Surgical performance can be compared to athletic performance. To master complex gross and fine motor skills is not easy. It takes long hours to perfect. Iain Yardley wrote a to The BMJ in 2013 to say that surgeons need to prepare mentally like athletes if they are to perform like athletes.
I agree with Yardley that mental visualization can lead to good results, but actual physical training needs to happen properly and regularly.
Anders Ericsson, PhD, popularized the role of deliberate practice in the acquisition of expert performance. He reported the practice habits of violin students in childhood. All had begun playing at 5 years of age with similar practice times. However, at age 8, practice times diverged. Elite performers had practiced more than the less able performers. They averaged more than 10,000 hours of practice.
At the Shouldice Clinic in the Toronto area, it takes 30 minutes to perform a hernia operation and with a recurrence rate of 1%. The secret of the clinic's success is that the 12 surgeons at Shouldice perform hernia operations and nothing else; each surgeon repairs around 800 hernias a year. This is more than most general surgeons do in a lifetime. All the repetition improves their technical skill level and their clinical outcomes.
Given these similarities, what can surgeons learn from the preparation and training of athletes?
If we closely examine the current state of surgical training, we will find that a surgical trainee will participate in ward rounds -- multidisciplinary team meetings to discuss the decision-making process, which is an extremely important part of surgical practice. But, when we examine the actual time spent in training to perform technical procedures, this is exceedingly low. Especially with limited working hours trainees do not get nearly enough time in the operating theatre. Getting a novice surgeon to become an expert, they simply need to do the time. They need to practice, practice, and then practice some more. That's how complex motor skills are developed; repetition. The structure of surgical training programs seems to ignore this obvious fact.
Simulation training is widely available but costly and infrequently effective in advancing skill level. Being told how to do a pyeloplasty in one afternoon and even completing the procedure on a well-produced 3D model of a kidney with simulated pelvi-ureteric junction obstruction does not give a trainee enough to actually perform the procedure skillfully. It is the repetition of the skill to be acquired that will advance a trainee's ability to do a procedure.
A surgical training program should dedicate protected time where trainees "hit the gym" to develop their skills. Simulation training labs should be available in every hospital that trains surgeons. This requires significant change to trainees' work schedules and to their trainers or "coaches" who will have a day packed with clinics, ward rounds, meetings, and a long surgical waiting list to go through.
Methodological technical training should be a part of surgical training rather than being sporadic and unstructured. A coach-athlete relationship and a gym where skill transfer and acquisition can happen is paramount. Simulation training is the present and the future of surgical training. A "gym for surgeons" is the way forward to develop better surgical skills, better outcomes, and ultimately guarantee patient safety.
Muhammad Ali said once: "The fight is won or lost far away from witnesses -- behind the lines, in the gym, and out there on the road, long before I dance under those lights."
Surgeons too need to win the fight in the gym, long before they dance under those operation room lights!
, MRCS, is a senior clinical fellow in pediatric urology at Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust. His special interest is reconstructive urology, especially hypospadias surgery.