Practice, rehearsal, and performance: an approach for simulation-based surgical and procedure training.

SURGEONS, LIKE MUSICIANS, CAN BE CONSIDERED PERformers. Traditionally, surgeons have learned their craft through a prolonged apprenticeship that allows trainees to gain a wide repertoire of skills by assisting at and performing numerous operations. Supervision was tailored to each surgeon’s level of experience and the demands of the procedure. Surgeons learned how to cope with a wide range of problems and complications by repeated practice located within the performance of actual operations. Dexterity was central to the process of learning a broad range of procedures. However, equally important were other skills that accrued with increasing experience: teamwork, leadership, communication, clinical judgment, and decision making. Unlike technical expertise, these qualities are most evident when coping with problems and dealing with the unexpected. The extended nature of surgical training, coupled with specific planning, ensured that trainees were exposed to a sufficient range of eventualities. The landscape of contemporary surgery is different. Demands for patient throughput are increasing, while reductions in work hours mean that trainees’ opportunities for hands-on interventional experience have been curtailed. Continual technological innovation applies relentless pressure to learn new techniques, and ethical imperatives support safer approaches to initial learning, such as simulation. Complex interventional procedures increasingly are being performed by physicians from many specialties, including surgery, cardiology, and radiology.