The Rafiee Educational Approach

What is the Rafiee Educational Approach?

The Rafiee Educational Approach is a six-phase framework for teaching surgical wound management and scar optimization (Assess, Plan, Handle, Close, Protect and Follow-up), developed by surgeon and medical educator Dr. S. Nouri Rafiee. The framework has been developed; its pilot implementation and evaluation are in development.

Its premise is simple to state and demanding to teach: the scar a patient lives with is the result of a chain of decisions, not of a single stitch. The approach makes each of those decisions visible, in the order in which they are made, so that they can be taught, practiced and assessed.

Why does it teach judgment and not only technique?

Because technique alone does not tell a clinician what to do first, whether a wound should be closed at all, or when to stop. Health professionals should learn not only how to perform a procedure, but when to perform it, why to perform it, how to perform it safely, how to evaluate the result, when not to intervene and when specialist referral is required.

Most procedural teaching concentrates on the first of those questions. The Rafiee Educational Approach gives the other six the same weight. It is designed so that a learner who completes it can explain a decision, not only carry it out, and can recognize the moment when the right decision is to do less, or to refer.

The six phases

Each phase corresponds to a moment in the care of a wound in which a different decision is made. The phases are taught in sequence, but they are not a checklist: judgment runs through all of them, and any phase can lead to the conclusion that the case belongs with someone else.

Assess

Everything begins with a structured assessment of the patient and of the wound: mechanism of injury, time since injury, contamination, tissue viability, the structures that may be involved and the patient factors that change how a wound heals. The learner is expected to describe the wound precisely and to identify features that change the plan, such as possible injury to nerves, tendons, vessels or ducts, signs of infection or foreign material.

When not to intervene: when assessment reveals involvement of deeper structures, significant tissue loss or a situation beyond the clinician’s competence, the correct outcome of this phase is referral.

Plan

Planning decides the objective before the technique. Should this wound be closed now, later, or allowed to heal by secondary intention? Which anesthesia, which closure, which orientation of the future scar along the skin tension lines? Planning is where the scar is first considered, before it exists.

The learner is expected to justify a plan and to name its alternatives. Referral at this phase is appropriate when the best plan requires skills, resources or follow-up that the setting cannot provide.

Handle

Tissue handling is treated as a clinical skill in its own right. Preparation, irrigation, debridement when indicated, hemostasis and atraumatic technique decide a large part of the result before closure begins. Tissue that is crushed, dried or devitalized heals less well, whatever the quality of the suture that follows.

The learner is expected to handle tissue gently and deliberately, and to recognize when debridement or hemostasis exceeds what can be done safely in the setting.

Close

Closure restores alignment without excess tension. It includes layered repair when appropriate, edge eversion, and the choice of suture material and technique according to site, tension and purpose. The subcuticular, simple interrupted and mattress sutures each have their place, and each has a cost; Aesthetic Surgical Skills for Physicians is dedicated to them.

The learner is expected to match technique to the wound rather than apply one technique to every wound, and to recognize closures that belong with a specialist.

Protect

Care of the repair does not end with the last stitch. Dressing, tension management, infection awareness, suture removal timing and clear patient instructions protect the repair in the days and weeks that follow, and influence how a scar matures.

The learner is expected to give patients specific aftercare instructions and to explain which signs should bring them back early.

Follow-up

Follow-up reviews healing and scar maturation over time. It is where early complications are recognized, where abnormal scarring such as hypertrophic scars and keloids can be identified early, and where intervention should stop and specialist referral begin.

The learner is expected to know the normal course of scar maturation and the signs that healing is departing from it.

What does the approach draw on?

The Rafiee Educational Approach draws on established principles of procedural skills education. Demonstration is structured along the lines of Peyton’s four-step approach, which a meta-analysis found effective for procedural skill acquisition, particularly with small groups of learners per teacher (Giacomino et al., 2020). Practice is organized as deliberate practice: focused repetition with specific feedback, the pattern associated with the development of expert performance (Ericsson, 2004). Progression is mapped onto Miller’s pyramid, from knowing and knowing how to showing how and, finally, doing (Miller, 1990).

As an integrated framework, the approach has not yet been formally evaluated. A pilot evaluation is in development, and its methods and results will be reported on the research page.

How does it relate to the programs?

The approach is the common structure of the Academy’s teaching. Wound-to-Scar™ applies all six phases to surgical wound management and scar optimization. Foundations of Clinical & Minimally Invasive Procedural Medicine lays the procedural ground the other programs stand on. Aesthetic Surgical Skills for Physicians concentrates on Handle and Close. Clinical Aesthetic Practice & Patient Safety applies the same logic of assessment, planning, protection and follow-up to aesthetic practice.

Beyond the core programs, the advanced and specialized programs apply the approach in depth: Clinical Simulation, Procedural Skills & Assessment to how skills are practiced and assessed, Aesthetic Consultation, Ethics & Practice Development to the consultation and the organization of a practice, and Clinical Imaging & Ultrasound in Aesthetic Medicine to what lies beneath the surface before any procedure.

Program 05, on wound biology, genetics and regenerative medicine, is a research line. It studies the science behind the phases rather than teaching them.

Where does the approach stand today?

The framework has been developed. Its pilot implementation and evaluation are in development, and the Academy is building an assessment framework to measure what learners know, what they can do and how they decide. Until that evidence exists, the approach is presented for what it is: a structured, evidence-informed way of teaching, not a validated method.