AANS Neurosurgeon | Volume 29, Number 2, 2020


Mastery of New Skills: The Science of Practicing Well

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Even after completion of residency new technical skills must constantly be acquired if a neurosurgeon is to practice good medicine. Malcolm Gladwell’s 2008 book Outliers popularized the notion that 10,000 hours of deliberate practice are required to master a skill. The current length of neurosurgical residency aligns adequate time and structured education to develop the skills to be adroit.  During this period, residents are trained to grow our technical and intellectual skills and transition from novice to expert. Paul Fitts in 1964 outlined one of the first frameworks for motor learning where a student passes initially through a cognitive phase of understanding. The components of a task to be learned are consciously acquired and the movement requires conscious awareness. After this period, an associative stage emerges where the movements are smoothed out and become reproducible. Finally, motor skills enter an autonomous stage where movement is effortless and with minimal or no error. Others detail stages of learning such as Burch’s description of unconscious incompetence, conscious incompetence, conscious incompetence and conscious competence. Trotter in 1986 used the more familiar terms novice, advanced beginner, competence, proficient and expert. All of these descriptions of skill acquisition share transitions from unconscious ignorance to conscious awareness, understanding and eventual incorporation.   

There are broadly speaking three key periods of skill acquisition in neurosurgical life: (1) residency/fellowship, (2) the immediate few years post-training and (3) independent practice. Skill acquisition in residency relies on the ACGME curriculum, institutional case diversity, local teaching culture and self-motivation. In the current era, impressive tools exist for a resident to practice technical skills outside the operating room. Notably, the modern neurosurgical text is now accompanied by beautiful intraoperative videos like in Aaron A. Cohen-Gadol, MD, MSc, MBA, FAANS, product, The Neurosurgical Atlas. Virtual and augmented reality, like that used at Stanford’s Neurosurgical Simulation and Virtual Reality Lab, allow patient specific data to be studied from any angle to aid in surgical planning and preoperative visualization. Moreover, simulation is a contemporary immersive and essential educational technique. The endovascular and cerebro-vascular educators have created a series of progressively complex simulation models for carotid stenting, angiography, aneurysm treatment and bypass. Neuro-endoscopy training has also benefitted greatly from simulation. Data from both university settings and industry have shown improvement in metrics such as decreased operative time, fluoroscopy use and contrast doses in junior surgeons trained on simulation.

Critical Transition

The period of practice immediately after residency is crucial to long-term success. During this period of skill acquisition, practicing alongside more experienced partners is an ideal framework for technical progression. This is often a critical period resulting in further development and growth of skills from residency or contraction of skills. Practice culture for skill refinement, adoption of new skills and mentorship are critical in this first two to three years and potentially undervalued when exploring employment.

The final period of new skill acquisition and skill refinement is in independent practice. This can be challenging with all the obligations of work and family but it is a necessity if a surgeon wants to stay up to date. Disruptive innovation is a common source for pressure to acquire new competencies, and it provides a framework for new skill acquisition. For example, flow diversion has revolutionized the treatment of many wide necked, fusiform and blister type aneurysms. Its skillful application is a necessity of a modern cerebrovascular practice. Many providers had to learn these challenging devices outside of fellowship training. The model for integration into a practice can include course work and simulator deployment followed by a proctored assistant and primary operating cases.

Institutional Experience

At our institution, our experienced endovascular surgeons recognized the importance of learning flow diversion; the commitment to learn was demonstrated by performing cases jointly, utilizing a common proctor and staff and reviewing cases upon completion. Paralleling this cerebrovascular experience, our tumor surgeons have begun their initial series of tumor resections aided by 5-ALA; this group is using a similar model of thoughtful intellectual and technical skill accretion.

The transition from unconscious incompetence to conscious competence takes years but can be jumpstarted with didactics, digital video, virtual reality, simulation and mentorship. Successful incorporation benefits from deliberate practice and teamwork along with institutional and practice support. 


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