EDUCATION CORNER
From the Society for Clinical Vascular Surgery
Visuospatial and psychomotor aptitude predicts
endovascular performance of inexperienced
individuals on a virtual reality simulator
Isabelle Van Herzeele, MD, PhD,a,b Kevin G. L. O’Donoghue, BSc,a
Rajesh Aggarwal, MA, MRCS, PhD,a Frank Vermassen, MD, PhD,b Ara Darzi, KBE, MD, FRCS,a and
Nicholas J. W. Cheshire, MD, FRCS,a,c London, United Kingdom; and Gent, Belgium
Objectives: This study evaluated virtual reality (VR) simulation for endovascular training of medical students to determine
whether innate perceptual, visuospatial, and psychomotor aptitude (VSA) can predict initial and plateau phase of
technical endovascular skills acquisition.
Methods: Twenty medical students received didactic and endovascular training on a commercially available VR simulator.
Each student treated a series of 10 identical noncomplex renal artery stenoses endovascularly. The simulator recorded
performance data instantly and objectively. An experienced interventionalist rated the performance at the initial and final
sessions using generic (out of 40) and procedure-specific (out of 30) rating scales. VSA were tested with fine motor
dexterity (FMD, Perdue Pegboard), psychomotor ability (minimally invasive virtual reality surgical trainer [MIST-VR]),
image recall (Rey-Osterrieth), and organizational aptitude (map-planning). VSA performance scores were correlated with
the assessment parameters of endovascular skills at commencement and completion of training.
Results: Medical students exhibited statistically significant learning curves from the initial to the plateau performance for
contrast usage (medians, 28 vs 17 mL, P < .001), total procedure time (2120 vs 867 seconds, P < .001), and fluoroscopy
time (993 vs. 507 seconds, P < .001). Scores on generic and procedure-specific rating scales improved significantly (10
vs 25, P < .001; 8 vs 17 P < .001). Significant correlations were noted for FMD with initial and plateau sessions for
fluoroscopy time (rs ⴝ ⴚ0.564, P ⴝ .010; rs ⴝ ⴚ.449, P ⴝ .047). FMD correlated with procedure-specific scores at the
initial session (rs ⴝ .607, P ⴝ .006). Image recall correlated with generic skills at the end of training (rs ⴝ .587, P ⴝ .006).
Conclusions: Simulator-based training in endovascular skills improved performance in medical students. There were
significant correlations between initial endovascular skill and fine motor dexterity as well as with image recall at end of the
training period. In addition to current recruitment strategies, VSA may be a useful tool for predictive validity studies.
( J Vasc Surg 2010;51:1035-42.)
From the Department of Biosurgery and Surgical Technologya and the
Regional Vascular Unit,c Imperial College Healthcare NHS Trust, London; and the Department of Thoracic and Vascular Surgery, University
Hospital Ghent, Gent.b
This work was supported by funding from the Imperial College Healthcare
Biomedical Research Centre, a Clinical Doctoral Grant from the Fund for
Scientific Research Flanders (FWO), Belgium, and a grant from Mentice,
Gothenburg, Sweden, and Boston Scientific Corporation, Natick, Mass
and Nanterre, France. They did not, however, interfere in the study
design, data collection, analysis, or interpretation of the data, or in the
decision to submit the manuscript for publication.
Competition of interest: none.
Winner of the Poster Session at the Society of Vascular Surgery Vascular
Annual Meeting, San Diego, Jun 7, 2008.
Correspondence: I. Van Herzeele, Department of Thoracic and Vascular
Surgery 2K12IC, University Hospital Ghent, De Pintelaan 185, 9000
Gent, Belgium (e-mail: [email protected]).
The editors and reviewers of this article have no relevant financial relationships
to disclose per the JVS policy that requires reviewers to decline review of any
manuscript for which they may have a competition of interest.
0741-5214/$36.00
Copyright © 2010 by the Society for Vascular Surgery.
doi:10.1016/j.jvs.2009.11.059
The introduction of catheter-based minimally invasive
interventions has revolutionized the management of vascular disease.1,2 Vascular surgeons and patients have accepted
the role of endovascular therapy due to reduced procedurally related discomfort, faster recovery, and decreased hospital length of stay.3 These advantages are reduced when
endovascular procedures are done by inexperienced or
poorly supervised physicians, which may lead to increased
complications and poorer patient outcomes.4,5 Inexperienced practitioners need to learn how to maneuver endovascular tools carefully through blood vessels by manipulating endovascular tools within a 3-dimensional (3D)
environment whilst viewing only a 2D fluoroscopic image.
The operator must also work with reduced tactile feedback.
Until recently, core endovascular skills were acquired
by performing diagnostic angiograms. However, the increased use of noninvasive imaging techniques and budgetary constraints in the operating room have restricted
training opportunities,6 and the implementation of the
European Working Time Directive in many European
1035
JOURNAL OF VASCULAR SURGERY
April 2010
1036 Van Herzeele et al
Table I. Brief description of visuospatial and psychomotor tests
Test
Rey-Osterrieth Complex Figure
Perdue Pegboard
Grooved Pegboard
Map Planning
Minimally Invasive Surgical Trainer
Description test
Skills tested
Image is copied and then drawn from memory
instantly and after a delay
Small pins are placed in a board by using left
and right hands individually and also
simultaneously
Grooved pins are placed into grooved holes
using only the dominant hand
Participant must find the shortest route
between two points on a schematic of a city
map whilst avoiding roadblocks
Laparoscopic surgical simulator in which
participants complete abstract tasks with
both left and right hands
Visuospatial constructional ability, visual
memory, and executive function
Fine motor dexterity
countries has resulted in a marked reduction in the hours
available for training (15,000 hours vs 35,000 hours 10
years ago).7,8 Patients have also become more demanding
and less tolerant toward surgical errors and expect their
primary operator to be proficient.9 Surgical educators have
therefore been compelled to search for more effective and
creative means of teaching surgical skills.10
Simulation has been used extensively in other high-risk
professions, such as aviation, allowing the acquisition of
essential skills before the person is required to function in
real-life situations.11,12 Virtual reality technology has the potential to improve patient safety by allowing inexperienced
individuals to train away from the patient in a nonpressured
environment, to be trained at their own pace, and to learn
from their mistakes without putting patients at risk.13
Previous studies have used simulators to examine the
possibility of predicting surgical performance in laparoscopic or general surgical procedures by testing innate
visuospatial abilities.14-17 To our knowledge, however, no
studies have attempted to relate innate abilities to endovascular performance on a virtual reality (VR) simulator. The
two aims of this study were to determine (1) if medical
students could acquire the appropriate endovascular skills
to perform a renal artery angioplasty and stent procedure
on a VR simulator and (2) if differences in performances
between naïve individuals could be due to variability in
their psychomotor and visuospatial abilities (VSA).
METHODS
Participants. The study recruited 20 medical students
from a university teaching hospital. Excluded were individuals with prior endovascular experience, surgical simulation, or visuospatial testing. All participants gave informed
consent before enrollment in the study.
Cognitive skills training. The endovascular tools,
skills, indications, and protocol required to safely perform a
renal artery dilation and stenting procedure were described
and clarified during a half-hour interactive presentation.13,18
Visuospatial abilities testing. Five validated tests of
VSA and psychomotor ability were chosen after an extensive literature search.16,19-22 It was the intention for each
Fine motor dexterity
Organizational aptitude
Ability to interact in a 3D environment
from 2D screen
test to measure skills relevant to endovascular procedures
(Table I; Fig 1). Each student was given written instructions about the task and a mock question to determine if
the task was understood. All tasks were timed and completed as instructed in the literature.19-21
The simulator. The simulator used in the study was
the Vascular Intervention Simulation Trainer (Procedicus
VIST, Mentice, Gothenburg, Sweden) and has been extensively described previously.11,23-25 At the commencement
of the study, a standardized brief introduction to the VR
simulator was delivered to all students before the endovascular treatment of a right-sided, nonostial lesion of the
renal artery was demonstrated. A protocol for endovascular
treatment of renal artery stenosis, correct handling of endovascular tools, and major errors possible during each step
of the intervention were explained and demonstrated in a
standardized fashion.13,26,27 Before each assessment on the
VR simulator, every participant had to explain the protocol
from memory to ensure retention of cognitive skills.
Task performed. All participants treated an identical
simulated left-sided nonostial renal artery lesion 10 times, a
module that has been validated in other studies.23,28 The
patient’s case summary showing the renal lesion was explained. Passive assistance was provided during the simulated
procedure. Appropriate endovascular tools were selected
when asked for, and orientation of the C-arm was modified as
requested. A virtual ruler was available but could not be
moved. In line with similar experiments in the literature, a
maximum of two sessions per day were allowed with a minimum of 1 hour between sessions.23 Verbal advice was provided only when a student performed the same error three
times.
Performance evaluation. Visuospatial and psychomotor aptitude were evaluated using the scoring systems provided with the tests. The VIST automatically provides a
procedure report for each session containing two types of
internal assessment parameters. Procedure time, contrast
volume, and fluoroscopy time were the quantitative metrics
recorded for this study. Qualitative metrics are also registered by the VIST and include the clinical parameters of
placement accuracy of stent or balloon (mm), lesion cover-
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Volume 51, Number 4
Van Herzeele et al 1037
not result in rupture of the artery. At the end of each task,
a procedure report was automatically generated that included all recorded simulator metrics.
During the first and tenth procedure, an experienced
endovascular interventionalist (external assessment) used
two rating scales to assess the candidates. The generic
rating scale was based on the global rating scale used in
Objective Structured Assessment of Technical Skills
(OSATS)30-33 and evaluates basic and generic endovascular
skills (maximum score, 40). The procedure-specific rating
scale (maximum score, 35; Fig 2) was developed by experienced endovascular practitioners who analyzed and
scored the different steps and skills required to safely complete a renal artery stenting procedure 29 After the initial
session, the observer provided standardized, formative
feedback to each medical student by identifying the areas of
weakness in renal artery stenting based mainly on the
definitions provided in the procedure-specific rating scale.
Statistical analysis. Data were analyzed with nonparametric tests using SPSS 15.0 software (SPSS Inc, Chicago, Ill). Learning curves were analyzed using a Friedman
(nonparametric repeated measures analysis of variance) test.
Sequential comparisons were made to identify plateau levels
for all significant variables. Both initial and plateau performances were analyzed for correlation on the visuospatial tests.
The Spearman rank test was used to examine correlations for
continuous data, and a Kendall tau B test was used for categoric data. The Wilcoxon signed rank test was used to investigate skills improvement from the first to tenth session, as
measured by the rating scales. Data results with a value of P ⬍
.050 were considered statistically significant.
RESULTS
Fig 1. A, The Rey-Osterrieth Complex Figure, is first copied, then
drawn from memory instantly, and drawn again after a delay of 10
minutes. B, Individuals who take the Perdue Pegboard test must
perform a variety of single-and double-handed fine motor tasks.
Performance on this test correlated well with initial performance.
age by the balloon or stent (%), balloon/vessel ratio (range,
0-1), residual stenosis (%), and stent/vessel ratio.5,29 A
stent/vessel ratio of 1 is ideal, with a value of ⬍1 indicating
an undersized stent and ⬎1 an oversized stent for the
virtual lesion. Error scoring was not available for this module at the time the study was undertaken and errors did not
cause complications, for example, over-dilating a vessel did
Demographics. Eight men and 12 women participated,
consisting of 10 third-year and 10 fourth-year medical students who were a median age of 22 years (range 20-26 years).
All were right handed, except for one. All students successfully
completed each of the VSA tests before commencing the
training program. Although all students finished the required
10 sessions on the simulator in groups of five ⱕ2 weeks, 31 of
the 200 procedure reports (15.5%) were incomplete because
of technical difficulties with the VIST.
Learning curves. Medical students exhibited statistically significant learning curves for total procedure time
(medians, 2120 vs 867 seconds, P ⬍ .001, Fig 3), fluoroscopy time (993 vs 507 seconds, P ⬍ .001), contrast usage
(28 vs 17 mL, P ⬍ .001), and number of recorded angiograms (6.5 vs 4, P ⫽ .003). The plateau phase for the
learning curve occurred at the seventh session for total
procedure time, the sixth session for fluoroscopy time, the
fourth session for contrast volume, and the eighth session
for number of angiograms. The qualitative metrics of the
VR simulator (eg, stent/vessel ratio) did not improve significantly when the initial and final sessions were compared
(medians, 1.06 vs 1.04, P ⫽ .673). However, the experienced observer scored the final performance significantly
higher than initial performance using both the generic
1038 Van Herzeele et al
JOURNAL OF VASCULAR SURGERY
April 2010
Fig 2. A procedure-specific rating scale was used for live external assessment by an experienced interventionalist at the
initial and final session.
(median scores, 10 vs 25, P ⬍ .001) and procedure-specific
(8 vs 17, P ⬍ .001) rating scales (Fig 4).
Initially, the group demonstrated a large variability
in performance, but as their training progressed, this led
to increased consistency. This becomes clear when the
final session is compared with the initial session for the
valid internal metrics (interquartile range of the first
session vs the final session for procedure time was 783 vs
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Volume 51, Number 4
Van Herzeele et al 1039
Fig 5. The procedure times are illustrated for three different
participants. The triangles represent a student in the 95th percentile for initial procedure time, squares represent a student with
approximately a median value for the initial procedure time, and
circles represent a student in the fifth percentile.
Fig 3. Box and whisker plot represents the total procedure time
necessary to complete the virtual renal artery stenting procedure
for each of the 10 sessions (Friedman test, P ⬍ .001). The plateau
phase is represented by the grey boxes. The horizontal line in the
middle of each box indicates the median, the top and bottom borders
of the box mark the 75th and 25th percentiles, respectively, the
whiskers mark the 90th and 10th percentiles, and the circles represent the outliers.
Fig 4. Box and whisker plot represents the improvement from
session 1 to 10 during external assessment using generic and
procedure-specific rating scales. (Wilcoxon signed rank test, P ⬍
.001). The white boxes illustrate scores at the initial session and
hatched boxes scores for the final session. The horizontal line in the
middle of each box indicates the median, the top and bottom borders
of the box mark the 75th and 25th percentiles, respectively, the
whiskers mark the 90th and 10th percentiles, and the circles represent the outliers.
332 seconds, Fig 3). Fig 5 illustrates how the procedure
times for three different students diminished during the
10 sessions, illustrating individual learning patterns.
Correlation between visuospatial ability and initial
simulator performance. The medical students who scored
higher on the Perdue Pegboard pressed the fluoroscopy pedal
for a shorter duration (rs ⫽ ⫺0.5640, P ⫽ .010) and used
contrast less liberally (rs ⫽ 0.511, P ⫽ .021). Higher scores on
the Perdue Pegboard also tended to lead to higher procedurespecific scoring at the initial session (rs ⫽ .607, P ⫽ .006). The
other test of fine motor dexterity, the grooved pegboard, also
correlated with initial endovascular performance rated by the
procedure-specific scale (rs ⫽ ⫺0.564, P ⫽ .011). The ReyOsterrieth Complex Figure (ROCF) test, map planning, and
the minimally invasive virtual reality surgical trainer (MIST-VR)
did not correlate with initial performance during virtual renal
artery stent procedures (Table II).
Correlation between visuospatial ability and end
performance. The correlation between fine motor dexterity (Perdue Pegboard) and the performance on the VR
simulator at the plateau phase was less apparent than with
the initial performance (fluoroscopy time: rs ⫽ ⫺0.449,
P ⫽ .047). Those medical students with superior image
recall (ROCF) tended to press the fluoroscopy pedal for a
shorter amount of time (rs ⫽ 0.489, P ⫽ .029).
Performance on the ROCF correlated with the external
assessment of generic endovascular skills (time to copy
ROCF, rs ⫽ ⫺0.587, P ⫽ .006). The Perdue Pegboard
(rs ⫽ 0.674, P ⫽ .001), MIST-VR (rs ⫽ ⫺0.588, P ⫽
.006), and map planning (rs ⫽ 0.579, P ⫽ .007) were also
observed to correlate with the generic rating scale at the
final session. The grooved pegboard test, however, did not
correlate with end performance (rs ⫽ ⫺0.286, P ⫽ .221;
Table II).
DISCUSSION
This study has revealed that naïve individuals can acquire endovascular skills to perform a renal artery stent
JOURNAL OF VASCULAR SURGERY
April 2010
1040 Van Herzeele et al
Table II. Correlations between visuospatial and psychomotor ability scores with internal simulator metrics and external
interventionalists based assessment (Spearman rank test)
Initial session
Test
Fine motor tests
Grooved Peg Board, rsa
P
Perdue Pegboard
Dom hand, rs
P
Non-dom hand, rs
P
L ⫹ R ⫹ both, rs
P
Perdue Pegboard
Assembly, rs
P
Visuospatial Ability Tests
ROCF
Copy time (s), rs
P
Imm recall time, rs
P
Del recall score, rs
P
Del recall time, rs
P
Map planning, rs
P
MIST-VR time, right
hand, rs
P
Plateau session
Final session
Quantitative simulator metrics
Interventionalist
ratings
Quantitative simulator metrics
Interventionalist
ratings
Internal metrics
External metrics
Internal metrics
External metrics
Procedure Fluoroscopy Contrast ProcedureProcedure Fluoroscopy Contrast Proceduretime
time
vol
specific Generic
time
time
vol
specific Generic
⫺0.564
.011
⫺0.564
.01
0.48
.032
0.502
.028
0.607
.006
0.46
.048
⫺0.497
.026
⫺0.449
.047
0.502
.028
0.511
.021
0.484
.03
0.674
.001
⫺0.587
.006
⫺0.486
.035
0.494
.027
0.489
.029
0.579
.007
0.55
.012
⫺0.491
.033
⫺0.588
.006
Del, Delayed; Imm, immediate; L, left hand score; R, right hand score; MIST-VR, virtual reality minimally invasive surgical trainer; ROCF, Rey-Osterrieth
Complex Figure.
a
Correlation coefficients (rs) values are presented with P values. An empty cell represents a nonsignificant correlation (P ⬎ .050).
procedure on the basis of VR simulator metrics and expert
ratings. Furthermore, VSA and psychomotor testing correlate
with initial and end performance during simulated complex
endovascular interventions. FMD correlated clearly with initial performance on the VR simulator based on the internal
quantitative metrics and the external ratings of the interventionalist. For example, students who scored higher on the
Perdue Pegboard test pressed the fluoroscopy pedal for a
shorter duration at the initial session. This suggests that the
more dextrous students had the innate ability to maneuver
the wires more gently and to keep the endovascular tools
steadier, allowing a more economic fluoroscopy use at their
first endovascular intervention. The quality of their procedure specific skills was also scored higher by the expert
observer and may imply that fine motor testing is able to
predict initial performance during a complex endovascular
intervention and reflect the handiness of naïve individuals.
We also wanted to establish whether any of these tests
could predict the performance at the end of training. The
ROCF results did indeed show significant correlation with
fluoroscopy time at the end of training. This suggests that
candidates with a poorer ability to recall images might need
to press the fluoroscopy pedal more frequently to visualize
the renal lesion, thus exposing the virtual patient and the
interventional team to more radiation.
The link with the expert rating of generic endovascular
skill at session 10 suggests that the quality of technical
performance of medical students with greater VSA and psychomotor abilities during a complex endovascular procedure
was higher. The ROCF test is believed to test executive
function along with visuoconstructional ability.21 This could
further explain its correlation to end performance because it
may be able to identify those candidates with superior frontal
lobe aptitude. These students may have a greater ability to
learn and understand the complex task of endovascular renal
artery stenting. Stefanidis et al16 did an analogous study in the
laparoscopic domain and observed significant correlations between time to reach proficiency and the ROCF test scores.
Wanzel et al17 demonstrated that visuospatial abilities correlated with surgical performance for dental students but not for
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Volume 51, Number 4
surgical residents or staff surgeons, suggesting surgical experience eventually becomes more important than innate VSA.
This study, however, showed that at least in the early phase of
learning, VSA is an important correlate of technical endovascular skill.
Among the study limitations are that the study protocol
did not require the medical students to reach previously
established benchmark levels of skill in the simulation lab.
Likewise, this study did not investigate the transfer of
motor skills from the simulator lab to the operating room
or angiography suite.
An identical lesion was treated during all 10 simulations; hence, the improvement in simulator metric performance could be attributed to student familiarity with the
module, resulting in automated tool selection and C-arm
positioning. However, this would not solely explain the
significant improvement in quality of performance as
scored by the observer, although we must note that the
assessor was not blinded to the session number.
Technical difficulties occurred on 15.5% of simulations,
which potentially affected the results in this study but also demonstrates the significant reliability limitations with this simulator.
Finally, although several positive associations were
noted between the students’ VSAs and their initial and end
performances during a complex endovascular intervention,
several others did not correlate. Further research is required, including more participants, to investigate this intermittent and complex relationship between the psychomotor and visuospatial abilities of naïve individuals.
Future work ought to focus on the effect that natural
variations in VSA might have on long-term skills acquisition, because this study did not investigate if the higher
performance levels were sustained (retention).
There is a perception that these tests may have a future
role in selecting candidates for surgical training, but their
validity in this context needs to be further proven before
practical application, particularly as this study was undertaken using a VR simulator as a surrogate for technical
endovascular skill in an interventional suite.14-17
In the current training environment of reduced training hours, it is essential to move away from the classical
Halstedian method of training and to modernize education
to ensure appropriate access to surgical simulation as an
integral part of the training experience.6-8,32 Once trainees
have reached a predefined set of proficiency criterion in the
skills laboratory, cognitive and motor behavior can be used
and shaped in the real angiography suite. VR simulation has
been shown to enable surgical trainees to reach an encouraging level of proficiency before entering an interventional
suite to treat actual patients.13
The VIST simulator used in this study currently costs
£120,000; in addition, substantial maintenance costs
would be incurred to address technical difficulties if these
simulators were routinely used in residency training programs. Although it is unlikely that many institutions would
be able to afford such expensive resources, these simulators
should be available to all trainees in specialist regional or
national surgical skills centers.33,34
Van Herzeele et al 1041
Although not the focus of this study, individuals were
noted to demonstrate various learning patterns (Fig 5).
VSA testing may be helpful not only to select future endovascular physicians but also to assist in tailoring the training
programs to the needs of the trainees. It may identify those
who may acquire technical skills more rapidly and those who
may need additional training to reach proficiency. Further
studies are in progress to explore this finding in more detail.
Aptitude testing may also be used to highlight specific technical tasks that trainees find more challenging and that may
require supplementary instructions and mentoring.
CONCLUSIONS
This study has demonstrated that novice trainees can
improve their technical endovascular skills during a virtual
reality complex endovascular intervention. More important, visuospatial and psychomotor abilities have been identified as good predictors of initial and end performance in a
VR endovascular simulator training schedule. These tests
may find a new role in trainee selection or in identifying
trainees’ strengths or weaknesses to allow more tailored and
efficient approaches to training programmes.
We thank Dimitrios Stefanidis, MD, PhD, for his valuable
assistance in the design of this study, and we also thank all of
the medical students who agreed to participate in the study.
AUTHOR CONTRIBUTIONS
Conception and design: IV, KO
Analysis and interpretation: IV, KO, RA, FV, NC
Data collection: IV, KO
Writing the article: IV, KO
Critical revision of the article: IV, RA, FV, AD, NC
Final approval of the article: IV, KO, RA, FV, AD, NC
Statistical analysis: IV, KO, RA
Obtained funding: AD, NC
Overall responsibility: IV
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Submitted Jul 27, 2009; accepted Nov 1, 2009.
INVITED COMMENTARY
Peter F. Lawrence, MD, Los Angeles, Calif
For surgery residents, the challenges of achieving technical
excellence have become greater as the number of hours available to
train has been reduced and the range of procedures performed by
a vascular surgeon has increased. Medical students spend less time
on surgery rotations, so the process of selecting for vascular surgery
residencies students who have the potential to develop into excellent technical surgeons has become more difficult.
This article by Van Herzeele et al assesses the variation in medical
students’ performance on nonmedical technical exercises and correlates their psychomotor skill level with performance of a renal angioplasty on a simulator. Their initial proficiency in nonmedical visuospatial and psychomotor tests was predictive of a better performance of
renal angioplasty on a simulator. After six sessions of simulator training, most students reached a plateau in improvement.
This is important information, primarily because it demonstrates that medical students arrive at a residency training program
with variable levels of technical facility, so that a “one size fits all”
approach to education, which currently characterizes most surgical
education, is unlikely to lead to optimal technical skills acquisition
during the residency. The article supports an approach where
residents achieve maximal technical proficiency on a simulator by
practicing about six procedures, and then advance to patients, in
addition to serving for a prescribed time on each rotation.
The article is also important for what it does not claim. There
is no claim that those with excellent initial psychomotor skills will
become better technical surgeons—“isoperformance,” or transfer
of skills to the operating room, depends on many other factors and
may or may not be correlated with the initial skill level. In addition,
the authors do not attempt to determine whether higher initial skill
levels are inherent or acquired by practicing other motor skills
before medical school. Ericsson has shown that “expert performance” in other fields, particularly athletics and music, is as dependent on the number of hours of practice and that at least 10,000
hours are required, even of a prodigy, to achieve excellence.
Further research in the acquisition of technical excellence is
critical to our technique-oriented specialty. The acquisition of technical skill must become as important an area of assessment as cognitive
ability for surgeons in training. We need to learn how to initially assess
skill levels and then develop more effective methods of skills training
to enable each resident to reach their maximum technical potential.