Practice Makes Perfect? The Role of Simulation-Based Deliberate Practice and Script-Based Mental Rehearsal in the Acquisition and Maintenance of Operative Neurosurgical Skills

Neurosurgery (Impact Factor: 3.62). 01/2013; 72:A124-A130. DOI: 10.1227/NEU.0b013e318270d010


Despite significant advances in technology and intraoperative techniques over the last century, operations on the brain and spinal cord continue to carry a significant risk of serious morbidity or mortality. Potentially avoidable technical errors are well recognized as contributing to poor surgical outcome. Surgical education is undergoing overwhelming change, in part as a result of changes in the economic, political, social, cultural, and technological climates in which it operates. Shortened training, reductions in the working week, economic difficulties, and increasing emphasis on patient safety have required educators to radically rethink the way in which surgical education is delivered. This has resulted in the development of simulation technology, mental script-based rehearsal, and simulation-based deliberate practice. Although these tools and techniques are garnering increasing evidence for their efficacy, the evidence for their use in neurosurgery is somewhat more limited. Here, we review the theory behind these tools and techniques and their application to neurosurgery. We conclude that further research into the utility of these tools and techniques is essential for determining their widespread adoption. If they ultimately prove to be successful, they may have a central role in neurosurgical training in the 21st century, improving the acquisition of technical skills in a specialty in which a technical error can result in grave consequences. ABBREVIATION: LC, laparoscopic cholecystectomy

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    • "Although the development of expertise had been studied extensively in disciplines such as athletics, music, and other arts for some time, it is only within the last few years that its value has become increasingly recognized within the medical com- munity [5, 6]. Many fields such as internal medicine, emergency medicine, and general surgery have studied the importance of deliberate practice in transforming learners into experts, but little has been published regarding its role in creating expert orthopedic surgeons [4,91011. If the goal of orthopaedic residency programs continues to be the graduation of qualified and skilled orthopaedic surgeons in this era of reduced work hours, then the overall quality of each of those hours is critically important. "
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    ABSTRACT: Although much attention has been paid to the role of deliberate practice as a means of achieving expert levels of performance in other medical specialties, little has been published regarding its role in maximizing orthopaedic surgery resident potential. As an initial step in this process, this study seeks to determine how residents and program directors (PDs) feel current time spent in training is allocated compared with a theoretical ideal distribution of time. According to residents and PDs, (1) how do resident responsibilities change by level of training as perceived and idealized by residents and PDs? (2) How do resident and PD perceptions of current and ideal time distributions compare with one another? (3) Do the current training structures described by residents and PDs differ from what they feel represents an ideal time allocation construct that maximizes the educational value of residency training? A survey was sent to orthopaedic surgery resident and PD members of the Midwest Orthopedic Surgical Skills Consortium asking how they felt residents' time spent in training was distributed across 10 domains and four operating room (OR) roles and what they felt would be an ideal distribution of that time. Responses were compared between residents and PDs and between current schedules and ideal schedules. Both residents and PDs agreed that time currently spent in training differs by postgraduate year with senior-level residents spending more time in the OR (33.7% ± 8.3% versus 17.9% ± 6.2% [interns] and 27.4% ± 10.2% [juniors] according to residents, p < 0.001; and 38.6% ± 8.1% versus 11.8% ± 6.4% [interns] and 26.1% ± 5.7% [juniors] according to PD, p < 0.001). The same holds true for their theoretical ideals. Residents and PDs agree on current resident time allocation across the 10 domains; however, they disagree on multiple components of the ideal program with residents desiring more time spent in the OR than what PDs prefer (residents 40.3% ± 10.3% versus PD 32.6% ± 14.6% [mean difference {MD}, 7.7; 95% confidence interval {CI}, 4.4, 11.0], p < 0.001). Residents would also prefer to have more time spent deliberately practicing surgical skills outside of the OR (current 1.8% ± 2.1% versus ideal 3.7% ± 3.2% [MD, -1.9; 95% CI, -.2.4 to -1.4], p < 0.001). Both residents and PDs want residents to spend less time completing paperwork (current 4.4% ± 4.1% versus ideal 0.8% ± 1.6% [MD, 3.6; 95% CI, 3.0-4.2], p < 0.001 for residents; and current 3.6% ± 4.1% versus ideal 1.5% ± 1.9% [MD, 2.1; 95% CI, 0.9-3.3], p < 0.001 for PDs). Residents and PDs seem to agree on how time is currently spent in residency training. Some differences of opinions continue to exist regarding how an ideal program should be structured; however, this work identifies a few potential targets for improvement that are agreed on by both residents and PDs. These areas include increasing OR time, finding opportunities for deliberate practice of surgical skills outside of the OR, and decreased clerical burden. This study may serve as a template to allow programs to continue to refine their educational models in an effort to achieve curricula that meet the desired goals of both learners and educators. Additionally, it is an initial step toward more objective identification of the optimal educational structure of an orthopaedic residency program.
    Full-text · Article · Mar 2015 · Clinical Orthopaedics and Related Research
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    • "Without exception , these studies demonstrate consistent and robust improvements in clinical performance based on deliberate practice principles. Simulation-based deliberate practice studies in medicine versus nursing are also more likely to use research designs that include preintervention baseline measurement and comparison groups (Kessler, Auerbach, Pusic, Tunik, & Foltin, 2011; Marcus, Vakharia, Kirkman, Murphy, & Nandi, 2013; McGaghie et al., 2011). "
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    ABSTRACT: The purpose of this study was to establish the efficacy of a deliberate practice intervention designed to enhance levels of clinical performance in senior baccalaureate nursing students.MethodA randomized control design was used. Forty participants were randomly assigned to control and intervention groups.ResultsThe deliberate practice-based intervention resulted in statistically significant improvements to key aspects of participants' efforts in each of the four scenarios.Conclusions The deliberate practice protocol prompted participants to reconsider and act on salient stimuli present in the simulated task environment, resulting in substantive performance improvement.
    Full-text · Article · Nov 2014 · Clinical Simulation in Nursing
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    ABSTRACT: The purpose of this study was to evaluate the accuracy of ventriculostomy catheter placement on a head- and hand-tracked high-resolution and high-performance virtual reality and haptic technology workstation. Seventy-eight fellows and residents performed simulated ventriculostomy catheter placement on an ImmersiveTouch system. The virtual catheter was placed into a virtual patient's head derived from a computed tomography data set. Participants were allowed one attempt each. The distance from the tip of the catheter to the Monro foramen was measured. The mean distance (+/- standard deviation) from the final position of the catheter tip to the Monro foramen was 16.09 mm (+/- 7.85 mm). The accuracy of virtual ventriculostomy catheter placement achieved by participants using the simulator is comparable to the accuracy reported in a recent retrospective evaluation of free-hand ventriculostomy placements in which the mean distance from the catheter tip to the Monro foramen was 16 mm (+/- 9.6 mm).
    Full-text · Article · Oct 2007 · Journal of Neurosurgery
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