SurgeryFebruary 2013

300 Letters to the Editors

15. Choudhry NK, Fletcher RH, Soumerai SB. Systematicreview: the relationship between clinical experienceand quality of health care. Ann Intern Med 2005;142:260-73.

16. Van Sickle K, Ritter EM, Baghai M, Goldenberg AE,Huang IP, Gallagher AG, et al. Prospective, randomized,double-blind trial of curriculum-based training for intra-corporeal suturing and knot tying. J Am Coll Surg 2008;207:560-8.

17. Seymour NE, Gallagher AG, Roman SA, O’Brien MK, Ban-sal VK, Andersen DK, et al. Virtual reality training improvesoperating room performance: results of a randomized,double-blinded study. Ann Surg 2002;236:458-63; discussion63-4.

18. AhlbergG, EnochssonL, Gallagher AG,HedmanL,HogmanC, McClusky DA III, et al. Proficiency-based virtual realitytraining significantly reduces the error rate for residents dur-ing their first 10 laparoscopic cholecystectomies. Am J Surg2007;193:797-804.

http://dx.doi.org/10.1016/j.surg.2012.06.030

You can�t beat experience, but you can cheat it

To the Editors:We thank Smith and colleagues for their positive

comments regarding our study. We certainly endorse thedevelopment of training curricula that are based upon asound evidence base and an understanding of theprocesses that underpin skill acquisition. Indeed, wehave been working with clinicians for a number of yearsto apply knowledge derived primarily from sports psy-chology and human movement science to the acquisi-tion and performance of laparoscopic skills.1-4 Althoughthe apprenticeship model may have served surgical train-ing well, there is increasing recognition that both a goodunderstanding of skill acquisition processes5 and anappreciation of the influence of stress on technicalperformance6 are important when designing effectivetraining. We also agree with the authors that ‘‘throwingmore money’’ at the problem of training (eg, high-fidelity, virtual-reality simulators) is not the onlyanswer---especially if there is no integrated, evidence-based strategy to guide their adoption.

We note that the authors raised concerns about ouruse of the phrase cheating experience. Our use of this lin-guistic ‘‘eye candy’’ may or may not trivialize the impor-tance of the findings, but given that we are now engagedin a positive dialogue about skill acquisition for surgery,the eye candy appears to have served its purpose: atten-tion has been drawn to the article and to the field ofinquiry in general. The title is more than just provoca-tive, however, because our research shows that traineescan achieve proficient levels of performance withoutnecessarily completing a criteria-based number of repeti-tions as part of a rigid training curriculum. Instead, theycan expedite or ‘‘cheat’’ the learning curve to achieveproficiency more quickly. Specifically, trainees in ourstudy did not waste time acquiring an expert-like visuo-motor gaze strategy by gaining experience from trialand error over many trials (as most experts do), butinstead were helped to apply an expert-like visuomotor

gaze strategy from the outset of learning---effectivelycheating experience.

Clearly, training in technical skills is only a small partof all that constitutes surgical training, so we acknowl-edge the limitations of gaze training. However, reachingproficiency earlier in the learning of basic technical skillsaffords the trainee more time to develop complex(and arguably more important) judgment anddecision-making skills. Indeed, research in skillacquisition has shown that complex decision making isbetter during motor performance when the motor skillshave been acquired implicitly, with few demands onworking memory.7,8 Such gains may be particularly im-portant in the current medical education climate, wherelegislation (eg, the European Working Time Directive)limits the time available for training. Making the bestuse of this time by augmenting the learning process isone way to ‘‘cheat’’ experience.

Samuel J. Vine, PhDRich S. W. Masters, DPhil

John S. McGrath, MDElizabeth Bright, MDMark R. Wilson, PhD

College of Life and Environmental SciencesUniversity of ExeterSt Lukes CampusHeavitree Road

Exeter EX1 2LU, UKE-mail: s.j.vine@exeter.ac.uk

References

1. Masters RS, Lo CY, Maxwell JP, Patil NG. Implicit motorlearning in surgery: implications for multi-tasking. Surgery2008;143:140-5.

2. Zhu FF, Poolton JM, Wilson MR, Maxwell JP, Masters RSW.Implicit motor learning promotes neural efficiency duringlaparoscopy. Surg Endosc 2011;25:2950-5.

3. Wilson MR, Vine SJ, Bright E, Masters RSW, Defriend D,McGrath JS. Gaze training enhances laparoscopic technicalskill acquisition and multi-tasking performance: a random-ized controlled study. Surg Endosc 2011;25:3731-9.

4. Vine SJ, Masters RSW, McGrath JS, Bright E, Wilson RM.Cheating experience: guiding novices to adopt the gazestrategies of experts expedites technical laparoscopic skilllearning. Surgery 2012;152:32-40.

5. Gallagher AG, O�Sullivan GC. Fundamentals of surgical sim-ulation: principles and practices. London: Springer Verlag;2011.

6. Arora S, Tierney T, Sevdalis N, Aggarwal R, Nestel D, Wo-loshynowych M, et al. The Imperial Stress Assessment Tool(ISAT): a feasible, reliable and valid approach to measur-ing stress in the operating room. World J Surg 2010;34:1756-63.

7. Masters RSW, Poolton JM, Maxwell JP, Raab M. Implicitmotor learning and complex decision making in time con-strained environments. J Motor Behav 2008;40:71-9.

8. Poolton JM, Masters RSW, Maxwell JP. The influence of anal-ogy learning on decision making in table tennis: evidencefrom behavioural data. Psychol Sport Exerc 2006;7:677-88.

http://dx.doi.org/10.1016/j.surg.2012.10.002