What Clementines Can Teach Surgeons

Originally published on June 28, 2012 8:45 am

Clementines and pelvic anatomy are two things you probably wouldn't ever talk about in the same sentence, unless you're Pamela Andreatta.

Andreatta, a medical educator at the University of Michigan Medical School, knows all about how people learn. And lately, she's been spending a lot of time scrutinizing how residents are taught to do minimally invasive surgery.

In particular, she's been looking at how doctors master laparoscopic surgery, performed with a camera and surgical instruments inserted through tiny incisions in the body.

"We can do better — much better," she says.

The traditional apprentice model of learning by watching then doing is putting young doctors in operating rooms before they've mastered basic skills, she says.

And while there are surgical simulators on the market, including high-tech digital systems offering a virtual reality, she believes the skills crucial to laparoscopic surgery might be better taught with something as simple as a clementine.

The idea came to Andreatta after a colleague in gynecologic oncology asked whether she could come up with a simulation to teach the delicate task of removing lymph nodes, something done to minimize the spread of cancer.

She considered the fact that throughout the pelvic anatomy, there is a mix of substantial and delicate tissue. And then she thought about a clementine. It has a sturdy outer peel, but also the more fragile pith, the white spongy layer under the skin.

Andreatta set up an exercise using an opaque box with holes in the top through which you can insert a camera, scissors and grasper. She invited residents, medical students and faculty to dissect clementines.

They had to take off the peel in as few pieces as possible, remove the pith, separate the segments, then put everything back together and suture the peel closed. They had two hours to complete the task.

Andreatta designed a complex scoring system, which took into consideration the finished state of the fruit, each person's planning and clinical judgment, plus some other factors.

In all, 41 people dissected clementines. The minimally invasive surgery specialists scored the highest, by far. Residents and nonsurgical faculty scored significantly lower. Medical students, with little or no surgical experience, fared worst.

The results, Andreatta says, confirm that the clementine is a suitable model for training. Faculty surgeons backed up that assertion, remarking on the similarities between the simulation and actual surgery.

The clementine is in fact just one of several dozen low-cost simulations Andreatta has developed for teaching minimally invasive surgery. Another uses colorful foam shapes purchased from a craft store.

Her hope is that at the University of Michigan and elsewhere, the training boxes, clementines and foam pieces can be placed in offices and hospital call rooms, so that residents and faculty can practice whenever a free moment arises.

Moreover, Andreatta says, these models can work just about anywhere. Already, she's taken them to Ghana, where the University of Michigan supports a laparoscopic surgery training center.

"You can find clementines or setsumas or tangerine variations all over the world," Andreatta says. "You can go out and pick them off a tree, and it costs very little or nothing... and yet it's very advanced training."

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Now, a story about a low-tech way of training doctors to do some high-tech surgeries. It involves fruit. Stick with us. We're talking about minimally invasive surgery, which is becoming the norm for many procedures. Things such as knee repairs and hysterectomies are often done through tiny incisions.

While at the University of Michigan, NPR's Andrea Hsu found a medical educator with a new idea for how to practice on produce.

ANDREA HSU, BYLINE: When Pamela Andreatta brought in medical residents to test a simulation she developed, she kept hearing this.

PAMELA ANDREATTA: Why are we doing this? Seriously.

HSU: She'd given them clementines, the tangerine-like fruit. She'd also provided a vinyl box with small holes in the top and basic laparoscopic instruments to go in those holes: a grasper, scissors and a scope or a camera. The task was to peel the clementine, separate the segments, remove the pith - that's the white stringy, spongy stuff - then put it back together and suture the peel closed.

ANDREATTA: So that the clementine looks like it did before you've opened it, except with some sutures.

DR. ADRIANNE GASPERUT: It's a lot harder than it actually sounds.

HSU: Adrianne Gasperut(ph) is a third year resident in obstetrics and gynecology. She managed to get her clementine peeled and sectioned but ended up having to open the box and sew it close by hand. Though frustrated by the exercise, Gasperut admits practicing on fruit could be valuable.

GASPERUT: It's a lot less threatening, I think, than starting in the operating room where obviously it's of critical importance that you're safe.

HSU: And that's Pamela Andreatta's point too. She's not a physician. Her doctorate is in educational psychology. But she spends a lot of time talking to doctors and nurses. One day, a colleague in gynecologic oncology asked, could she come up with a simulation for stripping nodal tissue, something they do to try to minimize the spread of cancer? Andreatta thought for a moment about the pelvic anatomy.

ANDREATTA: You have relatively substantial tissue, but then you've got that fine, delicate tissue, like ureters and vessels.

HSU: A clementine, she reasoned, likewise has a somewhat sturdy outer peel as well as the more fragile inner pith.

DR. DAVID MARZANO: It felt actually surprisingly similar. And I have to say, initially, I was somewhat skeptical.

HSU: David Marzano is an OB-GYN at the University of Michigan. A dozen years ago, when he was a resident, they practiced laparoscopy on live pigs. Today, he believes many of the same skills can be honed through simulations that are far less costly, yet still highly representative of the task at hand.

MARZANO: If you squeeze too hard on the orange pieces, all of a sudden you've got juice all over the place, which is similar to, if you squeeze too hard on an ovary that has a cyst on it, you're going to break the cyst.

HSU: Pamela Andreatta has logged many hours in operating rooms, observing. She's seen residents struggle as they drive the camera for the first time. She's watched as attending physicians have had to coach young doctors on how to hold the graspers, all of which prolongs the patient's surgery.

ANDREATTA: I look at that, and I think: We can do better.

HSU: It's not that Andreatta doesn't value the operating room experience. She knows there's a lot of critical learning that goes on there. It's just that she thinks residents should master some basic skills before they get to the patients.

ANDREATTA: Just the use of the instruments alone, it's tricky. It's challenging to use those instruments.

HSU: And beyond skillful instrument handling, she says, the clementine teaches planning and judgment. When do you decide that the removal of more pith is going to cause too much damage to the underlying structure? How long will you go before you decide it's safer to open the patient - in this case, the box - and finish the operation by hand?

The clementine is just one of many training models Andreatta has developed. She's also experimented with Meyer lemons and globe grapes, and she's been brainstorming about another piece of fruit she thinks may be a useful simulation for the removal of ovaries.

ANDREATTA: I'm still kind of on the fence about an apricot for an oovectomy. I'm thinking an apricot might work.

HSU: Residents, stay tuned. Andrea Hsu, NPR News. Transcript provided by NPR, Copyright NPR.