Invited Commentary on “The Role of Anxiety in Simulation-Based Dexterity and Overall Performance: Does It Really Matter?”

This article is referred to by:

The Role of Anxiety in Simulation-Based Dexterity and Overall Performance: Does It Really Matter?

There is a paradigm shift in the way operative and technical skills are acquired, with the age-old apprentice model giving way to workshop and simulation based learning. Subsequently, the psychomotor skill learned in this way is translated to actual clinical setting. The advent of endoscopic procedures, along with other factors like reduced work hours, ethical concerns, increased patient awareness, and litigation led to increased adoption of these new modalities of learning.¹ Moreover, the shift to alternate learning modalities for skill acquisition was accelerated in the aftermath of European Working Time Directive. It resulted in significant reduction of total training hours from 30,000 to 6,000 h.² This necessitated introduction of optimum training modules and change in the paradigms of skill acquisition.

There are many accepted theories about skill development, which form the basis of various skill training modules and workshops. In the apprenticeship-based model, trainees and students acquired the essential skills on the go, imbibing the steps involved in the process unconsciously. In this context, Halsted stressed the importance of graded responsibility in the surgical training. However, one of the drawbacks in the system was lack of standardized steps and scientific basis. The seminal articles by Kopta et al. in 1971 deconstructed the steps involved in the process of skill acquisition based on Fitts' model. The whole process of skill acquisitions could be knocked down to three essential steps: cognitive, integrative, and autonomous.³ The first component deals with the procedural steps and the knowledge base. Second component consists of integration of the deconstructed movements with the knowledge base with the help of feedback, followed by the final stage of autonomous reflexive movement without any conscious afore. The difference between the expert and novice is that the movement occurs unconsciously in the case of expert whereas each movement is consciously done in the case of novice. Deliberate practice helps in early achievement of expertise in movements and hence expedites the above process. In addition, repeated practice can shorten time to proficiency in the skill with inbuilt bench mark scores and real-time feedback from experts.⁴ The integrative phase can be accomplished with describing the steps vocally or with visual cues. The intelligent use of various sounds during each component of the movements can be observed in the training of all martial arts and other art forms. Association of any sound repeatedly with each component of the sequence of movement, results in early conversion of conscious movements into unconscious reflexes. This type of training for consolidation of integration is not yet adopted in the surgical field. Interestingly, the parallels of this model could be found in the Indian system of jnana (knowledge), yoga (integration), kriya (practice), charya (habit) in Tantras (techniques)

The different phases of skill acquisition are the cognitive, integrative, repetitive, and reflexive phases. Every kind of psychomotor skill set is attained through these phases. Omission of one phase will result in subnormal expertise. Once a particular movement is internalized and made into a reflex, the preceding components of the movements occur unconsciously. This explains the difficulty of the experts in deciphering and teaching the skills. As a result, the essential components of a movement could be deconstructed from the video documentation of a few experts performing the complex skill set and identifying the key steps. This results in a series of essential steps for the expert accomplishment of a complex skill.

Expertise in a procedure or any motor skills could be learned with the aid of simulation outside the actual setting. This simulation based learning ranges from bench models to sophisticated virtual reality models. Moreover, the speed of acquisition of skills can be accelerated to expert level with deliberate, repetitive practice and regular feedback under supervised structured programs.⁵ This brings into question the importance of experience. Expertise in a field need not be akin to experience.⁶

The role of dexterity in helping resident or students in skill acquisition is debatable. If dexterity is an innate non-modifiable trait of an individual, then whether practice modifies it is a mooted question.⁷ In many studies, dexterity plays only a minimal role in altering the outcome of structured programs. However, the dexterity is one of the predictors of baseline skills of residents.⁸ Hence this needs to be taken into account in analyzing the effect of any structured programs.⁹

In this issue of investigative journal of surgery, the authors attempt to explore the association between demographics, dexterity, anxiety, and surgical skill in a structured simulation based learning program in an orthopedic procedure for undergraduate medical students from Europe.¹⁰ Both anxiety and dexterity were evaluated using previously validated instruments like West-Side Test Anxiety Scale and Johnson-O'Connor tweezer dexterity test. After a didactic lecture on open reduction and internal fixation, the participants carried out the practical session in low-fidelity and high-fidelity procedures in bamboo rods and swine legs, respectively. Psychomotor skills were assessed with validated “direct observation of procedure skills (DOPS)” instrument. They report a higher dexterity score for females. In addition, right-handed students were found to have more dexterity scores. Interestingly, there was no difference in the skill set between junior and senior students. Hence, the authors put forward a strong argument for inclusion of skill-based training to medical students. However, there are some statistical issues in this article. The sample size was inadequate for the multiple statistical tests done. The difference in dexterity scores in gender and handedness may be the result of multiple statistical tests with low sample size. This could also explain the lack of difference in surgical skill between junior and senior students. The negative association between anxiety and low fidelity score alone can be due to the affect component or due to the lack of enough power for the study. Actual clinical scenario with live patients may aggravate the anxiety, interfering with the performance. Despite all the methodological flaws, this study attempts to highlight the importance of introduction of simulation-based learning in the academic curriculum from the undergraduate level itself.

With the advances in the new technologies like artificial intelligence, augmented reality, and haptics, adoption of new technological advances in virtual reality could pave the way to widespread use in simulation-based learning with cost of the equipment coming down. The future surgeons will most probably be trained to proficiency outside the real setting with the help of these technologies before embarking on actual scenario.

DECLARATION OF INTEREST

The author reports no conflicts of interest. The author alone is responsible for the content and writing of the article.