Cognitive simulation may help shorten surgical learning curve

Issue: February 2016

ByDanny Ryan, MA, MB BChir (Cantab), PGCME, FRSA, MRCSEng, MFSTEd, MacadMEd

Editor’s note: In this article, a member of the FORTE organization discusses some advantages orthopaedic surgeons in-training may experience when they use cognitive simulation. Look for more articles from FORTE members in future issues of Orthopaedics Today Europe.

The landscape of surgical training is constantly shifting. Although the days of “see one, do one, teach one” are firmly entrenched in the past, reduced working hours and increased rates of litigation have created an environment where experience can be hard to accumulate.

Simulation training, for practice away from patients, has been proposed as a solution to this deficit, and can take many forms: from cadaveric dissection, to the development of life-like synthetic materials, to computer-based virtual reality simulators and multi-million euro reality simulation suites. However, few orthopaedic trainees are in the privileged position to be able to afford such systems at these high costs and to have the time to access these facilities along with our trainers. In fact, even when access to high-fidelity simulators is possible, sometimes these have been found to have a negative impact on performance. Therefore, cognitive simulation provides a more affordable way to shorten the learning curve in surgery.

Understand cognitive simulation

Cognitive simulation is a mental technique that does not suffer from the problems of physical simulators. It is available 24 hours a day, requires no financial sponsorship and can be used for any situation. Based on elements of sports psychology used to achieve and maintain peak performance, it is the multi-sensory creation, or re-creation, of an experience, in the absence of external stimuli.

Cognitive simulation goes further than just visualizing an experience, such as an operative procedure, because it combines all the sensory modalities to develop the feel of the experience: the sight, the sounds, the movement. Strong evidence from sport supports how psychomotor skills are enhanced through mental practice, and it is this area that offers the greatest potential benefit to surgeons. As they seek perfection in their sport, athletes will physically and mentally practice actions thousands of times; yet surgeons, whose motor actions are far finer and more varied, do so to a lesser extent and mainly focus on the practical aspect of the action.

It is well established that merely thinking about a movement can generate the same nerve impulses that occur during the action itself, resulting in more refined synaptic efficiency. Thus, combining the sensory recreation of a procedure with the kinaesthetics of the requisite actions can have the same effect as actually performing the procedure. In this way, that combined activity becomes a powerful tool for transferring mental practice to physical results via reinforcement of neural pathways.

Mirrors step-wise aspects of surgery

As with all skills, cognitive simulation requires practice. A good starting point is making yourself aware of your senses during a procedure, from the feel of the instruments in your hands, to the sound of the drill and the smell of the cautery. Some people may be able to conjure up these sensations easily, but for others, it may require effort and deliberate practice at first. It can help to begin with simple, everyday experiences, such as eating an apple. Close your eyes and recall the smoothness of the skin, the sweet smell, the juicy crunch as you bite into it. Can you taste it?

For trainees, cognitive simulation fits nicely into the step-wise manner in which surgical procedures are learned. Rather than learning from a verbal or written list, someone in training may dramatically shorten the learning curve by vividly recreating each step in his or her mind with the sensory stimuli, as if performing it for real.

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Studies show improved performance

Studies that involve medical students and surgeons with all levels of skill have shown there is a clear benefit of combined mental and physical practice vs. physical practice alone for improving the overall quality of performance. Results from a recent randomized control trial, in which participants in the intervention group used a mental ‘script’ with sensory cues for a procedure, showed that blinded assessors rated the performance of the intervention group during the procedure significantly higher than that of the control group.

A cognitive walkthrough done prior to operative procedures also can be of benefit, in the same way an athlete will imagine his or her performance before an event. This highlights the practical application of cognitive simulation as both practice and preparation. While some individuals who are considered “experts” use the technique more often and produce qualitatively better imagery, frequent practice has been shown to help novices develop their imagery ability. Once the ability has been developed, it is possible to recreate situations to acquire, maintain and improve skills, as well as create new scenarios that allow for transfer of skills, correction of errors and more variation in ability. Cognitive simulation also can help reduce stress through its mental readiness and psychophysiological changes.

Summary

Cognitive simulation, in conjunction with traditional aspects of physical practice, has a wealth of potential benefits in training. It is free, personalized, can be done anywhere, requires no extra facilities, is applicable to any situation, aids with stress management, and can improve learning and advancement of skills. As with all tools, the outcomes will only be as good as the application, and this method must be practiced to yield the best results. Fortunately, that practice can be performed anywhere, with a great level of detail.

Psychologically, athletes have been ahead of surgical training for years, given their more complex skill set, the subtler motor control required for athletic activities and the high-level performance they deliver on a more consistent basis. Therefore, it is about time orthopaedic surgery trainees took advantage of athletes’ way of thinking and training.

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For more information:
Danny Ryan, MA, MB BChir (Cantab), PGCME, FRSA, MRCSEng, MFSTEd, MacadMEd, can be reached at 6 The Hendre, Overton Park Road, Cheltenham, Gloucestershire, United Kingdom GL50 3BW; email: danny.ryan@cantab.net.

Disclosure: Ryan reports no relevant financial disclosures.