The Effect Of Deliberate Practice On Surgical Skills And Technical Proficiency

Effect of Deliberate Practice on Surgical Skills

Question:

Discuss about the Deliberate Practice Improves Clinical Performance.

Deliberate practice related to any skills is used to refer to a special kind of practice that is systematic and purposeful. Regular practice of any task involves mindless repetitions. However, practicing a task deliberately requires more attention and focus. Its main goal is performance improvement. It helps in maximizing the potential by turning the former into reality. Surgery refers to medical specialties that utilize operative instrumental and manual techniques upon a patient and investigates any serious pathological condition to improve body functioning (Hambrick et al., 2014). Deliberate clinical practice fosters surgical skills by motivating learning, providing detailed feedback and refinement opportunities. This report will include a literature review that will illustrate the effect of deliberate practice in enhancing surgical skills and technical proficiency.

The overall purpose of the literature review is to investigate the effects of deliberate practice results in enhanced technical performance in an operation theatre. The research studies were selected from databases like CINAHL, MEDLINE and SCOPUS. The inclusion criteria included peer reviewed journals, published in English not before 2012. Studies published prior to 2012 were excluded. One study conducted by Palter & Grantcharov, (2014) used a blinded randomized trial to assess the effects of deliberate practice on surgical skill improvements. 16 novice surgical residents were recruited to a deliberate practice group and conventional training group. A video recording of laparoscopic cholecystectomy was done for both the groups. 3 assessment tools measured the technical performance of the residents. The trainees practiced a task again if the scores were less than 60%. It was found that DP residents showed improved technical skills post intervention (17.0 median score). Another study that assessed the effect of deliberate practice on expert surgical performance recruited 15 junior residents and the practice group was given 30 minutes of practice sessions between laparoscopic surgeries while, the control group read journals or viewed educational videos. On comparing the performance using Mann-Whitney U test and Wilcoxon signed rank test it was found that the DP group showed increased surgical performance in procedure-specific rating scale and global scale. However, the control group did not show any significant improvement in procedure-specific rating scale. This study provided evidence for the improvement in LC performance over many sessions (Hashimoto et al., 2015). A randomized controlled trial was conducted to evaluate the effect of virtual reality training on laparoscopic surgery that included 32 trainees who did not have any experience of laparoscopic surgery. Proficiency based virtual reality simulation training was used as the intervention. Laparoscopic salpingectomy training was provided to the participants and the controls were subjected to standard education. On measuring the technical performance, the simulator trained group showed a better median score of 33 points while, the control group reached a score of 23 points. This study established that virtual reality simulator training increases proficiency in laparoscopic surgery (Larsen et al., 2012).

Literature Review on the Effect of Deliberate Practice

Another study compared the effect of OSATS (Objective Structured Assessment of Technical Skills) on the performance of two gynecology and obstetrics resident groups. Some postgraduate students who underwent focused and deliberate training in hysteroscope assembly and operative hysteroscopic polypectomy performed better when compared to the untrained residents. Their global skills cores, resection and assembly time scores significantly improved (Rackow et al., 2012). The effect of virtual reality training on improvements of ear, nose and throat surgery was demonstrated by a study that used computer generated imagery as the simulated training environment. A randomized control trial included 210 participants and showed that virtual reality group performance significantly increased and displayed better psychomotor score (mean difference -1.66, 95% CI 0.52-2.81; 10-point scale) and shorter time to complete the operation (mean difference-5.50, 95% CI 9.97-1.03). One particular study showed that medical students who acquire anatomical knowledge by virtual training perform better during surgeries than those who participate in conventional training (mean difference- 4.3, 95% CI 2.05-6.55) (Piromchai et al., 2012). A meta-analytic comparative review assessed the effect of simulation-based medical education (SBME) and traditional clinical education on skill acquisition. The results showed that SBME with deliberate practice is more consistent and powerful. SBME proved superior when compared to traditional clinical education for acquiring a wide variety of medical skills.  The study proved that a laparoscopic surgery, advanced cardiac life support, hemodialysis catheter insertion, cardiac auscultation, central venous catheter insertion and thoracentesis improves when residents participate in deliberate practice (McGaghie et al., 2014).

A study conducted by Yudkowsky et al., (2013) evaluated the impact of simulation-based practices on virtual brains on the performance of neurosurgery residents in live and simulated neurosurgical procedures like ventriculostomies. CT scans were used to prepare a library of 15 virtual brains for haptic simulator, ImmersiveTouch system and head and hand-tracked augmented reality. Linear mixed model was used to analyze the performance of the residents on novel brains in the simulator and before and after surgery following intervention was analyzed. Live procedure outcomes and simulator cannulation rates showed an increase after intervention and improved procedural skills. Improved performance among 4^th year medical students compared to senior surgery residents was displayed by a study that assessed the impact of deliberate practice dedicated instruction coronary anastomosis proficiency using a porcine heart model. The participants were compared to non-simulator trained senior surgery residents. Deliberate practice methodology was used for 4 months and the respondents were filmed during anastomosis by three cardiac surgeons. The median combined final scores suggested focused simulator training improves technical proficiency compared to real-time training (Nesbitt et al., 2013). Improvement of subarachnoid block performance on simulation based deliberate practice was measured by a study. Half of 21 residents were randomized to receive deliberate practice that included expert guidance, repetition and real-time feedback. The subarachnoid performance of residents was tested on the next three patients in the operation theatre. It was found that the intervention group showed significant improvement benefits from the deliberate practice training (Udani et al., 2014).

The Benefit of Virtual Reality Simulation and Deliberate Practice Methodology

Drawing inferences from the literature search it can be stated that medical professionals need to continuously learn to deliver superior quality of health care. Life long learning, involves continuous scrutinizing and building of real-time practice, which helps doctors to improve their skills. Medical schools do not prepare a resident doctor completely for the challenging tasks, responsibilities and long work hours at operation theatres. The fittest doctors survive by learning from deliberate practice and implementing the learned outcomes while performing surgeries. On the other hand, doctors who are not exposed to simulation based training fail to learn new aspects of medicine and often become mentally and physically exhausted.  This causes dissatisfaction, surgical errors and burn out. The current restrictions imposed on working hours, shorter hospital stay, changes in organization of healthcare and breakdown of medical firms make the situation even worse and necessitate efficient learning from practice (Macnamara, Hambrick & Oswald, 2014). Deliberate practice acts as a highly structured training. It explicitly directs improvement of performance in particular surgical domains.  Such practices involve rigorous assessment of skills, repetitive performance related to psychomotor and cognitive skills, providing regular feedback and their implications on better skill performance. The specific tasks are designed in such a way that they assist in overcoming weaknesses. The performances after the training carefully monitored, generally using video recordings. This provides cues to the doctors to identify their drawbacks and achieve further improvement.

Thus, it can be stated that deliberate practice is not just a mindless repetition of certain medical tasks. However, they associate training to a focused approach and motivate the participants to reach a well-defined goal.  Results from several research studies indicate that high fidelity simulation mechanisms contribute to the development of novice junior medical practitioners to experts during their undergraduate training in medicine. This leads to effective performance. Real world exposure to wide range of surgical procedures may give the doctors an idea of the events and challenges that might occur inside an operation theatre (Ericsson, 2015). However, inadequate training may affect patient safety while participating in complicated surgeries. Virtual simulation based environment therefore serve as an effective tool for training. They reduce chances of failure or life-threatening risks.  It can be deduced from the study results that such practice trainings reduce the number of surgical errors and enhance the rate of skill acquisition. Moreover, it helps healthcare practitioners to improve their planning strategies based on the experiences and shortcomings they encountering while practicing surgery in a simulated environment.

Conclusion

It not only helps novices and trainees who lack adequate experience in real-time surgical context, but also assists experienced and professional surgeons to acquire more exposure to new surgical procedures and become adept at learning new technologies before they can be implemented on a patient in an operation theatre. It can be deciphered from the research studies that have been conducted that practicing surgical activities attributes to an increase in focus and awareness among students on the desired outcomes of the surgical intervention. This significantly enhances effectiveness of the practice (Weller et al., 2012). Thus, the medical surgeons are able to refine their performance by utilizing these aspects of deliberate practice. On interpreting the results if the research studies it can be concluded that the junior surgeons gradually learn to make efficient use of their time, resources and energy while practicing in a virtual hospital setting.

Routine practice is not just enough to enable the surgeons to gain better expertise. The progress of surgeons also depends on their sustained efforts to enhance their performance by identifying the specific targets that need improvement. Though, construction of a fully immersive virtual operation theatre environment can be expensive, the advancements that they produce in learning of surgical techniques are quite significant when compared to common training methods. Hence, it can be concluded that clinical skill development can be facilitated by making junior surgeons equipped with surgical skills through deliberate practice and not just by experience.

References

Ericsson, K. A. (2015). Acquisition and maintenance of medical expertise: a perspective from the expert-performance approach with deliberate practice. Academic Medicine, 90(11), 1471-1486.

Hambrick, D. Z., Oswald, F. L., Altmann, E. M., Meinz, E. J., Gobet, F., & Campitelli, G. (2014). Deliberate practice: Is that all it takes to become an expert?. Intelligence, 45, 34-45.

Hashimoto, D. A., Sirimanna, P., Gomez, E. D., Beyer-Berjot, L., Ericsson, K. A., Williams, N. N., … & Aggarwal, R. (2015). Deliberate practice enhances quality of laparoscopic surgical performance in a randomized controlled trial: from arrested development to expert performance. Surgical endoscopy, 29(11), 3154-3162.

Larsen, C. R., Oestergaard, J., Ottesen, B. S., & Soerensen, J. L. (2012). The efficacy of virtual reality simulation training in laparoscopy: a systematic review of randomized trials. Acta obstetricia et gynecologica Scandinavica, 91(9), 1015-1028.

Macnamara, B. N., Hambrick, D. Z., & Oswald, F. L. (2014). Deliberate practice and performance in music, games, sports, education, and professions: A meta-analysis. Psychological science, 25(8), 1608-1618.

McGaghie, W. C., Issenberg, S. B., Barsuk, J. H., & Wayne, D. B. (2014). A critical review of simulation?based mastery learning with translational outcomes. Medical Education, 48(4), 375-385.

Nesbitt, J. C., St Julien, J., Absi, T. S., Ahmad, R. M., Grogan, E. L., Balaguer, J. M., … & Putnam, J. B. (2013). Tissue-based coronary surgery simulation: medical student deliberate practice can achieve equivalency to senior surgery residents. The Journal of thoracic and cardiovascular surgery, 145(6), 1453-1459.

Palter, V. N., & Grantcharov, T. P. (2014). Individualized deliberate practice on a virtual reality simulator improves technical performance of surgical novices in the operating room: a randomized controlled trial. Annals of surgery, 259(3), 443-448.

Piromchai, P., Avery, A., Laopaiboon, M., Kennedy, G., & O’Leary, S. (2012). Virtual reality training for improving the skills needed for performing surgery of the ear, nose or throat. status and date: New, published in, (11).

Rackow, B. W., Solnik, M. J., Tu, F. F., Senapati, S., Pozolo, K. E., & Du, H. (2012). Deliberate practice improves obstetrics and gynecology residents’ hysteroscopy skills. Journal of graduate medical education, 4(3), 329-334.

Udani, A. D., Macario, A., Nandagopal, K., Tanaka, M. A., & Tanaka, P. P. (2014). Simulation-based mastery learning with deliberate practice improves clinical performance in spinal anesthesia. Anesthesiology research and practice, 2014.

Weller, J. M., Nestel, D., Marshall, S. D., Brooks, P. M., & Conn, J. J. (2012). Simulation in clinical teaching and learning. Med J Aust, 196(9), 594.

Yudkowsky, R., Luciano, C., Banerjee, P., Schwartz, A., Alaraj, A., Lemole Jr, G. M., … & Bendok, B. (2013). Practice on an augmented reality/haptic simulator and library of virtual brains improves residents’ ability to perform a ventriculostomy. Simulation in Healthcare, 8(1), 25-31.