Abstract
More than a decade of neurophysiological and behavioral research has demonstrated that very specific changes occur in the corticostriatal and corticocerebellar systems of the brain during the acquisition and refinement of motor skills. 1 Magnetic resonance imaging data confirm an initial “fast” learning phase is required to lay down the neural pathways of learning a new sequence of movements. This must then be followed by a “slow” repetitive practice phase through which automation of the motor sequences is perfected. Practice, therefore, results in delayed incremental gains in performance and reflects basic mechanisms of neuronal plasticity in the adult brain. 2
Surgical educators recognize this need for practice of surgical skills to create the proficient surgeon. Simulation-based training (SBT) of complex surgical skills is a method by which trainees can repetitively practice in a risk-free environment to acquire and master challenging skills especially in minimally invasive access surgery. However, expert feedback to ensure trainees are developing their surgical skills correctly is imperative.
Kim and colleagues in this study have provided important and practical information to surgical educators on the timing of this feedback sequencing in junior-level residents. They found that early feedback in learning the skill of flexible ureteroscopy (fURS) resulted in improved proficiency scores, and residents preferred this timing of feedback compared with feedback after their initial learning and practicing of the technique. This would also support the neurophysiological evidence for motor skill learning in which the initial laying down of the neural pathways of learning a new sequence of movements must be done correctly so that automation of the motor sequences is perfected through repetitive practice.
Although the authors accurately identify the small sample size as the major limitation of this study, they have nicely defined the specific domains of performance assessment in determining proficiency scores and thus provide valuable information for educators teaching fURS using SBT in junior-level residents. It would be very interesting and helpful to educators if critical errors of the specific procedure had also been defined and included in the evaluations performed on the video performance reviews. Hopefully this will be included in future studies of this SBT training technique for fURS.