Surgeons as Educators A Guide for Academic Development and Teaching Excellence

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Ericsson’s theories on the development of expertise further inform current mod-
els of surgical education. Experts are those individuals whose performance of a
particular task is identified as reproducibly superior to that of their peers. For these
individuals, continued improvement in performance occurs gradually and over
extended periods of time. Indeed, 10 years or 10,000 h is generally regarded as the
time investment required to attain expert levels of performance. Mastery of a task
requires motivation on the part of the trainee, detailed, immediate feedback on their
task performance, and repeated practice. This concept has been termed “deliberate
practice” [ 13 ]. In contrast with previous theories by Sir Francis Dalton implicating
innate ability as the primary factor for expert performance, the idea of deliberate
practice suggests that expertise is attainable primarily through motivated and
focused practice.
A critical component of deliberate practice and attainment of expert performance
is both the quantity and nature of feedback. Within the education literature, there
remains disagreement as to the optimal timing and quantity of feedback to maxi-
mize procedural mastery. Across several studies, frequent, intermittent, and imme-
diate feedback appears to be most effective in improving procedural performance,
decreasing error, and improving learning curves among cohorts of novice trainees
[ 14 , 15 ]. However, other studies have demonstrated that too intense feedback during
the early stages of learning may actually hinder learning [ 16 ]. Regardless, the role
of feedback is central to the development of expert performance and plays a critical
role in the education of surgical residents in the current training paradigm.
Current methods of surgical skills evaluation are limited in scope, timing, and
objectivity. Accreditation Council for Graduate Medical Education (ACGME) oper-
ative case logs serve as an overall surrogate for a trainee’s surgical exposure and, by
extrapolation, the development of their surgical skills. However, this remains an
imprecise marker for technical skill, as it does not completely capture the extent of
a trainee’s involvement in the case, their innate surgical ability and clinical judg-
ment, or technical progress. Moreover, it depends on accurate and appropriate log-
ging of cases by the trainee and is therefore prone to a degree of subjectivity. Surveys

Table 6.1 The Fitts-Posner three-stage theory of motor skills acquisition

Stage Goals Method Characteristics

Cognitive Establish task goals

Determine appropriate

sequence of actions to

achieve desired goal

Explicit

knowledge

Slow, inconsistent,

interrupted movements

Associative Understand and perform

mechanics

Attention to specific subparts

and transitions within the

sequence

Exploration of

details

Deliberate

practice

Feedback

More fluid and efficient

Autonomous Task performance is honed

Development of automatized

routine

Continued

feedback

Repetition

Accurate, consistent,

fluid, continuous

Adapted, Fitts and Posner [ 12 ]

6 Crowdsourcing and Large-Scale Evaluation