COGNITIVE SIMULATION  -  For surgeons across specialties


Improving skills

Developing SkillsCognitive simulation is generic method that can be used in improving any kind of surgical skills. To apply it effectively we need to understand the operative skills from the perspective of human kinetics. Skill improvement involves strengthening the neuromuscular pathways. In the initial phases of skill development, we consciously make neurons fire one after another to achieve the movement. As these sequences fire repeatedly, the neural system begins to strengthen those pathways, which as they strengthen, reduce the need for conscious focus. The process of actions becoming habitual through repetition is an important feature of improving a skill.

Skill improvement occurs in three stages

1) Cognitive stage - This first stage involves conceptualization of the skill, during which the indications, contra-indications, complications and basic technique of the procedure are understood.


A simple procedure like colonoscopy illustrates the practical aspects of the cognitive phase. During the cognitive phase of colonoscopy, the novice becomes familiar with the basic functions of the colonoscope, in addition to the anatomy of the large intestine. He is expected to be aware of concepts such as looping and paradoxical scope movements. The trainee should know and be able to describe how to counteract these difficulties, such as by applying pressure and reducing the length of the bowel.

2) Associative stage - In this second stage, movements specific to the task are applied to prevent ineffective actions. During this phase, the operator is able to comprehend and put into practice the mechanics of the skill and respond to the feedbacks.

During the associative stage of colonoscopy, the surgeon will be able to navigate through the straight sections of the colon and perhaps also be able to complete a relatively simple procedure. However, the performer may need feedback throughout and possibly assistance at some stages.

3) Autonomous stage - In the last stage, the skills turn out to be automatic. One does not need to ponder over every stage or to count on outside clues. In this stage, the surgeon should be able to perform the task with speed, efficiency and precision. The skill undertaken needs minimal cognitive input, with the focus directed almost entirely towards refining the performance. The skill at this point is fluid, continuous, and adaptive.

While performing a procedure these three stages overlap. Some part of the procedure may be in autonomous stage while other in cognitive. Cognitive simulation can be applied to skill development in all three stages. It could be applied to a review of anatomy as it helps surgeon to become oriented in complex areas. Accurate mental representations of structures in the vicinity of a dissection will ensure more efficient planning of maneuvers. Cognitive stage involves working out actions that are usually implicit, to make them explicit, which is helped by kinesthetic modality of cognitive simulation. For example, it will help an inexperienced trainee to focus on just what is involved in the insertion of a trocar for a laparoscopic procedure. A trainee with more experience could simulate the specific stage of an operation, which he has previously only observed. An experienced surgeon meanwhile may rehearse the variations that could occur in the course of a more complicated presentation. As learning evolves to the stage of automation, cognitive simulation assumes a form of risk management.


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