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Finding The Best Strategy for Surgical Skills Acquisition and Retention: A Neuroscience Perspective

Finding The Best Strategy for Surgical Skills Acquisition and Retention: A Neuroscience Perspective



by Marcel Martin, M.D.


Simulation is a good technique to learn skills, but retention of these skills could be improved by the use of adjuvant techniques. A huge gap seems to remain in our understanding of simulation and skills retention. For example, the optimal relationship between patient outcome and the effect of simulation has not yet been clearly established in translational medicine [1].

This knowledge gap has catched the interest of the neuroscience and computational science communities. Recently, Lensjø helped understand the balance between inhibition and stimulation of neuroplasticity [2]. Researchers are now looking for the best strategy to use neuromodulation for cognition, which requires basic understanding of neuroplasticity. This multidisciplinary approach has the potential to generate new and efficient techniques to improve skills retention.

Pugh [3] recently suggested that error management [4] can also be taught in simulation and that sensor technology [5] should be added in an holistic model of surgical expertise. Simulation alone is not the optimal solution anymore. Obtaining a maximal effect on patient outcome with the use of simulation requires an adapted use of technology-enhanced simulation, as well as a strategic use of neuromodulation. Adjuvants and enhancers should be added using an adapted strategy based on learning style and needs.

I think surgical and ER expertise can be obtained and maintained using a holistic model, including pre-, intra- and post-simulation periods, and involving the use of so-called “neuro-enhancers” tools and Technology-Enhanced Education (TEE). The pre-simulation step is a combination of cognitive task analysis, script concordance for decisions, and debriefing over videos of action captured in the OR, ER or ICU. These activities, done in preparation to simulation, involve the trainee and trainer analysing together movement decompositions and decision processes. At simulation time, the same action is practiced physically and mentally on the simulator by the trainee. After simulation, motor imagery and neurofeedback are developed using Computer Brain Interface in Mental Imagery (CBI-MI).

Surgical education has indeed come a long way since Morbidity and Mortality (M&M) meeting and OR training without simulation, but I beleive the simulation world still needs reframing by neuroscience and computational science to give the optimal training results.


(1) Cook DA, et al. Technology enhanced simulation for health professions education: a systematic review in meta-analysis. JAMA 2011, 306(9): 978-88.
(2) Lensjø KK, et al. Removal of perineuronal nets unlocks juvenile plasticity through network mechanism of decreased inhibition and increased gamma action. J Neurosci 2017, 37(5): 1269-83.
(3) Pugh CM. A holistic model of surgical expertise and competency. Ann Surg 2017, 265(2): 268-9.
(4) Keith N, et al. Effectiveness of error management training : a meta-analysis. J Appl Psycho 2008, 93(1): 59-69.
(5) Laufer S, et al. Sensor technology in assessments of clinical skill. N Engl J Med 2015, 372(8): 784-6.



Marcel Martin, M.D.