Building Surgical Expertise Through Deliberate Practice

Abstract

Objective

To characterize the role of deliberate practice in the changing landscape of surgical training.

Methods

A review examining various applications of deliberate practice was conducted, with a focus on the surgical training space and utility of this methodology in otolaryngology residency.

Results

With many programs turning to simulation-based practice and other learning modalities based outside the operating room, deliberate practice is emerging as a promising method for more efficient and efficacious learning.

Conclusion

Identifying and addressing weak areas, maintaining motivation to continue to grow and reach new milestones, and continually responding to external feedback from instructors can lead to improvement in a variety of skills essential for success in surgical fields. Further implementation of deliberate practice methodology could improve surgical training at all levels.

Acquisition of Expertise Through Deliberate Practice

Are expert surgeons born or are they made? Investigators in a wide range of fields have long sought to explain the origins of mastery, and specifically to determine whether high achievement can be attributed to innate talent or dedicated effort. To answer this question, psychologists turned to the experiences of superlative performers in disciplines spanning from athletics to art to industry. Bloom et al. examined the early careers of 120 experts across a range of fields, noting that none showed any clear early indications or inherent features that could have foretold greatness. ¹ The only features that consistently predisposed experts to success were physical traits in sports, such as the significance of height in basketball stars. Studying a group of chess masters, Simon and Chase first made the claim that consistent, long-term practice—more specifically, 10,000 hours or more—was what distinguished the great chess players from the good ones. ² Psychologist K. Anders Ericsson reached a similar conclusion, conducting a study of how violinists spent their time that showed that the better musicians were practicing significantly more and participating in leisure activities less than their colleagues. ³

While investigating the stories of an array of experts, Ericsson noted a crucial distinction: experience and expertise are not one and the same. Achieving competency in a new skill typically requires at most 50 hours of effort, after which the action becomes rote and can be practiced and repeated without active engagement. Upon reaching this point, most learners will plateau (a state of “arrested development”) rather than ascend to the elite level of an expert. ⁴ To describe how select individuals overcome this stagnation, Ericsson introduced the term “deliberate practice,” contending that while hours spent practicing provide a trainee with experience, they may not be effective in helping to reach expert status if not utilized to their fullest potential. Ericsson suggested that in honing a new skill, a learner cannot simply repeat tasks with which he or she has grown comfortable. Instead, repetition must be applied to carefully selected, challenging tasks aimed at addressing the individual’s specific weaknesses. To do so, learners may break complex tasks down into smaller ones that can be practiced individually and refined. Ericsson also noted that while individual practice is beneficial, receiving immediate feedback from an instructor and incorporating that feedback into the practice plans help to further optimize the process. Finally, deliberate practice hinges on the individual’s motivation to learn and willingness to work methodically through challenges rather remaining stagnant at a comfortable level of effort. ⁵

The effects of deliberate practice have been studied in relation to nearly every form of peak performance. An investigation of the learning environments of expert musicians showed that these performers were surrounded by a wider range of instructors and band members who could offer them direct feedback, were exposed to a more diverse pool of musical compositions during training, and were thereby challenged to actively practice different styles and techniques early on. ⁶ Another study examining Gaelic rugby players demonstrated the difference in attitudes toward practice between experts and competent players, with the experts describing their practice sessions as effortful rather than enjoyable and competent players being more likely to practice drills with which they were already familiar. This non-challenging practice led to mildly improved performance in the competent players but did not support long-term retention. ⁷ A study of the effects of deliberate practice in pilot training showed that pilots who had engaged in deliberate practice for crisis flying scenario management performed significantly better in simulations of 83 common disaster scenarios. ⁸ Deliberate practice in these scenarios helped the pilots not only by allowing them to run through the decision-making processes associated with possible malfunctions but also by challenging them to do so under the pressurized conditions of a true emergency.

A Paradigm Shift in Surgical Education

In his explorations of the different skills that are or could be impacted by deliberate practice, Ericsson postulated that specific areas within the field of medicine—namely, medical diagnosis, perceptual diagnosis, and surgical performance—could benefit from the effects of deliberate practice. Given the significant challenges and changes facing the surgical training field today, standardized implementation of this model could have significant benefit moving forward.

Previously based around an apprenticeship system composed of didactic teaching followed by observation and hands-on practice in a clinical setting, surgical training is now in the midst of a decades-long transformation and reprioritization. Firstly, resident work hour restrictions, while crucial to reducing fatigue-based errors and burnout, also reduce the time available for trainees to learn by participating in cases and watching how experts handle challenging situations and complications on the spot. ⁹ Operating room time for trainees to practice and instructors to demonstrate and teach is further limited by institutions growing progressively focused on shortening procedure lengths to cut costs. A study examining four common surgical procedures performed with and without the assistance of a PGY-3 resident found that all four types of cases took significantly longer to complete when a resident was involved. ¹⁰ In another study investigating the timing of laparoscopic cholecystectomies performed with residents, operative time was found to be increased to a similar degree across all residency years, meaning that resident participation in operative procedures is costly regardless of trainee experience level. ¹¹ Finally, a growing focus on safety and outcome metrics has led to increased pressure on residents to gain proficiency in operative skills before applying them to procedures performed on live patients.

In a quality-control based system of healthcare administration, the lack of standardization and objective evaluation inherent in the apprenticeship model is no longer sustainable. While this model cannot be abolished outright, programs are increasingly turning to ways to supplement and alter the training process to expedite the development of surgical skills and redirect a large deal of learning time to environments outside of the operating room. Much as a novice tennis player’s first volley would never take place at Wimbledon and a child picking up an instrument does not stutter through her first notes on the stage at Carnegie Hall, practice and performance are typically kept separate in high-stakes, high-skill environments. It would stand to reason that medical practitioners should follow suit and develop their skills in lower stakes environs prior to initiating human dissection. This has led to an increased focus on simulations and other non-operative training modalities. However, as with all other skill acquisition settings, for simulations to have a significant impact they must be used deliberately, especially given the limited time allotted to them in busy resident schedules.

Deliberate Practice in Surgical Education

Thus far, deliberate practice has largely been used in surgical education in the setting of simulations. In a review of 17 studies investigating the effects of deliberate practice in surgical training using simulation-based programs, all 17 showed significant improvement in performance following deliberate practice. ¹² In a study of surgical residents conducting laparoscopic cholecystectomy deliberate practice using virtual reality simulation compared to a control group, 100% of participants using deliberate practice reached target quality, with only 30% of the control group attaining similar achievement. ¹³

Deliberate practice has also been used to enhance hands-on training and lead to more efficient and competent surgical care among trainees. A study of fourth year medical students learning to perform a coronary anastomosis on a porcine heart model over the course of 4 months using deliberate practice found that by the end of the study, the medical students could perform the procedure at the same level as senior general surgery residents. ¹⁴ Another study following PGY-3 ophthalmology residents introduced a novel method for teaching trainees to perform cataract surgery by breaking the procedure down into small tasks and then practicing high-difficulty skills in both the OR and simulated settings with feedback from faculty. Learners who received this training were found to be better prepared for their PGY-4 years per supervisor evaluations. ¹⁵

While deliberate practice has been shown to provide benefit in surgical training settings, it is still only being used in a limited capacity due a lack of existing infrastructure and time constraints. Self-directed deliberate practice would seem like an ideal way to fit improvement opportunities into a hectic residency schedule; however, studies where students have been given deliberate practice work to do on their own time have found that learners view these homework assignments as burdensome rather than helpful. ¹⁶ Additionally, as this is a relatively novel premise in many institutions, faculty must be trained in how to support their residents effectively before their feedback can be truly useful. One study evaluated the way in which feedback is given to residents through the lens of deliberate practice. Finding that specific gaps in the trainees’ knowledge were only highlighted in 3.9% of the feedback, the investigators suggested that acquiring more substantive feedback could better enable trainees to target their practice and eventually meet a clear “expert” level. ¹⁷

Deliberate Practice in Otolaryngology

Otolaryngology has utilized simulation as a component of training for nearly a century, with Chevalier Jackson’s “Michelle the Choking Doll” for endoscopy practice being a prominent example. ¹⁸ Given the vast range of procedure types and lack of significant exposure to otolaryngology procedures throughout undergraduate medical training at most institutions, simulations are a vital component of early residency training as PGY-1s navigate the steep learning curve. Otolaryngology is among the surgical specialties that utilize simulation-based training most broadly, with a recent meta-analysis describing over 60 different types of surgical simulators currently in use in this field. ¹⁹ However, while simulation is becoming increasingly significant in the otolaryngology residency experience, few projects have examined the use of deliberate practice using these simulations and other learning activities during training.

Several studies of mastoidectomy performance in virtual reality surgery simulation demonstrated some of Ericsson’s original points. Mastoidectomy performance has been shown to typically peak early in simulated trainings, but an investigation by SA Anderson noted that with deliberate practice, dedicated trainees pushed through the performance plateau and continued to improve. They also performed better on reassessment three months after the initial training. ²⁰ Another study found that deliberate practice with a temporal bone simulator led trainees to complete tasks faster and with a lower error rate. ²¹ Ahmed et al. examined the performance of trainees in deepening dissection at the sinodural angle on a mastoidectomy simulator under distracting conditions, finding that deliberate practice had a positive effect on multitasking capabilities and mitigation of the detrimental effects of distractors. ²²

Some of these studies have also highlighted areas for possible improvement of deliberate practice methodology in otolaryngology. One study postulated that the learning curve in novice mastoidectomy training, found by multiple groups to plateau at an inappropriately low level, was due to an inability to appropriately self-assess in learners at this level. The investigators went on to suggest that novices invested reduced mental effort in the tasks once they perceived themselves to have reached a level of proficiency. This led the investigators to conclude that a standardized tool for improving self-assessment among new trainees could help to prepare the learners to evaluate their efforts correctly and subsequently elevate their performance. ²³ Malik et al.’s investigation of cortical mastoidectomy and facial recess dissection similarly found that self-directed simulations in the lab had a negative effect on performance, again highlighting that trainees need targeted feedback if they are to continue to progress. Additionally, trainees particularly interested in otology were found to have three times greater competency in the simple mastoidectomy tasks and ten times greater competency in difficult tasks than their peers with no specific enthusiasm for this field, reinforcing the idea that motivation and interest are key to mastery. ²⁴ Fostering this motivation through mentorship and faculty interactions could therefore lead to improved performance in virtually any task.

Avenues for Further Implementation

Moving forward, integrating deliberate practice more formally into otolaryngology residency could help to improve outcomes, reduce financial burden, and expedite the skill-acquisition process in training. Otolaryngologists operate in four modalities: open surgery, endoscopic surgery, microscopic surgery, and robotic surgery. At the University of Pittsburgh Medical Center, a deliberate practice curriculum has been implemented to increase competence in otolaryngology trainees quickly from the beginning of their residency, with task trainers and skills assessments for each of these modalities.

At the start of intern year, new residents all participate in a one-month deliberate practice rotation, involving 2 hours of surgical simulation skills teaching with a faculty instructor. This period of training, which relies heavily on simulation using 3D-printed models and other practice modalities, helps to establish the foundations of operative skills that would otherwise be learned in the operating room. By starting residency with this dedicated practice time, learners can enter the operating room with some experience behind them, making the learning that subsequently takes places in the operating room more efficacious and productive. This system aims to combat the learning plateau and expedite the process of gaining true competency. Implementation of this type of dedicated deliberate practice time early in residency across other programs should help to standardize the level of training in the field while also making the training process more efficient. Additionally, continuing with regular deliberate practice throughout the following years of training could help to hone existing skills and build new ones as residents progress through their training.

Elite athletes and world-class musicians never stop practicing. If they wish to continue performing at the highest level, they must continue to grow their skillset and strive to reach the next goal. Similarly, surgeons cannot achieve or maintain mastery without regular, life-long deliberate practice outside of the operating room. Thus, the application of these deliberate practice principles can and should continue beyond resident and fellow training and into the realm of faculty development and continuing medical education.

Though it may be difficult for experienced surgeons to find instructors to provide feedback, Ericsson noted that as people approach expert status, they are more capable of providing self-guidance. As such, at-home deliberate practice should be feasible in this demographic. Additionally, there is an emerging field of surgical coaching that may be utilized by surgeons to provide each other with feedback on their performance through post hoc review of surgical videos.

For surgeons of all levels, great skill is not innate. It is the product of hard work channeled into deliberate practice that enables one to push past the plateau of competency and to truly pursue mastery.