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programs to reexamine and restructure their educational approach to training resi-
dents. Furthermore, volume-based advancement ensures that patients will be
exposed to surgeons in their learning curves which may be negatively correlated
with outcomes. Given the rapid pace of new technological developments within
surgery over the past few decades, similar challenges are also being faced by gradu-
ated surgeons already in practice trying to master new surgical techniques and skills
not learned in residency.
Several other factors have contributed to renewed interest in how to foster mas-
tery of technical skills within the current training paradigm. National patient safety
concerns have drawn attention to the role of healthcare systems and practitioners in
preventable medical errors and spurred quality initiatives throughout the healthcare
system [ 3 – 5 ]. National malpractice claims have demonstrated that overall 41% of
errors in surgical and perioperative care resulting in patient injury are due to errors
in technical competence; of those cases, a trainee’s lack of technical competence
was implicated 40% of the time [ 6 ]. In this context, surgical skills development
takes on implications beyond simply training individual residents, as developing
technical competence directly impacts patient outcomes [ 7 ].
Cost is also a significant consideration in the current model of surgical education.
Resident involvement in operative cases decreases efficiency. Multiple studies of
general surgical procedures have demonstrated that resident involvement increases
operative time in almost all cases [ 8 – 10 ]. Given the high cost of operating room
time, which has been estimated at $900–1200 per hour, the annual cost burden
attributed to extra operating room time for resident education has been estimated at
$53 million [ 8 , 11 ]. The efficient development of surgical proficiency both within
and beyond the operating is therefore paramount.
To appropriately address the need for more efficient development of technical
skills, it is critical to understand the current educational theory surrounding the
acquisition and mastery of procedural skills. Much of the foundation for mechani-
cal and surgical learning theory is based on the classic three-stage theory of motor
skills acquisition proposed by Fitts and Posner in 1967. This separates learning
into cognitive, associative, and autonomous stages (Table 6.1). In the cognitive
stage, the task and its mechanics are largely intellectualized; the procedure is car-
ried out in a series of small steps, and the task performance is often erratic and
inefficient. In the associative phase, knowledge about how to perform the task is
translated into task performance. With deliberate practice and feedback, task per-
formance becomes more efficient. In the final autonomous stage, task performance
becomes fluid and continuous through continued feedback and refinement of per-
formance, with minimal dependence on conscious cognitive thought [ 12 ]. As
applied to surgical training, it is this autonomous mastery of basic skills such as
knot tying or suturing that allows trainees to focus on the more complex technical
and nontechnical aspects of operating and to grow as surgeons. Thus, it has been
suggested by some that the cognitive and associative stages should be practiced by
trainees largely outside of the operating room to maximize the utility of intraopera-
tive time [ 1 ]. Such calls have paralleled the increasing use of simulation in surgical
training.
J.C. Dai and M.D. Sorensen