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 Medical
Center

  Abstract

	Debate  was utilized by the authors as  a  teaching-learning activity in training general surgical residents on how to  handle controversial  issues in surgery.  The mechanics, format,  rating scale, benefits and problems were described.  A proceeding  of  a debate was included to illustrate the mechanics and format. Aside from training in handling controversial issues, the debate  could develop   skills   in   argumentation,   medical    presentation, audiovisual aids preparation, oral communication, problem-solving and  decision-making,  critical thinking, critical  appraisal  of journals, interpersonal relationships, and cooperative  learning. The  major problem identified was how to make  trainees  acquired the benefits of the debate to the maximum.  A resolution to  make trainees experienced at least two sessions of debate was made.

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:

     	Unilateral vs bilateral herniotomy in pediatric patients
     	Subtotal vs total mastectomy for breast cancer
     	Subtotal vs total thyroidectomy for thyroid cancer
     
     	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:

     	Total vs subtotal parotidectomy for parotid cancer
     	Total axillary dissection vs axillary sampling for breast cancer
    	Transhiatal vs transthoracic esophagectomy for esophageal cancer
     	Amputation vs limb-sparing operation for soft tissue sarcoma
     	Observation vs prophylactic neck dissection for oral cancer with no palpable neck node
     	Total vs subtotal mastectomy for breast cancer (2x)
     	Total vs subtotal thyroidectomy for papillary thyroid cancer
     	Total vs subtotal thyroidectomy for follicular thyroid cancer (2x)

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

     			Skills                                     		Grade    Comment
 	1. Critical analysis skills
     	    Analysis of the problems
      	    Analysis of the issues
     	    Analysis of journal articles and resource
     	    Problem-solving and decision-making
     	    Argumentation

 	2. Communication skills
                 Oral presentation
     	    Argumentation

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 appropriate
operations 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.

     	Basing 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.