**2. Theoretical models for surgical motor skill acquisition**

Advancement in surgical education research sheds light on the understanding of competency and assessment, in the sense that competency cannot be assumed when trainees can perform parts of a task or individual surgical skills, as many complex tasks require the integration of many skills. Literature showed that surgical trainees at both undergraduate [12] and postgraduate levels [13] do not feel competent or ready to operate independently at the end of their training. Competence is not equal to excellence. Due to the lack of time and opportunities to practice, the learning process focuses on competence rather than excellence [14]. For surgical motor skill acquisition, the following four theoretical models are commonly used (**Table 1**) - Fitts and Posner's 3-Stage Model of Motor Skills Acquisition, Bandura's Theory of Social Learning, Ericsson's Deliberate Practice Model, and Motor Simulation Theory of Jeannerod.

Mental practice (MP) is "the cognitive rehearsal of a task in the absence of overt physical movement" [19]. It has successfully improved psychomotor performance to enhance skill and performance in sports and music [20, 21]. Mental imagery (MI) has been shown to activate similar neural processes to those used in the actual performance of a given skill [22, 23]. MP has been used lately as an alternative strategy in surgical training. The current literature shows the successful use of MP in surgical training or enhancing surgical performance, but lacks methodological details for the development of educational resources incorporating MP.


#### **Table 1.**

*Summary of surgical training theories.*

## *Redefining Surgical Skill Acquisition DOI: http://dx.doi.org/10.5772/intechopen.99408*

In summary, the current body of knowledge on psychomotor skill acquisition to an expert level [24, 25] requires:


The current model of surgical training programmes for motor skill acquisition focuses on the direct supervision of the expert in the operating room, providing direct observation, guidance, and feedback, ensuring compliance to the preoperative plan. Graduated responsibility and progression in surgical performance are allowed based on the level of surgical performance and adherence to patient safety [26]. The emphasis has been the development of competencies which is a minimum level of skill to be demonstrated, rather than mastery associated with a higher level of proficiency. Competency requires much less training than mastery and is facilitated by the very structured and focused training. Hence, to overcome the reduced opportunity to learn and practice in the operating room, low fidelity bench models, basic surgical skills, surgical laboratory practice, and higher fidelity human cadaver models to live animal model practice have been utilised [27]. From simulation to gaming and robotics, technology has also become the enabler in surgical training [28, 29]. These strategies have implications in cost-effectiveness and universal accessibility, as they require resources - both physical and trainee/trainer time, as they are synchronous platforms for learning [30]. However, the current model is singularly deficient in that there is no universally accessible opportunity to practice the surgical procedure outside of the operating theatre and without access to physical simulators.

Based on the review of these theoretical frameworks, we propose a model for the expert acquisition of motor skills in **Figure 1**. This model incorporates the theoretical framework of Fitts and Posner, Bandura, Ericsson, and Jeannerod, and operationalises the steps described in the theories of skill acquisition and
