Ann. Pak. Inst. Med. Sci. 2012; 8(4): 205-206

Famous general surgeon Sir William Halsted introduced German-style residency training system with an emphasis on graded responsibility at Johns Hopkins Hospital in 1889.¹ He believed in an apprenticeship model of training where ‘see one, do one and teach one’ approach of training was used to develop skills in surgical practice. This system remains the cornerstone of surgical training in number of countries especially in the third world. However, advances in educational theory, as well as mounting pressures in the clinical environment, have led to questions about the reliance on this approach to teaching procedural/ technical skills. Those pressures include a move toward a shorter workweek for residents and an emphasis on operating room efficiency, both of which diminish teaching time. The increasing complexity of cases and a greater emphasis on mitigating medical error limit a faculty’s latitude in assisting residents with technical procedures.

A procedural/technical skill involves performing a procedure, which is a sequence of activities to achieve a goal. Synonyms include method, technique, skill, and rule (sometimes). A procedure can be either of two types:

• A physical procedure, which entails the execution of physical movements, like performing a lumbar puncture.
• A mental procedure, which entails the execution of mental operations, like recalling the steps of lumbar puncture.
• In actual practice , most procedures are a combination of physical and mental activities. A key aspect of the practice of surgery is the ability to perform practical procedures efficiently and safely.

These new training techniques and approaches are based on established theories of the ways in which motor skills are acquired and expertise is developed.

Here three important approaches are described

Fitts and Posner’s three-stage theory of motor skill acquisition is widely accepted in both the motor skills literature and the surgical literature.² In the cognitive stage, the learner intellectualizes the task; performance is erratic, and the procedure is carried out in distinct steps. For example, with a surgical skill as simple as tying a knot, in the cognitive stage the learner must understand the mechanics of the skill —how to hold the tie, how to place the throws, and how to move the hands. With practice and feedback, the learner reaches the integrative stage, in which knowledge is translated into appropriate motor behavior. The learner is still thinking about how to move the hands and hold the tie but is able to execute the task more fluidly, with fewer interruptions. In the autonomous stage, practice gradually results in smooth performance. The learner no longer needs to think about how to execute this particular task and can concentrate on other aspects of the procedure.

Frank and Nuth³ pioneered a nine step approach where first six steps are for trainer and last three for the learner. These include,.

Trainer,

1. Assesses the prior knowledge of the learner, 
2. Checks the Basic Concepts, 
3. Asks about the Contraindications/ Complications of the procedure, 
4. Demonstrates the Procedure, 
5.  Explains and Breakdown the Steps, 
6. Gives  Feedback/ Answer Questions ,

Learner,

7. Explains and verbalizes Steps,
8.  Demonstrates the Procedure, 
9.  Gives feedback on performance.

They recommended following Educational models for training and assessment

• Volunteers
• Mannequins/ Models
• Mannequins with simulated patient
• Cadaver/Animal laboratories
• Simulators
• Newly Dead

They also identified following Learner problems

1. fine motor coordination
2. Inadequate description: not paid attention, too much time lapse
3. Imprinting incorrect performance
4. Improper feedback
5. Affective factors: fear, anxiety, sense of skill irrelevance
6. Inaccurate learner perception of performance

McLeod⁴ has given seven principles for teaching procedural and technical Skills.

• Plan ahead, Review performance objectives, Assess learners needs, Assure that the learner has prepared (e.g., through lecture, discussion, visualization, CDs, books)
• Demonstrate the procedure, Make explicit commentary during the demonstration
• Allow for questions or interruptions
• Observe the learner in action and allow for practice. Ask the learner to verbalize what he/she is doing. Encourage self-assessment and reflection
• Provide feedback
• Be specific and descriptive; ensure feedback is nonjudgmental and performance-based
• Encourage learners’ self-assessment of perceived level of skill, perceived areas requiring improvement
• Allow for practice under less-than-ideal conditions and ensure varying degrees of complexity
• Prepare to modify approach for the unprepared learner at different learning sites that is ‘‘Opportunistic’’ learning and teaching.

Gaining proficiency at technical skills is an essential component of surgical training. Many programs still rely on the traditional apprenticeship model to accomplish this goal. This type of instruction is widely variable and critically dependent on the supervising physician. In addition, this method does not guarantee adequate exposure to all essential skills. Other programs have developed technical skill checklists to help teach and evaluate procedures and attempt to provide a standardized curriculum. Usually, these check-lists focus primarily on the execution of the skill with little or no regard to the underlying decision errors that may be made along the way.⁵

The current best evidence for a gold standard for assessment of procedural skills in surgery consists of a combination of previously validated checklists and global rating scales, used prospectively by a trained observer, for a procedure performed in an actual patient. These can be used in OSCE, OSATS, TOACS and OSTE and also in real settings.

Future research should include core assessment parameters to ensure methodological rigor and facilitate robust comparisons with other studies. These include (i) reliability, (ii) validity, (iii) feasibility, (iv) cost effectiveness, and (v) comprehensiveness with varying levels of difficulty. Simulation may become a key part of the future of formative and summative skills assessment in surgery; however, research is required to develop and test simulators that are realistic enough to be suitable for use in high-stakes evaluation.^6,7

References

1. Carter BN. The fruition of Halsted’s concept of surgical training. Surgery 1952;32:518-27.
2. Fitts PM, Posner MI. Human performance.Belmont, CA: Brooks/Cole, 1967.
3. Jason Frank and Janet Nuth, Teaching procedural skills . Online presentation 2013.Dept of Emergency Medicine, University of Ottawa
4. Peter J. McLeod, MD, Y. Steinert, PhD, J. Trudel, MD, and R. Gottesman, MD Seven Principles for Teaching Procedural and Technical Skills Acad. Med. 2001;76:1080.
5. Miller M. Education, training and proficiency of procedural skills. Primary Care Clinics in Office Practice. 1997;24:231–41. ,/
6. Reznick R, Regehr G, MacRae H, Martin,J, McCulloch W. Testing technical skill via an innovative “bench station” examination.Am J Surg 1997;173:226-30.
7. Richard K. Reznick, M.D., M.Ed., and Helen MacRae, M.DN Teaching Surgical Skills —Changes in the Wind.N  Engl J Med 2006;355:2664-9.