BTK CoSEF #9 Sold a Story
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[00:00:00] Hey, quick question. What does a third grader struggling to read have in common with the chief surgical resident struggling in the

or? Um, they both throw temper tantrums. Close guests but not quite. Keep

listening to find

out.

Hello everyone and welcome to another Behind the Knife episode, brought to you by the Collaboration Surgical Education Fellows, also known as ef.

I'm Maya Hunt EFS behind the Knife Lead for this year, and I'm a general surgery resident at Indiana University where I'm finishing up as a surgical education Research fellow while getting my master's in health professions education through the University of Illinois, Chicago. I hope you enjoyed our last episode on power and leadership.

Today I'm excited to be joined by three co-hosts from cof, Nicole Santucci, Brianna Dukes, and Zoe Jo Nicole, do you wanna introduce yourself and explain what Cof actually is?

Yeah, I'd love to. Hi everyone. I'm Nicole Santucci, a general surgery resident at WashU in St. Louis. Currently in my second year of professional development time, I also taught middle school science before going to medical school.

[00:01:00] So literacy both in the classroom and the hospital is something I care a lot about. And CEF SEF is a multi-institutional organization of surgical education research fellows working together to foster peer mentorship, networking, and scholarly contribution. We meet every week to discuss ongoing research efforts by individuals or by smaller groups within cef.

If you are a surgical education fellow or a surgery resident interested in education and are interested in joining cef, email us at cef connect@gmail.com. That's C-O-S-E-F connect@gmail.com. You can also learn more about us on our new website, csf.org.

Hi everyone. I'm Brianna Dukes. I'm a general surgery resident at UT Southwestern.

Right now I'm finishing up my second professional development year as well as my surgical education fellowship.

Hi everyone. I am Zoe Jo, and I'm a general surgery resident at Cornell. Currently finishing my second professional development year at Memorial Sloan Kettering in thoracic surgery and an active CEF [00:02:00] member.

And for today's journal review episode. We wanted to do things a little differently

because today we are talking about the literacy crisis in America, and I can already hear the questions. What does teaching children how to read have anything to do with teaching surgical residents? Well, we'll be exploring just how many parallels there actually are and what we can learn from systemic educational failures that mirror problems in surgical education and how it could even impact how we communicate with our patients in the future.

Really quick. I've maybe been under a rock, but I did not realize that there's a literacy crisis in this country.

No, Brianna, you're not alone. Literacy rates have been quietly trending down, particularly in the last decade, but as of 20, 24, 20% of adults in the US that's one in five adults struggle with basic reading skills, and over half of the adults in the US read below a sixth grade reading level.

Wow. I had no idea it was that many. Yeah, I actually didn't either until a few years ago when I listened to a [00:03:00] podcast that actually inspired this episode and is linked in the show notes. It's called Soul of Story, how Teaching Kids to Read went so wrong from American Public Media Reports and it chronicles the literacy crisis in America and how one method of teaching kids how to read became.

Entrenched in the American public school system even after the ideas behind the theory were debunked through literacy research. So this podcast chronicles the inception and adoption of the whole language method of teaching reading. Do you guys remember learning how to read?

I remember being told to sound out the word so many times.

Okay, so that's phonics instruction, which is different from whole language method, but yes, I heard that too. With phonics, you learn what letters sound like individually and then how to put those sounds together to form words.

Okay, so then what's whole language?

So the whole language method posits that kids don't need to be taught to sound out individual letters and words in order to learn to read.

Rather, it uses what's called a queuing system to quote decode [00:04:00] books in which kids use context clues and pictures to essentially kind of guess unknown words. This was a method that was based on observational research of what was seemed to be strong readers and gained popularity in the eighties to nineties to become a major educational model in US public schools.

And even after research emerged that debunked this theory of reading education, powerful individuals in a major publishing company with financial interests in the whole language method continued to perpetuate this theory due to faulty studies, financial greed, and political lobbying students across the US were and continued to be advancing grades, though actually learning how to read.

Leading to our current decline in literacy rates.

So, Maya, can you connect the dots for us? How does America's literacy crisis tie into surgical education specifically?

Yeah, absolutely. So the first parallel that I noticed is the gap between the appearance of competence and demonstrated competence. Zoe, do you wanna help me unpack this?

Sure. In the first episode of Sold a [00:05:00] Story, a mom talks about how her child looked like he was reading. Bring home books, read them aloud, and everything seemed fine, but she eventually realized he was memorizing the books, not actually reading, or as they say, decoding the words. Because a lot of the reading assessments weren't grounded in strong evidence.

Kids could compensate and their deficits stayed hidden.

We definitely see a similar dynamic in residency. Residents are so often judged on how polished they sound on rounds or how confident they appear, how smoothly they present. But those traits are subjective and they don't always reflect actual competence.

And this has been studied in surgical education. Yeah.

It has. There's a study in JAMA Surgery by Purdy and colleagues that looked at what characteristics are associated with quote unquote, outstanding general surgery residents. The investigators convened a multi-institutional expert panel of surgical educators to develop a list of 21 and important [00:06:00] characteristics embodied by top general surgery residency graduates.

Then faculty across multiple institutions rated their graduates on those traits and ranked residents into quartiles. What's interesting is that the overall ratings could be predicted using just three qualities, surgical judgment, leadership, and medical knowledge.

That all sounds reasonable on the surface, but how did they measure those qualities?

Great question. Take medical knowledge, for example. The authors described a resident with excellent medical knowledge as having quote, an exceptional fund of knowledge and keeps up with up-to-date literature and guidelines. It is obvious that they take time to read outside of work, unquote.

Obvious is doing a lot of work there, obvious to whom and based on what, is that really knowledge or is it just confidence and presentation?

Exactly. Those three traits, judgment, leadership, and knowledge are important, but may be hard to measure objectively. So evaluations [00:07:00] often rely on an educator's overall impression, which can be influenced by how a resident carries themselves. And just like those kids who could perform reading by memorizing residents can sometimes perform competence with confidence and communication.

While important gaps go unnoticed, that makes it harder to identify the residents who are quietly struggling.

So if impressions can be misleading, how are programs actually identifying struggling residents?

That's been studied too. Santo and colleagues published a paper in the Journal of Surgical Research Surveying General Surgery Program directors about how they identify and support struggling residents.

The most common ways residents were identified were faculty, word of mouth, resident, word of mouth, and formal evaluations like AB site performance.

Other than the AB site, though, those first two are just basically informal signals, not standardized assessments.

The survey also asked, which [00:08:00] A-C-G-M-E milestones residents struggle with the most.

Program director cited fund of knowledge, clinical judgment, and declarative knowledge. But the bigger issue is that across programs, it's often unclear how those milestones are being measured in a consistent evidence-based way, which

means that without objective measures of competency, residents can advance and sometimes even graduate without truly being competent in the areas we care about the most.

And that actually takes us right to our next parallel between Soul to Story and surgical education, advancing learners without competency. Brianna, you wanna tell us a little bit more?

Yeah, so students were still advancing grade to grade and keeping up with their peers despite not being able to read.

This is called social promotion, in which one advances grades to keep up with their age cohort without mastering the material. As reading becomes more complex, as great students advance, these poor readers are not able to compensate as much, and deficiencies are made [00:09:00] clear. But if these deficiencies aren't found by a certain point, it can become nearly impossible for students to catch up.

Also sounds like a recipe

to make kids hate reading,

which is devastating. But keep going, Brianna, because this sounds like when we hear concerns that residents are graduating who don't know how to operate anymore.

Ding. Ding. Exactly. Nicole. We see this kind of social promotion in surgery where residents advance PGY levels without truly achieving competency and key skills.

Since there's no effective mechanism in place to necessarily prevent advancement.

What evidence is there that residents aren't achieving competency?

Well, even back in 2013, a survey study by Matter etal of fellowship program directors described how fellows are often inadequately prepared with regard to their skills in the or, particularly with laparoscopic skills and suturing.

A 2017 study by George et al, examining independent practice readiness at 14 general surgery programs found [00:10:00] in their last six months of training. Only one third of residents were supervision only for the core procedures. By their last week of residency, only 80% of chief residents were labeled as competent and more complex core procedures.

So what's happening with the other 20%?

Well, that's a great point, Nicole. 'cause there are going to be consequences of this and perhaps is why we're seeing the proliferation of these bridging fellowships to provide additional training without further sub-specialization before transitioning to faculty.

One really shouldn't need that to practice general surgery if they're adequately trained during residency.

That's such an important point, not to mention the public safety implications of graduating those who haven't achieved competency, because yes, it could mean higher complication rates or poor outcomes, but it could also

further threaten public trust and physicians.

Absolutely. So we've talked about appearing versus being competent, [00:11:00] and we've talked about advancing without true competency. Nicole, do you wanna walk us through our next parallel?

Yeah. And this one honestly felt the most uncomfortable. So the third parallel is about blaming the learner. So in sold a story when kids struggled to read, the assumption wasn't maybe this reading curriculum is flawed or maybe we're not doing a good job teaching them.

It was, oh, this child has a deficit, or This child's not a good reader.

Exactly. They were labeled as behind or not motivated, or maybe they had a learning disability, but very few people were asking whether the method of instruction was actually the issue.

And that's the classic deficit model. Locating the failure inside the individual instead of examining the system.

And we do this in surgery too, if we're being honest. When a resident struggles, what do we hear? Oh, they don't get it. They're not cut out for this. They just don't have good instincts.

Yeah. I rarely hear, is our feedback clear? Have we trained faculty how to teach this [00:12:00] skill, or is this learning environment actually optimized for growth?

Right, and there's actually literature supporting this. Jan and colleagues in 2025 outline systemic barriers in surgical education. Things like biased assessments, poor feedback, literacy, lack of faculty training, and limited use of evidence-based educational practices.

Yet we're expected to assess competence, remediate, struggling learners, and determined readiness for independent practice.

It's very similar to what happened in reading education. Teachers were handed package curricula without necessarily being equipped to critically evaluate whether those methods were grounded in science. Then when students failed, we blame the student.

And there's also that rich get richer cycle we see in both systems,

right?

In reading, kids who decode early, they start enjoying reading more, and then they read more and they improve faster. Teachers even perceive them as strong students.

In surgery [00:13:00] early technical success leads to more autonomy. More autonomy leads to more practice. More practice builds confidence and confidence influences evaluations.

The riches of success early on build to make one richer.

Meanwhile, the resident who struggles early may get fewer operative opportunities, vague feedback, less trust, and sometimes negative labels that stick this negative cycle can perpetuate until we call it attrition.

So the question becomes are we truly identifying struggling learners or are we unintentionally creating them through structural bias?

Exactly. Because blaming the learner

protects the whole system from scrutiny

and in both literacy education and surgical education. That's what allowed ineffective systems to persist for decades.

So we've raised a lot of important challenges facing modern surgical education, but that begs the question, where do we go from here?

How do we make sure we're not advancing surgeons without [00:14:00] appropriate competency?

Even though the problems can feel daunting? One proposed path forward is transitioning from the traditional time-based model of residency training to competency-based medical education.

For listeners who maybe aren't as familiar, what exactly is competency-based medical education?

Zoe?

Sure. Competency-based medical education or CBME is a training paradigm that focuses on preparing physicians for practice based on clearly defined outcomes. Instead of assuming competence after a certain number of years, CBME uses observable milestones, benchmarks from novice to expert that faculty can actually see and assess in real clinical work.

A lot of us have heard about Entrustable professional activities or EPAs, so where do EPAs fit in?

EPAs are one practical way to operationalize CBME, and they're increasingly being used in general surgery. EPAs are discreet, observable units of professional practice [00:15:00] that can be fully entrusted to a trainee once they have demonstrated the necessary competence to execute this activity unsupervised.

The American Board of Surgery has published a set of 18 EPAs for general surgery, five of which were piloted in a national study conducted by Brazel et al. Published in the Annals of Surgery in 2023. In this study, they found that it was feasible to implement EPAs and the level of autonomy granted through EPA evaluations increased with increasing PGY level.

So this is what the simple app that so many programs in the US use

exactly. Simple is one platform that can capture EPA style feedback in real time. The idea is after a specific clinical encounter, the resident asks the attending for quick structured feedback. So if you just did a lap AP together, your attending can rate the level of guidance you needed ranging from I had to do most of it to practice ready and add a brief coaching comment.

Over time, those data points are meant to create a clearer [00:16:00] picture progression and readiness for independence.

It sounds like EPAs may be one promising way of addressing the issue of the lack of standardized measures for identifying struggling residents and for decisions on advancement, but it also sounds like a lot of work for residents and for faculty.

You're not wrong, Maya. That has been one of the many challenges consistently identified in the general surgery EPA literature making this work requires buy-in from everyone, hospital leadership, program leadership, faculty and residents. It also requires system level changes needed to reduce RVU pressure and create time for teaching and evaluation.

Although the EPAs are trying to create more objective standards for assessment of residency competent, it seems like achieving that goal is highly dependent on having evaluators who are properly trained to conduct these evaluations.

I completely agree, Brianna. EPAs won't fix assessment if we don't invest in training the people doing the actual assessing.

Which really brings us back to the big [00:17:00] lesson from Soul to story, which is that good intentions aren't enough. We need educational practices that are grounded in evidence, and we need a culture where curriculum and assessment are continuously revised and improved, not treated as. Set it and forget it, but, okay.

So we've talked about what surgical education can learn from the literacy crisis and where we can maybe go from here. But Nicole, you made an important point earlier. This isn't just about residents, is it?

Right. Because the literacy crisis doesn't stop in elementary school. It walks straight into our clinics and our emergency rooms.

If about one in five adults in the US is functionally illiterate or reading far below grade level, that has huge implications for surgical care. Think about what we give patients every day. Discharge instructions, consent forms, pre-op packets, medication lists, MyChart messages, and the average reading level of these medical documents is often around the 10th grade or higher.

But the American Medical Association actually recommends that all health materials are written [00:18:00] at or below the sixth or seventh grade reading level. So we're designing care for a literacy level. Many patients don't even have, which directly impacts outcomes. Health literacy has been linked to complication rights, adherence, readmissions, really everything.

This is real impact. This is the wound care instructions that aren't understood. This is those consent conversations where a patient nods but doesn't truly grasp what's happening.

And if literacy rates are declining and we're not intentionally training residents to communicate in a low literacy world, we're missing something major in competency-based education.

Exactly. We talk about EPAs, like independently perform a laparoscopic appendectomy, but maybe we also need to ask, can you explain that operation to a patient with limited health literacy in a way they actually understand

that's a competency and arguably one just as important as the technical skill itself.

Because preparing surgeons for practice isn't just about operative autonomy, it's about communication, [00:19:00] autonomy too.

Zoe, the literacy crisis isn't someone else's problem. It's shaping the patient population we serve. And if we don't adapt surgical education to that reality, we're not preparing trainees for the world they're actually entering.

Alright. Can we actually sit with that for a second? If literacy rates are declining, and if a significant portion of our patients struggle with reading, how do we teach residents to actually communicate in the low literacy world?

Yeah. And what would that actually look like? Because right now most of us are taught communication through modeling.

You just absorb how your attendings or chief residents explain things,

which means it's variable. Some faculty are phenomenal communicators. Others use a lot of jargon without realizing it. And residents are expected to just pick it up along the way.

Exactly, and that model assumes the baseline skill of the learner and the patient is adequate.

But in a low literacy world, that assumption doesn't hold. We need to be explicitly teaching skills like [00:20:00] using plain language instead a medical jargon, breaking complex ideas into smaller concrete chunks, asking patients to teach back what they understood, recognizing non-verbal cues of confusion, normalizing questions so patients don't feel embarrassed

that teachback is huge.

Not do you understand? Because most patients will just say yes. But you should really be saying, just so I know, I explained this clearly, can you tell me what the plan is when you get home?

And we could actually assess this if we're serious about competency-based education. Communication should be observable and measurable.

This could look like standardized patient encounters. OSCE stations focused on low literacy, counseling, and structured feedback on discharge conversations. This could be applied most in graduate and undergraduate medical education

and beyond assessment. We need curriculum time dedicated to it. We teach not Ty in simulation labs.

We teach central lines and boot camps. So why aren't we teaching how to explain anticoagulation management [00:21:00] to someone reading at a fifth grade level? For those listening, I'd encourage you to take your discharge instructions, your smart phrases that you give patients, and put them into a website that calculates reading levels and see what type of content you're giving to patients.

I think you'd be surprised.

I totally agree, Nicole. And if we know our patient population may struggle with written or complex information, then failing to adapt our communication is a systems failure and a health equity issue.

Absolutely. Well, that just about wraps up today's discussion.

Wait, you never told us the punchline of your joke.

What does a third grader struggling to read have in common with a chief surgical resident struggling in the or?

Oh, they both deserve better systems.

You're not wrong, but you should probably work on your jokes.

And with that, thank you for joining us for our discussion on how the literacy crisis in America is intertwined with surgical training and how it will impact [00:22:00] effective communication with our patients.

If you liked this conversation or wanna stay in the loop on everything Ksf does or even find us for future collaborations. Hit us up. Come follow us on X at Surge Ed Fellows and on Blue Sky Social at cef, C-O-S-E-F. Or again, check out our website@cef.org.

And if you wanna listen to Sold to Story, which we all highly recommend or dive deeper into anything we discuss today, you can find all of our sources behind this episode linked in the show notes.

Thank you for listening to The Behind the Knife Podcast, and as always, go forth and dominate, dominate the day, day.