one pro and one con team.
4. Each team would be required to use journals to back up its stand on the issue.
5. Transparencies during the presentation could be used.
The format of the debate -
Time allotment - one hour
Moderator - short introduction (5 minutes)
objectives of debate
ground rules
issues and situationer
clarification of issues and situationer
coin-tossing to determine which team would start first
Team A presentation - 10 minutes
Team B presentation - 10 minutes
Rebuttal A to B - 5 minutes
Rebuttal B to A - 5 minutes
Resource person - comments - 10 minutes
Audience - questions, comments, and feedback - 10 minutes
Faculty - comments and feedback - 5 minutes
Rating scale -
Key:
RFM - Room for improvement
NI - Need improvement
NALI - Need a lot of improvement
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Skills |
Grade |
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1. Critical analysis skills |
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Analysis of the problems |
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Analysis of the issues |
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Analysis of journal articles and resource |
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Problem-solving and decision-making |
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Argumentation |
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2. Communication skills |
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Oral presentation |
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Argumentation |
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Proceedings of a Debate (see Appendix)
Analysis of the Debates
The primary goal of the debates as conducted was to train future surgeons on how to deal with "controversial issues" in surgery. Just by the nature of the issues to be debated, usually in the form of ___ vs ___, the trainees were made aware that controversies abound in surgery. The trainees in preparing for the debate invariably read on the pros and cons of the issues. To defend their position, they had to do critical analysis. During the debate proper, especially during the presentation and rebuttal by the opposite team, they acquired an in-depth grasp of the controversy. At the end of the debate, they realized there would be no absolutely right or wrong stand and settlement of issues would defend on rational problem-solving and decision-making.
Beside the training on how to handle "controversial issues", there were other educational benefits that could be acquired. These were, namely:
1. Argumentation skills
2. Presentation skills and making audiovisual aids
3. Oral communication skills
4. Problem-solving and decision-making skills
5. Critical thinking
6. Critical appraisal of journal articles
7. Resourcefulness
8. Interpersonal skills
9. Cooperative learning skills
The primary problem identified was how to make the trainees fully acquire the educational benefits of debates. One session of debate was not enough. Two to three sessions might be needed.
In the PGH setting, the surgical trainees had an average of one debate session in the three months they rotated with the Division. In the ZCMC setting, the trainees had three debate sessions from 1993 to 1995. In 1995, a debate between PGH and ZCMC trainees was conducted using a telecommunication mode (2). Based on the judgement of the senior author, the ZCMC trainees performed better than the PGH trainees.
Resolutions
The experience with debate over the years has convinced the authors of its usefulness in teaching surgical trainees on how to handle "controversial issues". The senior author have incorporated debate as one of the teaching-learning activities in the undergraduate medical curriculum of Zamboanga Medical School Foundation, Bicol Christian College of Medicine in Legazpi City, and Southwestern University College of Medicine in Cebu.
To achieve the maximum benefits of the debate, the authors will have trainees experienced at least two sessions.
References
1. Palma JC: Curriculum Development System. Philippine, National Book Store, Inc., 1992.
2. Joson RO: Teleconferences for assessment of cognitive skills in general surgery. Education for Health 9(3):359-366, 1996.
Appendix
Proceedings
of a Debate
(Presentation and Rebuttal)
Issue: Breast Conservation Surgery vs Modified Radical Mastectomy for Early Breast Cancer
Presentation
Team A: We favor total mastectomy for early breast cancer because of the following reasons which we label as the 4 A's.
Acceptable: The procedure has been the standard treatment since the 18th century (Halsted) with good survival and low recurrence rates.
Affordable: The patients usually do not need radiotherapy with radical mastectomy unlike in breast conservation procedures, radiotherapy is part of the locoregional control methods.
Acceptability and affordability spell cost-effectiveness.
Applicable: Radical mastectomy can be performed in almost all patients. However, with breast conservation surgery, one cannot use radiotherapy in pregnant women (The National Institute of Health Consensus Development Conference, 1990, USA).
With irradiation, the breast after a conservation surgery is not cosmetically acceptable. If irradiation has been done to the breast prior to surgery, the breast is not suitable anymore to partial mastectomy. With the lack of quality radiotherapy from newer machines, the possible complications from radiotherapy pose a very real threat.
With tumors greater than 2 cm, breast conservation surgery can no longer be done since a wider margin is needed for excision and little breast if ever will be left behind.
If two tumors are located in different parts of the same breast, local excision or lumpectomy cannot be done with preservation of the breast in most cases.
When presented with diffuse mammographic calcifications in a breast, a lumpectomy cannot be done without risking the presence of tumor in the margins.
Adaptable: The procedure of radical mastectomy can be readily adapted by any hospital with a competent surgeon without the need for radiotherapy facilities, radiotherapists, and mammography for follow-up as in breast conservation surgical procedures which are only available in large centers.
Team B: For the past 20 years, the controversial issue has been raging about the appropriateoperations for patients with breast cancer. The debate was initially between classical radical and modified radical mastectomy and recently between modified radical mastectomy and lumpectomy/quadrantectomy with radiation.
Modified radical mastectomy has been the gold standard for Stages I and II. However,recently, breast conservation surgery has been applied for Stages I and II.
Breast conservation surgery combined with post-op radiation as a therapeutic option for Stages I and II has been proven efficacious by numerous studies with long-term follow-up.
The following are the reasons for advocating breast conservation surgery with radiation for early breast cancer:
1. Comparable survival rates
2. Comparable local recurrence rates
3. Encourages early consultation leading to early diagnosis and treatment
4. Better cosmetic results
5. Shorter hospital stay
6. Lesser morbidity
Let me support my reasons with studies:
Comparable survival rates and local recurrence rates:
A number of randomized studies have reported that conservation surgery with radiation therapy gives survival and locoregional or recurrence rates similar to those achieved by radical or modified radical mastectomy.
1. Veronesi and associates (1980) concluded in their studies that there was no significant difference in the overall disease free survival rates between the two groups at 8 year follow-up.
2. Fisher and associates (1985) in their three-arm studies likewise concluded that there is no difference in the locoregional control between breast conservation surgery and modified radical mastectomy.
3. Kuusk and associates (1992) stated that the disease free survival of two groups of patients who underwent breast conservation surgery and radical mastectomy were the same at 63% with the overall survival rate of 72% for patients with partial mastectomy and 69% for those underwent modified radical mastectomy and with recurrence and complication rates to be statistically the same.
4. Cooper (1994) reported that conservation surgery resulted in a 5-year survival rate of 85% compared with 76% for total mastectomy.
Better cosmetic results, maintains self-image and avoids psychological anguish:
Loss of self-image and psychological anguish are mainly the result of cosmetic failure following breast amputation and more so in women who cannot afford the high cost of breast reconstruction.
1. Lewin et al (1992) concluded that cosmetic result was good to excellent in all patients who underwent breast conservation surgery followed by radiotherapy.
2. Clough and Baruch (1992) claimed that 75% of their patients had good cosmetic results while 20-25% are with fair or bad results which were attributed to tumor volume loss, location and also as a result of surgery and radiation.
3. Lee et al (1992) showed in their study that cases of anxiety and depression are less during the pre and post surgery period in those who underwent breast conservation treatment than in those with radical mastectomy. Also these patients were found to resume sexual activity early and therefore higher quality sex life.
Two other studies conducted by Khanna (1992) and Moro (1993) reinforced the acceptable cosmesis without compromising cancer eradication.
Shorter hospital stay:
This shorter hospital stay leads to better economics. Tarter (1994) showed that the longer hospital stay was due to the unwillingness of the surgeons to discharge patients with drains. While it is true that the cost goes up with radiation therapy, this is an option that these patients are willing to undertake in selected cases.
Morbidity:
Karampoulos (1993) concluded that arm morbidity like arm edema, upper limb pain and shoulder joint mobility was 25% more likely to occur in patients who underwent radical mastectomy than those who underwent breast conservation surgery and radiation.
Based on all these data, we believe that breast conservation surgery with radiation for breast cancer stages I and II is a must option that the patient should be educated about and given the chance to decide on.
Rebuttal
Team A: With breast conservation surgery there is significant breast tissue left which is then at risk for tumor recurrence even though there are standard guidelines for tumor margins.
For recurrence of the tumor after breast conservation surgery, a salvage mastectomy will still have to be done. This in effect will add cost and psychological anguish to the patients.
Regarding the effects of radiation, most patients would complain of breast skin lesions related to radiotherapy which would include fibrosis, pigmentation, dryness, etc. Radiation related sarcomas are encountered also.
In the USA, the cost of the entire session is between 3 to 6 thousand dollars and this therapy is only available in large medical centers. In the Philippines, only Cebu, Manila, and Davao have such facilities which would add the expenses of travel, board, and lodging for people from the barrios.
Regarding follow-ups, an annual mammography is needed for the rest of their lives. In the next 2-3 years, frequent clinic visits are necessary to detect recurrences early.
Team B: It was clearly defined before hand that breast conservation surgery includes radiotherapy aside from the excision of the primary breast tumor. Radiotherapy aims to eradicate residual cancer foci which may remain after quandrantectomy or lumpectomy (Haga et al 1992). It has been proven by Cooper (1994) that the probability of the irradiated breast remaining free from tumor eight years after lumpectomy is 90% while an irradiated one without lumpectomy is 61%. In 1992, Pierce studied the long-term radiation complications following breast conservation surgery: the incidence of rib fractures, tissue necrosis, pericarditis, and second non-breast malignancies was low. Advocates of radical mastectomy claims that radiotherapy is not cost-effective and is not readily available. Clearly no local studies have cited the high cost of radiotherapy in the Philippines. In fact, most government hospitals have radiotherapy facilities and offer these services at affordable prices. Indigent patients may appeal to charitable institutions for support.
Another disadvantage of radical mastectomy is the discouragement it gives to early diagnosis since the patient is afraid of the mutilating effects of the procedure, hence, the tendency to consult at the advanced stage. The fear, the psychological anguish, and the destruction of self-image of having oneself submit to such a radical procedure are the main factors why breast cancers are diagnosed in the advanced stages. With the conservation treatment available, more patients with breast tumors in the early stage will seek consult and will subsequently be diagnosed and treated at earlier stages.
Text || Proceedings of a Debate