Improving Continuing Medical Education for
Surgical Techniques: Applying the Lessons
Learned in the First Decade of Minimal
David A. Rogers, MD,* Arthur S. Elstein, PhD,† and Georges Bordage, MD, PhD†
From the *Department of Surgery, Medical College of Georgia, Augusta, Georgia, and the †Department of Medical Education,
University of Illinois at Chicago, Illinois
To examine the first decade of experience with minimal ac-
cess surgery, with particular attention to issues of training sur-
geons already in practice, and to provide a set of recommen-
dations to improve technical training for surgeons in practice.
Summary Background Data
Concerns about the adequacy of training in new techniques
for practicing surgeons began almost immediately after the
introduction of laparoscopic cholecystectomy. The concern
was restated throughout the following decade with seemingly
little progress in addressing it.
A preliminary search of the medical literature revealed no sys-
tematic review of continuing medical education for technical
skills. The search was broadened to include educational,
medical, and psychological databases in four general areas:
surgical training curricula, continuing medical education,
learning curve, and general motor skills theory.
The introduction and the evolution of minimal access surgery
have helped to focus attention on technical skills training. The
experience in the first decade has provided evidence that sur-
gical skills training shares many characteristics with general
motor skills training, thus suggesting several ways of improv-
ing continuing medical education in technical skills.
The educational effectiveness of the short-course type of con-
tinuing medical education currently offered for training in new
surgical techniques should be established, or this type of
training should be abandoned. At present, short courses offer
a means of introducing technical innovation, and so recom-
mendations for improving the educational effectiveness of the
short-course format are offered. These recommendations are
followed by suggestions for research.
Laparoscopic cholecystectomy was developed in the late
1980s.1This new technique represented a substantial
change in the way this common surgical procedure was
performed. Based on the perceived advantages of this new
approach, it rapidly became the standard method for chole-
cystectomy.2Since the introduction of laparoscopic chol-
cystectomy, there has been an increase in the number of
surgical procedures that can be performed using this general
approach, and the term minimal access surgery (MAS) has
evolved to describe it.3This evolution has created an on-
going continuing education need among practicing surgeons
for training in these new techniques. This need has been met
with short courses developed by surgeons already experi-
enced with the new procedures.4These courses have con-
tinued to expand to meet this and other technical training
needs of surgeons. This type of continuing medical educa-
tion, developed primarily to teach a new technique, is the
focus of this review and is designated continuing medical
education for surgical techniques (CMEST).
Concern about the adequacy of short courses for CMEST
developed quickly and has persisted throughout the de-
cade.5–12For example, in 1991 Dent stated, “Rumors of a
steep learning curve, common bile duct injuries, massive
hemorrhage, and even deaths following laparoscopic sur-
Correspondence: David A. Rogers, MD, Department of Surgery, Southern
Illinois University School of Medicine, P.O. Box 19655, Springfield,
Accepted for publication July 18, 2000.
ANNALS OF SURGERY
Vol. 233, No. 2, 159–166
© 2001 Lippincott Williams & Wilkins, Inc.
gery are rife.”5That same year, Gadacz and Talamini6
stated, “Hands-on experience is essential and a 2- or 3-day
‘mini’ course is essential but not sufficient.” In 1992
Zucker7said, “Weekend courses ? are clearly no substitute
for hands-on experience.” Two years later Rock and War-
shaw8stated, “the presumption that new and technically
demanding surgical skills can be learned in a ‘weekend
course’ makes us vulnerable to the questioning of our pro-
fession and of our skill as surgeons.” Gates9in 1997 stated,
“Generally speaking, a weekend course in endoscopic sur-
gery would not be adequate to provide the required level of
knowledge or skill.” As the decade drew to an end,
Reznick10asked, “How can our profession avoid a repeti-
tion of the laparoscopic cholecystectomy fiasco, wherein
surgeons were learning a new technique on a live animal
model on Sunday and performing the procedure on
Studies evaluating the educational impact of these
CMEST short courses provide evidence that the concerns
were well founded. A survey of practicing surgeons re-
ported that most did not believe they were adequately
trained to perform laparoscopic cholecystectomy after a
2-day workshop.11Another survey showed that the compli-
cation rate was higher in the initial experience among sur-
geons who performed the new procedures after having taken
only one of these courses.13
This review examines the first decade of experience with
MAS, with particular attention to training aspects. The goal
was to discover, from this experience, solutions to the
general challenge of providing CMEST to surgeons in prac-
tice. Although the changes associated with MAS have been
profound, gradual technical innovation, both within and
beyond MAS, can be expected,14,15thus creating a lifelong
need for effective CMEST for every surgeon.
An initial search of the Medline database was undertaken
for the years 1989 to 1999 using the search terms “laparos-
copy,” “skills,” “technique,” “surgery,” “minimal access
surgery,” and “continuing medical education.” This search
yielded no systematic review of the general area of CMEST
during this period. Consequently, the review was focused on
four general areas: continuing medical education (CME),
surgical technical curricula, surgical learning curve, and
general psychomotor skills acquisition.
Seven different specific
searched covering the period 1989 to 1999 and limited to
English-language publications. All titles and abstracts were
reviewed and appropriate citations were selected for com-
plete review. A manual search of the references of these
citations was performed, and relevant papers and textbooks
were also selected for review. This included literature in the
period before 1989. For the CME literature, the term “con-
tinuing medical education” was used to search EBM Re-
views, Medline, ERIC, and Education Abstracts. The search
was narrowed by selecting review articles published in the
past decade. For the literature on surgical technical curric-
ula, the terms “surgery,” “skills,” and “techniques” were
used in various combinations to search Medline, EBM Re-
views, ERIC, PsycFirst, and Education Abstracts. For the
surgical learning curve literature, the terms “learning,” “per-
formance,” and “curve” were used in various combinations
to search Medline, Education Abstracts, ERIC, and News-
paper Abstracts. This search was narrowed by selecting only
articles that addressed the learning curve associated with
surgical procedures. For the motor skills literature, the terms
“motor,” “psychomotor,” “skills,” and “acquisition” were
used in various combinations to search ERIC, Education
Abstracts, and PsycFIRST. Finally, the websites for the
Society of American Gastrointestinal Endoscopic Surgeons
(SAGES) and the American Council on Continuing Medical
Education were searched for standards pertinent to CMEST.
The results of the literature search and analysis of those
results will be presented according to the four general areas
reviewed: CME, surgical technical curricula, surgical learn-
ing curve, and general psychomotor skills acquisition.
Continuing Medical Education
Early in the MAS movement, SAGES developed guide-
lines for CMEST courses16and for granting privileges for
MAS procedures.17The recommendations stated that in
addition to taking a course, a surgeon must have experience
as an assistant and then perform the initial procedures on
patients under the supervision of a surgeon with MAS
privileges. A survey of how surgeons actually obtained
training for laparoscopic cholecystecomy showed that only
about half of surgeons actually satisfied all the SAGES
recommendations.18Reasons cited for the failure of sur-
geons to satisfy all the requirements included a lack of
training opportunities, the cost of the training, and the lack
of experienced colleagues.
There has been considerable research in improving the
effectiveness of general CME courses in changing physician
behaviors and patient outcomes. Several factors have been
identified that increase the likelihood that change will occur
after a physician participates in a CME course.19,20Educa-
tional sessions that communicate or disseminate informa-
tion are less effective than interventions that provide the
information and facilitate the desired change or reinforce
the change. Multifaceted interventions are more effective at
producing change than are single interventions. A careful,
specific needs assessment improves the effectiveness of the
course. Longer programs are more effective than day-long
short courses. Performance change is greater when all par-
ticipants are from the same practice setting. Finally, inter-
active sessions that provide the opportunity for practice are
more effective than didactic sessions.
Improving Continuing Medical Education for Surgical Techniques
Ann. Surg.●February 2001
Most of the research on CME involved evaluating
courses designed primarily to impart new knowledge or
nontechnical skills. It has been recently recognized in the
CME literature that psychomotor skill acquisition is distinct
from other types of learning.21Consequently, it is unclear
which of the above factors should be present in CMEST
In summary, the research on creating effective CME has
not included CMEST. Further, many surgeons are not fol-
lowing the existing recommendations for obtaining training
in new techniques.
Surgical Technical Curricula
Before the introduction of MAS, the surgical literature
addressing technical training dealt primarily with different
animate and inanimate models, with little attention to spe-
cific aspects of a technical curriculum,22except for the short
courses developed in Britain for resident technical
The MAS movement has helped to focus attention on
surgical technical training, perhaps because these proce-
dures differed so significantly from the existing techniques.
Several studies have examined training methods for teach-
ing the new skills associated with the MAS approach.
Several “drills,” elemental skills that involve more com-
plex surgical skills, have been developed, with a modest
correlation between improvement in the performance of
these drills and the total task.24It has been shown that
clinical laparoscopy experience results in enhanced perfor-
mance on training tasks in a simulated environment,25sug-
gesting but not proving that the reverse might be true as
well. Substantial evidence has been developed that perfor-
mance, measured by either a subjective rating or time on
task, improves with practice.24,26,27
A major gap in this literature is the lack of proof of a
relationship between performance in these simulated envi-
ronments and actual surgery.25,28,29This gap between per-
formance in a simulated environment, either traditional or
computer-based, exists because no work has yet been done
demonstrating that performance of a procedure on models
relates to performance of the actual procedure on patients. A
first step in bridging this gap has been taken with the
demonstration that performance of a laparoscopic procedure
on an inanimate model translates to performance of the
procedure in an animal model.30
It could be argued that the findings of much of this
research do not apply to experienced practicing surgeons,
because most studies were done with surgical residents as
study subjects. However, it has been shown that “senior
surgeons” learn these skills in a fashion similar to
The review of technical skills curricula shows that one
positive effect of the MAS movement has been to focus
attention on training. That practice improves performance
suggests that learning a surgical skill shares features with
general motor skills learning,32and this appears to apply to
both experienced surgeons and residents. The approach of
teaching a complex surgical skill by dividing it into simpler
component tasks, a strategy described in the motor skills
literature,33has been validated.
Surgical Learning Curve
Another consequence of the MAS movement has been
increased attention to the learning curve in the surgical
literature.12,34–47A learning curve is a graphic representa-
tion of the relationship between experience with a procedure
and an outcome variable, usually a performance character-
istic of clinical interest, such as operative time. Studies have
generally shown that with increasing experience, operative
time decreases,34,36,37,39–44,47the complication rate is low-
er,34,35,37,41,42,47and there are fewer conversions to the
standard procedure.34,41,43,47Learning curves have four sig-
nificant implications for CMEST.
First, the general shape of surgical learning curves is
similar to the “performance curve” described in the general
motor skills literature.48,49An established characteristic of
performance curves is that improvement occurs more rap-
idly during the early experience.33,50Consequently, the
early part of the performance curve is steep, a feature also
observed in learning curves associated with surgical proce-
dures47(Fig. 1). As experience accumulates, the curve be-
comes flatter, with less improvement with each additional
experience. From an educational perspective, a relatively
small increase in the amount of practice provided during a
course could substantially improve technical performance.
Figure 1. A learning curve showing the relationship between operative
time and experience for laparoscopic fundoplication in children. (Used
with permission from Meehan JJ, Georgeson KE. The learning curve
associated with laparoscopic antireflux surgery in infants and children.
J Pediatr Surg 1997; 32:426–429.)
Vol. 233●No. 2
Rogers and Others
Second, the curves for the declining operative time and
complication rate are similar (Figs. 1 and 2). This suggests
that increased familiarity with the task increases confidence
and therefore increases speed and decreases errors. From the
perspective of curriculum design and performance assess-
ment, this relationship is helpful because operative time is
easily measured during a course, whereas the complication
rate of the actual surgical procedure is not. If the curriculum
is designed to optimize the performance characteristic of
operative time, then the complication rate should decrease
as well, although the extent to which this is true is yet to be
Third, there is evidence in the surgical literature that the
shape of the learning curve varies for each individual
learner and task,33,37,40,47a phenomenon recognized for
motor skills learning in the psychology literature.33,48A
feature of these individual performance curves is that they
do not follow the smooth predictable curve generated by a
group.33The educational implication for CMEST is that a
course should take into consideration the performance dif-
ferences among the participants.
Finally, the fact that surgical learning curves are similar
to motor performance curves provides additional evidence
that what is known of the psychology of learning motor
skills should be applied to teaching surgical skills. This
general educational strategy was suggested more than 100
years ago51and was endorsed for surgical training in 1987
Motor Skills Theory
Systematic research on motor skills acquisition has been
done for more than 100 years,53and several theories have
been developed to explain how motor skills are learned.48
The theories are sufficiently divergent to be considered
distinct schools.54For the purposes of curricular planning,
frameworks that describe stages of motor learning are per-
haps more useful than these general learning theories. Fitts
and Posner55described a three-stage model of motor skills
acquisition that has received attention in the surgical liter-
ature.56,57In the first stage, the cognitive phase, the learner
gains an understanding of the task, a process assisted by
instructor explanations and demonstrations. The second
stage is the associative phase, during which the learner
practices the task and eliminates error from the perfor-
mance. The role of the instructor is to provide feedback,
identifying errors and providing explanation for corrective
actions that the learner may take. Finally, the learner moves
into the autonomous stage of learning, where he or she
performs the task in a relatively automatic fashion with little
or no cognitive input.
To date, most theories and models of motor skills learn-
ing have been developed based on studies of extremely
simple motor tasks. In this context, even a basic surgical
skill, such as tying a knot, would be regarded as a complex
motor skill. This is important because some aspects of
optimal teaching of simple motor skills do not necessarily
apply to the teaching of more complex skills. For example,
it has been shown that instructor feedback given after each
performance of a simple motor task results in inferior mas-
tery of the skill compared with feedback given at inter-
vals.58The opposite has been found in the acquisition of a
complex motor task.59
The question of how best to teach practicing surgeons
new surgical techniques remains incompletely answered.
After a decade of MAS experience, there has been seem-
ingly little progress in developing alternatives to the
CMEST short courses, even though the literature shows that
these courses are insufficient to provide adequate training in
and of themselves. Based on the present review, a set of
recommendations is proposed to improve the educational
content of workshops or short courses designed to teach
technical skills. These include recommendations to the in-
dividual surgeon or “consumer” and to those responsible for
developing and accrediting the courses. In addition, some
suggestions for research are provided.
Recommendations for the Practicing
The surgeon consumer of CMEST should select a course
designed to move the students “further along the learning
curve.”60In other words, by the end of the course, the
surgeon should be at the point on the learning curve where
error is minimized and performance is optimal. For the
present, the surgeon should select a course that satisfies the
SAGES requirements, now interpreted in light of what has
been learned in the first decade of MAS experience:
1. The course should provide a set of objectives and a
description of the assessment methodology. The
current SAGES guidelines include the recommenda-
Figure 2. A graph of the calculated probability of bile duct injury during
laparoscopic cholecystectomy. (Used with permission from Southern
Surgeons Club, Moore MJ, Bennett CL. The learning curve for laparo-
scopic cholecystectomy. Am J Surg 1995; 170:55–59.)
Improving Continuing Medical Education for Surgical Techniques
Ann. Surg.●February 2001
tion that CMEST courses should have objectives that
describe the technical task and the method of assess-
ment.16These objectives and assessment criteria
should include specific performance characteristics:
for example, to pass the course, the participant should
be able to perform the technique in a given period with
a prescribed success rate.
2. The faculty should be qualified. The faculty should
be qualified to perform and teach the procedure. Evi-
dence of qualification to perform the procedure should
be based on performance data, not simply on clinical
experience or reputation. Instead, the faculty members
must justify their expert status by indicating their own
position on the learning curve. This performance data
should include information for both the teaching mod-
els used in the course and actual patients. Proof of
qualification to teach the procedure should be pro-
vided by qualitative and quantitative assessments from
prior course participants. Evidence that the learner can
actually master the technique during the course should
be provided. This should include estimates by past
participants of their ability to perform the procedure
on patients after having taken the course.
In addition to being qualified, faculty members
must be present in sufficient quantity to provide indi-
vidualized feedback throughout the training period.
There is little information to suggest an optimal fac-
ulty-to-student ratio, although a ratio of 1:4 has been
shown to produce a positive training effect.31The
precise number could be determined by surveys of
participants who assess the adequacy of feedback dur-
ing the training process.
3. The participants should possess the appropriate
fundamental knowledge, skills, and clinical experi-
ence. Participants should be surveyed before taking
the course regarding their current experience and mas-
tery level so that the course content can be adapted to
their specific needs. Pretesting at the beginning of the
course is recommended by SAGES and would vali-
date the survey results. Comparison of pretest and
posttest performance would provide evidence of the
educational effectiveness of the course, as has been
done with an ultrasound course for surgeons.61
4. The facility should be adequate. An adequate num-
ber of animate and inanimate models should be avail-
able for practice. There should be adequate facilities to
accommodate the learning needs of all participants,
allowing them to practice until they can demonstrate
the desired level of performance based on a position
on the learning curve.
5. The curriculum should incorporate educational
materials that will reduce the time required at the
course and will enhance the learning experience.
To enhance the cognitive phase of learning, video-
tapes of the procedure should be sent to course par-
ticipants before the course. This would allow them to
rehearse the procedure mentally before the actual
practice period.62The same video files could be dig-
itized and made available to participants to download
directly from the Internet. Videotape should also be
used to record participant performance during practice
to allow learner self-critique and review with a faculty
member.12,63The participant’s videotapes and those of
an expert’s performance should be given to partici-
pants for review of the course material as they begin to
perform the procedure on patients.
Recommendations for Course
Developers and Accrediting Agencies
1. The course developers should perform a formal task
analysis. This document describing the task should
include an analysis of the important aspects of the
technique, including equipment needed and environ-
mental constraints, as has been done for microsur-
gery.64An important aspect of the analysis is an
estimate of the degree to which the new technique will
represent a new motor skill for participants, because
this substantially influences the design of the course.
This analysis should also involve an inventory of the
errors that occur frequently with the technique. The
task analysis leads to the development of specific
goals and objectives for the course and a curriculum
that allows the participants to accomplish the objec-
tives. The description of the curriculum should include
the faculty-to-student ratios, practice environment,
and assessment methods.
2. The task analysis and curriculum should be approved
by the accrediting agencies. The ultimate goal of ac-
crediting agencies is to ensure that the innovation is
introduced with maximal safety to patients. These
groups should serve as repositories of information
about course elements that must be present to produce
effective training. Courses should be evaluated based
on performance data during the course and in the
3. Reevaluate the supervised experience requirement.
Even though supervised experience has been shown to
be important in reducing complication rates,39,65many
surgeons are either unable or unwilling to arrange this
supervision.18Hospitals have shown little interest in
requiring this experience, and legitimate difficulties exist
when a surgeon is in a rural environment and no other
surgeons are available, or when a surgeon is the first in
an area to perform a procedure. If it is impossible for a
surgeon to arrange a supervised experience, then he or
she should bring an assistant or partner to the course,
because this has been shown to reduce the incidence of
complications during the initial experience.13
Vol. 233●No. 2
Rogers and Others
Suggested Directions for Research and
More research is needed to increase our understanding of
the training needs for practicing surgeons. Improving
CMEST is an important way to reduce preventable compli-
cations. Having surgeons involved in research designed to
improve CMEST should provide evidence to the public that
the profession is committed to improving the quality of
surgical care by reducing errors.66,67
1. Evaluate the educational effectiveness of CMEST
short courses. The short courses that are currently
offered do not provide adequate training in new tech-
niques, but they are an important venue for innova-
tions in patient care. Can this format be improved so
that it may be preserved? The learning needs of prac-
ticing surgeons must be examined and the educational
impact of short courses reviewed. The goal of these
courses should be to produce surgeons who can per-
form a procedure on patients with a minimum of error.
The first area of research should be to establish pre-
dictive validity between performance on models and
performance with patients. If the predictive validity is
low, then the courses must be either improved or
eliminated. Research is needed on the effective use of
computer-based instruction. This instructional tool
should allow the simulation of pathologic states that is
not possible in animal models. This would reduce the
need for animals and might enhance the effectiveness
of transferring skills from the course to patients.
2. Develop and evaluate alternative training curric-
ula. It some cases, it may not be possible to teach a
technique in a day-long short course. Are the longer
alternatives that have been suggested11,68effective?
Are they practical for practicing surgeons?
3. Determine the feasibility of a training network. It
has been argued that CME is an obligation of aca-
demic medical centers,69and a role for such centers
has been suggested specifically for CMEST.4,70A
review of the past decade of experience with MAS
reveals that academic medical centers have been slow
to react. As technologic innovations continue to occur,
the feasibility of establishing a network of training
centers should be explored. Creating this network in
academic medical centers would create an excellent
opportunity to study the evolving learning needs of
practicing surgeons. It would also provide an excellent
opportunity for practicing surgeons to have an impact
on the training of surgical residents and medical stu-
dents by providing the perspective of surgeons outside
academic medical centers.
4. Determine which attributes of effective CME apply
to CMEST. The CME literature has identified many
course attributes that will affect physician behaviors
and improve patient outcomes. Similar work is needed
for CMEST. Some of the lessons learned from general
CME would seem applicable to CMEST. For exam-
ple, it has been shown that there is greater perfor-
mance change when all participants are from the same
practice setting.19This is thought to be true because
the local environment was enhanced when the course
participants returned to their practice setting. This
would appear to be true for CMEST as well, because
the rate of complications was reduced when the phy-
sician brought a partner to the course.13
5. Investigate ways improve the efficiency of CMEST.
Taking time away from a practice creates substantial
hardships for surgeons. What is known about produc-
ing the most efficient and effective teaching and learn-
ing of motor skills learning should be applied to
CMEST. For example, it is known that by varying the
distribution of practice, it is possible to modify the rate
of learning.33,71Enhancing the efficiency of learning
would shorten the course and reduce the time require-
ments and costs for participants.
In conclusion, this review of the first decade of MAS
experience provides several useful lessons that can be ap-
plied to improve CMEST. Perhaps the most powerful lesson
is that ample evidence has been generated showing that
there is much in common between learning a surgical skill
and other motor skills acquisition. This provides the oppor-
tunity to improve CMEST by applying what is known of
motor skills teaching. Investigation in motor skills learning
began a century ago in response to telegraphy, the techno-
logic innovation of that day.53In the same way, MAS has
drawn attention to technical skills instruction and should
provide the impetus for research that will improve CMEST
and possibly contribute to the field of motor skills acquisi-
tion in general.
1. Litynski GS. Profiles in laparoscopy: Mouret, Dubois, and Perissat: the
laparoscopic breakthrough in Europe (1987–1988). JSLS 1999; 3:163–
2. Giurgiu DI, Roslyn JL. Calculous biliary disease. In: Greenfield LJ, ed.
Surgery: Scientific Principles and Practice, 2d ed. Philadelphia:
3. Sackier JM. Evaluation of technical surgical skills. Lessons from
minimal access surgery [editorial]. Surg Endosc 1998; 12:1109–1110.
4. Cuschieri A. Reflections on surgical training [editorial]. Surg Endosc
5. Dent TL. Training, credentialling, and granting of clinical privileges
for laparoscopic general surgery. Am J Surg 1991; 161:399–403.
6. Gadacz TR, Talamini MA. Traditional versus laparoscopic cholecys-
tectomy. Am J Surg 1991; 161:336–338.
7. Zucker KA. Training issues [editorial]. Surg Laparosc Endosc 1992;
8. Rock JA, Warshaw JR. The history and future of operative laparos-
copy. Am J Obstet Gynecol 1994; 170:7–11.
9. Gates EA. New surgical procedures: can our patients benefit while we
learn? Am J Obstet Gynecol 1997; 176:1293–1299.
10. Reznick R. Let’s not forget that CME has an “E.” Foc Surg Ed 1999;
Improving Continuing Medical Education for Surgical Techniques
Ann. Surg.●February 2001
11. Morino M, Festa V, Garrone C. Survey on Torino courses. The impact
of a two-day practical course on apprenticeship and diffusion of
laparoscopic cholecystecomy in Italy. Surg Endosoc 1995; 9:46–48.
12. Wright D, O’Dwyer PJ. The learning curve for laparoscopic hernia
repair. Semin Laparosc Surg 1998; 5:227–232.
13. See WA, Cooper CS, Fisher RJ. Predictors of laparoscopic complica-
tion after formal training in laparoscopic surgery. JAMA 1993; 270:
14. Shackford SR, Rogers FB, Osler TM, et al. Focused abdominal sono-
gram for trauma: the learning curve for nonradiologist clinicians in
detecting hemoperitoneum. J Trauma Inf Crit Care 1999; 46:553–562.
15. Giuliano AE. See one, do twenty-five, teach one: the implementation
of sentinel node dissection in breast cancer. Ann Surg Oncol 1999;
16. Framework for Post-Residency Surgical Education and Training. A
SAGES Guideline. Available at: http://www.sages.org/sg_pub17.html
17. Guidelines for Granting of Privileges for Laparoscopic and/or Thora-
coscopic General Surgery. Available at: http://www.sages.org/
18. Escarce JJ, Shea JA, Schwartz JS. How practicing surgeons trained for
laparoscopic cholecystecomy. Med Care 1997; 35:291–296.
19. Umble KE, Cervero RM. Impact studies in continuing education for
health professionals. A critique of the research synthesis. Eval Health
Prof 1996; 19:148–174.
20. Davis D, O’Brien MA, Freemantle N, et al. Impact of formal continu-
ing medical education. Do conferences, workshops, rounds, and other
traditional continuing education activities change physician behavior
or health care outcomes? JAMA 1999; 282:867–874.
21. Lewis CE. Continuing medical education: past, present and future.
West J Med 1998; 168:334–340.
22. Barnes RW, Lang NP, Whiteside MF. Halstedian technique revisited.
Innovations in teaching surgical skills. Ann Surg 1989; 210:118–121.
23. Bevan PG. Craft workshops in surgery. Br J Surg 1986; 73:1–2.
24. Rosser JC, Jr., Rosser LE, Savalgi RS. Skill acquisition and assess-
ment for laparoscopic surgery. Arch Surg 1997; 132:200–204.
25. Derossis AM, Fried GM, Abrahamowicz M, et al. Development of a
model for training and evaluation of laparoscopic skills. Am J Surg
26. Derossis AM, Bothwell J, Sigman HH, et al. The effect of practice on
performance in a laparoscopic simulator. Surg Endosc 1998; 12:1117–
27. Chung JY, Sackier JM. A method of objectively evaluating improve-
ments in laparoscopic skills. Surg Endosc 1998; 12:1111–1116.
28. Anastakis DJ, Regehr G, Reznick RK, et al. Assessment of technical
skills transfer from the bench training model to the human model.
Am J Surg 1999; 177:167–170.
29. Reznick RK. Virtual reality surgical simulators: feasible but valid?
[editorial; comment]. J Am Coll Surg 1999; 189:114–127.
30. Fried GM, Derossis AM, Bothwell J, et al. Comparison of laparoscopic
performance in vivo with performance measured in a laparoscopic
simulator. Surg Endosc 1999; 13:1077–1081.
31. Rosser JC, Jr., Rosser LE, Savalgi RS. Objective evaluation of a
laparoscopic surgical skill program for residents and senior surgeons.
Arch Surg 1998; 133:657–661.
32. Ericsson KA, Charness N. Expert performance. Its structure and ac-
quisition. Am Psychol 1994; 49:725–747.
33. Lane NE. Skill Acquisition Rates and Patterns. Issues and Training
Implications. New York: Springer-Verlag; 1987.
34. Meehan JJ, Georgeson KE. The learning curve associated with lapa-
roscopic antireflux surgery in infants and children. J Pediatr Surg
35. Southern Surgeons Club, Moore MJ, Bennett CL. The learning curve
for laparoscopic cholecystectomy. Am J Surg 1995; 170:55–59.
36. Poulin EC, Mamazza J. Laparoscopic splenectomy: lessons from the
learning curve. Can J Surg 1998; 41:28–36.
37. Watson DI, Baigrie RJ, Jamieson GG. A learning curve for laparo-
scopic fundoplication: definable, avoidable or a waste of time? Ann
Surg 1996; 2:198–203.
38. Ford WD, Crameri JA, Holland AJ. The learning curve for laparo-
scopic pyloromyotomy. J Pediatr Surg 1997; 32:552–554.
39. Liem MS, van Steensel CJ, Boelhouwer RU, et al. The learning curve
for totally extraperitoneal laparoscopic hernia repair. Am J Surg 1996;
40. Meinke AK, Kossuth T. What is the learning curve for laparoscopic
appendectomy? Surg Endosc 1994; 8:371–375.
41. Cagir B, Rangraj M, Maffuci L, et al. The learning curve for laparo-
scopic cholecystecomy. J Laparoendosc Surg 1994; 4:419–427.
42. Hawasli A, Lloyd LR. Laparoscopic cholecystectomy. The learning
curve: report of 50 patients. Am Surg 1991; 57:542–544.
43. Rege RV, Joehl RJ. A learning curve for laparoscopic splenectomy at
an academic institution. J Surg Res 1999; 81:27–32.
44. Lekawa M, Shaprio SJ, Gordan LA, et al. The laparoscopic learning
curve. Surg Lapar Endosc 1995; 5:455–458.
45. Wishner JD, Baker JW, Hoffman GC, et al. Laparoscopic-assisted
colectomy: the learning curve. Surg Endosc 1995; 9:1179–1183.
46. Hunter JG, Sackier JM, Berci G. Training in laparoscopic
cholecystectomy: quantifying the learning curve. Surg Endosc 1994;
47. Soot SJ, Eshraghi N, Farahmand M, et al. Transition from open to
laparoscopic fundoplication: the learning curve. Arch Surg 1999;
48. Magill RA. Motor Learning Concepts and Applications, 4th ed.
Indianapolis: WCB Brown and Benchmark; 1993.
49. Schmidt RA. Motor Learning and Performance: From Principles to
Practice. Champaign, IL: Human Kinetics Books; 1991.
50. Ohlsson S. Learning from performance errors. Psychol Rev 1996;
51. Dewey J. Psychology and social practice. Psychol Rev 1900; 7:105–
52. Barnes RW. Surgical handicraft: teaching and learning surgical skills.
Am J Surg 1987; 153:422–427.
53. Adams JA. Historical review and appraisal of research on the learning,
retention, and transfer of human motor skills. Psychol Bull 1987;
54. Dul J, Pieters JM, Dijkstra S. Instructional feedback in motor skill
learning. PLET 1987; 24:71–76.
55. Fitts AM, Posner MI. Human Performance. Belmont, CA: Brooks-
56. Kopta JA. An approach to the evaluation of operative skills. Surgery
57. Kaufman HH, Wiegand RL, Tunick RH. Teaching surgeons to
operate: principles of psychomotor skills training. Act Neurochir 1987;
58. Weeks DL, Sherwood DE. A comparison of knowledge of results
scheduling methods for promoting motor skill acquisition and reten-
tion. RQES 1994; 2:136–142.
59. Wulf G, Shea CH, Matschiner S. Frequent feedback enhances complex
motor skill learning. J Mot Beh 1998; 30:180–192.
60. Royston CM, Lansdown MR, Brough WA. Teaching laparoscopic
surgery: the need for guidelines. Br Med J 1994; 308:1023–1025.
61. Ali J, Rozycki GS, Campbell JP, et al. Trauma ultrasound workshop
improves physician detection of peritoneal and pericardial fluid. J Surg
Res 1996; 63:275–279
62. DesCoteaux J, Leclere H. Learning surgical technical skills. Can J
Surg 1995; 38:33–38.
63. Kardash K, Tessler MJ. Videotape feedback in teaching laryngoscopy.
Can J Anaesth 1997; 44:54–58.
64. Starkes JL, Payk I, Jennen P, et al. A stitch in time: cognitive issues in
microsurgery. In: Starkes JL, Allard F, eds. Cognitive Issues in Motor
Expertise. New York: North-Holland; 1993:225–240.
Vol. 233●No. 2
Rogers and Others
65. Yamashita Y, Kuorhigi T, Kakegawa T. Evaluation of two training Download full-text
programs for laparoscopic cholecystecomy: incidence of major com-
plications. World J Surg 1994; 18:279–285.
66. Chassin MR, Galvin RW. The urgent need to improve health care
quality: Institute of Medicine national roundtable on health care qual-
ity. JAMA 1998; 280:1000–1005.
67. Concerning patient safety and medical errors: Hearings before the
Subcommittee on Labor, Health, and Human Services and Education
Committee on Appropriations, 106th Congress, First Session (Dec. 13,
1999). Available at: http://www4.nas.edu/ocga/testimon.nsf/ByTopic/
68. McKernan JB, Saye W. Laparoscopic general surgery. J Med Assoc
Ga 1990; 79:157–159.
69. Davis D, Parboosingh J. “Academic” CME and the social contract.
Acad Med 1993; 68:329–332.
70. Mansberger AR Jr. Personal thoughts on laparoscopic general surgery.
J Med Assoc Ga 1990; 79:148.
71. Snoddy GS. Learning and stability. J Appl Psychol 1926; 10:1–36.
Improving Continuing Medical Education for Surgical Techniques
Ann. Surg.●February 2001