A new way of teaching surgery: deliberate practice
Seance of wednesday 27 september 2023 (IRCAD-IWC au service de l'enseignement)
DOI number : 10.26299/xg6q-hb58/emem.2023.27.06
Abstract
Medical error is the third leading cause of death in developed countries [Makary and Daniel, 2016]. In its current form, initial and continuing medical training do not address this issue.
With regard to initial training, the reduction in interns' working hours has had the effect of altering surgical performance without reducing fatigue-related errors [Hamid et al., 2014].
With regard to continuing education, recent research has confirmed that highly experienced people are not necessarily more competent than those with little experience. This is known as the experience trap: some people even become less competent with experience alone. Practice alone is not the key to performance.
This being the case, it is imperative to implement training methods that complement companionship and simple experience, in order to meet the public health objective of improving surgical performance.
Many non-medical disciplines have long used deliberate practice to improve performance [Erickson, 2015].
It involves defining an objective and demonstrating the motivation required to achieve it. The learner must receive feedback on his or her results, which helps to highlight weak points and identify areas for improvement with the help of an outside expert. The exercise must be repeated many times until the target is reached. This learning process, which has proved its worth in sports, music and chess, requires intense personal investment.
In sport, deliberate practice applies, for example, to a sprinter whose aim is to improve his performance at the start of the race. His trainer films the first 20 meters of the race and analyzes several data: the thrust into the starting blocks, the acceleration in the first 2 seconds, the kinetics and the distance between each step. The trainer identifies areas for improvement and suggests exercises to enhance the athlete's performance. By repeating the exercises, the goal is gradually achieved.
In music, a violinist learning a new piece begins by mentally picturing the melody he wishes to produce. He then plays the piece on his instrument. Then he listens to the recording with his teacher, who makes critical comments and suggests corrections. Finally, he plays the piece again until he achieves the desired result.
World-class chess players use resolution software to perfect their techniques.
Today, surgeons simply perform surgery. They don't measure their performance, they don't seek to improve their weaknesses, they don't get feedback on their practice, they don't seek expert advice. They just operate. Experience will do the rest, or so they believe.
It is commonly accepted that the minimum length of deliberate practice to become an expert in any field is 10,000 hours [Ericsson, 2015]. This is the length of time a professional violinist reaches at the age of 20 after 15 years of practice. A surgical intern is supposed to become autonomous at the end of his or her training. Yet everyone knows that he or she is far from being an expert in surgery. But why?
The first reason is that he starts his surgical training very late, on average at the age of 24, after 6 years of general medical studies, during which he had little or no contact with surgery. When he begins his residency, he is a complete novice.
The second reason has more to do with the quality than the duration of the training. The legal maximum working week is 48 hours in the European Union and 80 hours in the USA. Considering 48 working weeks per year for 5 years, an intern completes around 11520 hours of work in the European Union and 19200 in the USA. But just because an intern attends the same procedure dozens of times doesn't mean he or she will be able to reproduce it. In fact, the actual duration of deliberate practice during internship is extremely short, if not non-existent.
Like sport, music and chess, deliberate practice could become an excellent method of initial and ongoing training for surgeons, without excluding companionship or simple experience.
Some authors have improved the performance of junior surgeons operating on distal radius fractures. The first step was to film their operations, the second was to give them an OSATS (Objective Structured Assessment of Technical Skills) score, the third was to give them feedback on their errors, and the last was to give them suggestions for improvement. This study took these surgeons from level 3 to level 5 (maximum) performance [Ducournau et al., 2021].
In conclusion, surgeons should embrace deliberate practice to improve their performance and reduce operative risk.
With regard to initial training, the reduction in interns' working hours has had the effect of altering surgical performance without reducing fatigue-related errors [Hamid et al., 2014].
With regard to continuing education, recent research has confirmed that highly experienced people are not necessarily more competent than those with little experience. This is known as the experience trap: some people even become less competent with experience alone. Practice alone is not the key to performance.
This being the case, it is imperative to implement training methods that complement companionship and simple experience, in order to meet the public health objective of improving surgical performance.
Many non-medical disciplines have long used deliberate practice to improve performance [Erickson, 2015].
It involves defining an objective and demonstrating the motivation required to achieve it. The learner must receive feedback on his or her results, which helps to highlight weak points and identify areas for improvement with the help of an outside expert. The exercise must be repeated many times until the target is reached. This learning process, which has proved its worth in sports, music and chess, requires intense personal investment.
In sport, deliberate practice applies, for example, to a sprinter whose aim is to improve his performance at the start of the race. His trainer films the first 20 meters of the race and analyzes several data: the thrust into the starting blocks, the acceleration in the first 2 seconds, the kinetics and the distance between each step. The trainer identifies areas for improvement and suggests exercises to enhance the athlete's performance. By repeating the exercises, the goal is gradually achieved.
In music, a violinist learning a new piece begins by mentally picturing the melody he wishes to produce. He then plays the piece on his instrument. Then he listens to the recording with his teacher, who makes critical comments and suggests corrections. Finally, he plays the piece again until he achieves the desired result.
World-class chess players use resolution software to perfect their techniques.
Today, surgeons simply perform surgery. They don't measure their performance, they don't seek to improve their weaknesses, they don't get feedback on their practice, they don't seek expert advice. They just operate. Experience will do the rest, or so they believe.
It is commonly accepted that the minimum length of deliberate practice to become an expert in any field is 10,000 hours [Ericsson, 2015]. This is the length of time a professional violinist reaches at the age of 20 after 15 years of practice. A surgical intern is supposed to become autonomous at the end of his or her training. Yet everyone knows that he or she is far from being an expert in surgery. But why?
The first reason is that he starts his surgical training very late, on average at the age of 24, after 6 years of general medical studies, during which he had little or no contact with surgery. When he begins his residency, he is a complete novice.
The second reason has more to do with the quality than the duration of the training. The legal maximum working week is 48 hours in the European Union and 80 hours in the USA. Considering 48 working weeks per year for 5 years, an intern completes around 11520 hours of work in the European Union and 19200 in the USA. But just because an intern attends the same procedure dozens of times doesn't mean he or she will be able to reproduce it. In fact, the actual duration of deliberate practice during internship is extremely short, if not non-existent.
Like sport, music and chess, deliberate practice could become an excellent method of initial and ongoing training for surgeons, without excluding companionship or simple experience.
Some authors have improved the performance of junior surgeons operating on distal radius fractures. The first step was to film their operations, the second was to give them an OSATS (Objective Structured Assessment of Technical Skills) score, the third was to give them feedback on their errors, and the last was to give them suggestions for improvement. This study took these surgeons from level 3 to level 5 (maximum) performance [Ducournau et al., 2021].
In conclusion, surgeons should embrace deliberate practice to improve their performance and reduce operative risk.