COGNITIVE SIMULATION  -  For surgeons across specialties


Evidence - It's not all in the mind

The initial research was carried out in athletic performance.

A review of literature reveals the paradigm of mental practice studies as
1. Physical practice, when subjects practice the task a fixed number of times
2. Imagery, when subjects mentally rehearse the task the same number of times
3. The control, when subjects do not practice

The outcomes have been consistent across a number of studies. Physical practice has a greater effect on performance than imagery practice, which in turn is more effective than no practice at all (1). Examining the effect of combining mental and physical practice (initial physical practice followed by mental practice) is where results are particularly interesting when compared to physical or imagery practice alone. Those studies have shown that a combination achieves far better results than mental practice or physical practice alone (2). Thus replacing part of physical practice with cognitive simulation will save time and resources while achieving similar performance improvement. (3)


Studies in surgical literature have shown that cognitive simulation can be used to optimize the skill learning (4). Results of the first randomized controlled trial of mental practice in surgery were published in 2007 in the Annals of Surgery (5). In this study the effect of cognitive training on performance of a simulated surgical procedure was evaluated. A statistical analysis of the results showed that there was a significant improvement in performance in the mental training group, but not in the practical training group. Mental training accomplished superior results, compared to other groups, in the task specific checklist.

Mental Training in Surgery

A recent randomized controlled study determined whether mental practice really does improve surgical skills (6). Participants were assigned randomly to an intervention arm or a control arm. Subjects from the intervention group were trained in mental practice. All participants practiced one procedure every day on a simulator for five days. Prior to each session, participants in the intervention group conducted mental practice for half an hour. Each participant from the control group spent the same amount of time with a faculty member, during which time they were asked to conduct an academic activity. Since all participants were engaged in some kind of activity, they were oblivious to the fact that they were either in the intervention or control group, ensuring blind control. Every subject from the intervention group was trained in mental practice using a written script. The script depicted steps of the procedure, and also highlighted the related clues intended to improve the mental representation of the skill. The main outcome of the study concerned quality of performance during five surgical procedures. All the procedures were recorded and sent to experienced surgeons for assessment, adhering to blind protocols. The results showed that the intervention group performed considerably better than the control group during all sessions.


1) Richardson A. Mental Practice: a review and discussion, part one. Research Quarterly. 1967;38, 95-107.

2) Weinberg R. The relationship between mental preparation strategies and motor performance: a review and critique. Quest. 1982;33 (2): 195-213.

3) Durand M, Hall C, Haslam IR. The effects of combining mental and physical practice on motor skill acquisition. The Hong Kong Journal of Sports Medicine and Sports Science. 1997;4, 36-41.

4) Shi-Hyun PARK, Irene H. SUH , Jaehyon PAIK, Frank E. RITTER , Ka-Chun SIU et al . Modelling Surgical Skill Learning with Cognitive Simulation. Medicine Meets Virtual Reality 18 J.D. Westwood et al. (Eds.) IOS Press, 2011: 428-432

5) Immenroth M, Buerger T, Brenner J, Nagelschmidt M, Eberspaecher H, Troidl H. Mental training in surgical education - randomized control trial. Annals of Surgery. 2007;245 (3): 385-395.

6)Arora S, Aggarwal R, Sirimanna P, Moran A, Grantcharov T, Kneebone R, Sevdalis N, Darzi A. Mental practice enhances surgical technical skills, a randomized controlled study. Annals of Surgery. 2011;253 (2):265-270.


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