Many consultants of today learnt their skills by volume by ‘practicing’ on patients. Basic Surgical Skills were acquired and rarely taught. Many a trainer, when asked how they executed a specific task will not be able to deconstruct the actions into set up, posture, instrument handling, angles etc. They will when it is explained i.e. the tacit is made explicit. Surgery is a motor skill that has to be learnt through practice. The acquisition of motor skills and the principles are well documented especially in sport. The theory and practice of coaching all athletes at every level involves an understanding of the fundamentals of movement and ergonomics.
The handling of instruments and the passage of the needle through the tissue can be explained in a similar way – this theory has been published and the success of this teaching is realised over sixteen years delivering critically acclaimed courses – PAR Excellence and PAR Aorta courses. The feedback from trainees includes “I wish I was taught this earlier!” and “why hasn’t anyone explained this to me before!”
The time it takes an expert surgeon and a trainee to deliver a needle through the tissue is the same for a single pass “systole”– but the difference between the expert and the trainees becomes obvious when examining the time it takes to set up to take the second stitch “diastole”. The diastolic time is reliant on the ergonomics of the setup, posture, positioning and handling of the instruments – these skills are tacit for the expert surgeon and have been honed by volume and time. For the trainee, this aspect can be explained and taught in educational terms as largely due to ‘Negative Passive behaviours’ of ‘not doing what should be done’. Have you ever wondered why a good operation appears as smooth; it because the diastolic period is minimized and the surgeon makes it look easy because they have attended to the setup, their posture, address to the table and angles i.e. all the negative-passive behaviours. These are poorly explained, taught or realised by the trainee or trainer alike but can be understood and more importantly practiced and rehearsed on low fidelity systems at home.
You will observe that most skills workshops have trainees seated on fixed chairs operating at tables – this is not optimising the functional anatomy of the upper limb and cannot be further from the movements and understanding of the ergonomics required to effect a smooth action at the operating table where we are standing. Those disciplines that do sit to operate undoubtedly have a stool that is on wheels and goes up and down. The stools can move through three dimensions. It is not fixed. We are training our surgeons incorrectly. Moreover, we do not offer a framework of understanding or provide models for deliberate practice.
The practice of surgery like all sports requires the application of the same principles. It is important to deconstruct the movements and explain ergonomics required to achieve the action. It is this understanding and rehearsal or these movements that will cultivate and reinforce a motor memory resulting in a reduction in the diastolic time of an operation and a smooth transition between actions.
The 10 000 hours needed to become an expert can be helped in the early stages of training with deliberate practice and observation by a skilled trainer.
These simple principles have been employed in the instruction of the martial arts for thousands of years. The power and flow is achieved with an attention to the practice of the deconstructed movements; the first skill is to master correctness.