Decisions, Decisions – Surgical Cognitive Training with Touch Surgery.

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Andre Chow BSc, MRCS, Jean Nehme BSc, MSc, MRCS describe developments in Touch Surgery – a mobile surgical simulation platform that was created specifically to address the needs of surgical cognitive training

Touch Surgery is a mobile surgical simulation platform created to address surgical cognitive training using Cognitive Task Analysis. Image Credit: Touch Surgery

“The decision comes before the incision” is a common saying in surgical practice, explaining how it is a surgeon’s mind and not just his hands that are critical to performing an effective and safe operation. This distinction of cognitive abilities separate from technical abilities has been the subject of increasing attention in recent years, with writer and surgical safety guru Atul Gawande explaining in a 2011 New Yorker piece that “…doing surgery is no more physically difficult than writing in cursive. Surgical mastery is about familiarity and judgment. You learn the problems that can occur during a particular procedure or with a particular condition, and you learn how to either prevent or respond to those problems”.

This split between the mind and body has even been formally investigated, with esteemed surgeon Lord Ara Darzi explaining in the British Medical Journal that “a skillfully performed operation is 75% decision making and 25% dexterity.” Studies deliberately investigating the relationships between cognitive and technical skill have also shown that conscious rule and knowledge-based behaviors precede any motor response. However, despite understanding the importance of cognitive surgical skill, decision making within surgery is not formally taught or assessed within surgical training programs, and remains a vital but hidden part of the curriculum.

Challenges of Surgical Practice

Like traditional craft specialties, much of surgical training and experience is based upon an apprenticeship model. The process of gaining surgical experience extends beyond core resident programs as even senior surgeons are required to attend educational courses and conferences to keep up with the latest evidence based practice.

Learning by repetition and observation of experts, expecting to attain all the subtleties and intricacies of the surrounding surgical process is an inherently variable and inefficient process -- and potentially dangerous to patient care. A novice surgeon must progress through the stages of unconscious incompetence as a novice, conscious incompetence, conscious competence and finally unconscious competence when an expert. Expert surgeons have automated many of their procedural skills, which makes it difficult to articulate decisions in both simple and complex decisions . Transfer of these skills to a novice is often incomplete, with studies demonstrating that experts omit up to 70% of the required information to trainees when explaining complex tasks .

The success of this type of training relies heavily on the relationship between the expert and training surgeon, and the amount of time spent in the operating theatre being able to observe and practice. However, this training model is becoming increasingly strained by changes to working hour practices and increasing demands from service delivery and patient safety. In addition, it does not address continued surgical training and revalidation of experts. A significant gap in the process exists here. It is clear to all within the surgical education field that surgical training needs to change, and become more efficient with the necessary objective measurable outcomes of proficiency.

Advances in Surgical Training: Simulation

A comparison is commonly made between training in surgery and the aviation industry. Both surgeons and pilots need to operate under potentially stressful conditions, with time-sensitive decision-making and lives at risk. The aviation industry has an enviable safety record, aided in a large part by a robust simulation-based training program, with regular 6 month assessments for pilots. Within medicine, the issue of safety is paramount. There are 98,000 deaths in the US alone resulting every year from medical error , and the majority of adverse events have been shown to occur in the operating room . Recognizing the potential gains from surgical simulation, there are now many simulation solutions ranging from simple suturing rigs, to life-size mannequins, to expensive computer laparoscopic simulation rigs with tactile feedback, and even entire simulated operating suites. It has been repeatedly demonstrated that simulation can work, with a Cochrane review finding reduced operative time and error rates associated with virtual reality training. Simulation training can also affect clinical outcomes with a significant fall in infection rates associated with central line insertion . However, healthcare systems have been slow to incorporate simulation into training curricula. Part of this is due to considerations of economy and scale. The airline industry is currently struggling with estimates that the annual need for pilots will grow to approximately 25,000 per year, with current training capacity being around 15,000. Compare this with the almost 1 million surgeons in the western world alone, and it becomes clear that attention to economy and scalability of training programs is a key to success.

A good example of a systems-based approach to surgical simulation training is the Fundamentals of Laparoscopic Surgery curriculum for US-based residents. This is a low-cost, low-fidelity box trainer that allows practice of generic laparoscopic technical skills. It allows objective assessment of these skills, and therefore standardization across the country. However, key surgical cognitive skills are not taken into account with this or the majority of surgical simulation solutions.

Touch Surgery and Cognitive Task Simulation

Touch Surgery is a mobile surgical simulation platform that was created specifically to address the needs of surgical cognitive training. It builds on a process called Cognitive Task Analysis (CTA), a method for obtaining sophisticated performance expertise for areas where many covert decisions are linked with complex overt actions3 . CTA has been used in highly technical fields as well as in the military to hasten the acquisition of expert skill, and can improve learning and retention of technical skills as well as decision-making in surgical procedures.

Touch Surgery utilizes CTA to create an operative framework, and then combines this with a proprietary software engine to create a Cognitive Task Simulation, which teaches operative steps and decision-making using interactive computer generated images to depict the surgical process. The integration of interactivity into the platform is a key point for education as knowledge retention can be significantly increased when using an interactive learning method compared with traditional learning method such as lectures, reading or video.

Touch Surgery will host modules ranging from basic procedures to more complex tasks aimed at attending surgeons. Touch Surgery captures data on surgical cognitive performance as well as mistakes and will have modules aimed at specific complications experienced by the most senior surgeons. In this way Touch Surgery will be able to facilitate the transfer of knowledge between experts on a global basis.

Touch Surgery and Assessment of Surgical Cognitive Skill

The Touch Surgery engine is built upon a base of powerful analytics. Touch Surgery not only teaches intra-operative decision making, but also has a test function, allowing surgeons to actually practice and simulate the decision making process. This allows a quantitative analysis of decision-making pathways and skill, building of individual learning curves, and identification of weakness and areas that require development. The platform therefore has the potential to allow objective assessment and standardization of surgical decision-making training in curricula. Furthermore, being a software solution that is based upon readily available and accessible devices makes the Touch Surgery platform extremely scalable, and accessible to surgical trainees worldwide at minimal cost.

Touch Surgery Validation

In the field of healthcare and surgical training, validation of novel technologies is paramount to prove effect prior to widespread adoption. Within the realms of simulation, studies of face, content and construct validity are the “gold standard” measures used for validation. These studies involving Touch Surgery are currently underway at leading institutions in the US and UK with interim reports demonstrating strong face and content validity for the platform (unpublished data), and studies on construct validity upcoming. Currently further academic collaborations are currently being agreed to allow continued development of this platform to the standards needed by surgical training curricula.

Touch Surgery, Clinical Outcomes, and Patient Safety

Although surgeons work their whole careers to provide the best care for their patients, inevitably mistakes will be made that will ultimately lead to patient harm. This is because despite all our advances in technology, surgery is still a very human profession. Although system-based measures are undoubtedly important to improving care and reducing error, ultimately outcomes will come down to the interaction and mistakes that occur between a surgeon and their patient. This is a fact that was described in the report from the Institute of Medicine “To Err is Human”. Atul Gawande addressed this issue of surgeon error by saying that “…the real problem isn’t how to stop bad doctors from harming… It’s how to prevent good doctors from doing so”. Errors of judgment and decision-making are central to this theme. It has been shown that errors of cognition account for two-thirds of all malpractice claims in surgery. This is a huge proportion, and indicative of how important high quality cognitive training and assessment is for surgeons, no matter at what stage of their careers. Using systems like Touch Surgery could help to make a vital difference.

The Concept of Surgical Rehearsal

One area that is often overlooked in the field of simulation is the concept of rehearsal. If you turn up to a concert early, you will see the orchestra busy practicing and warming up for the main event. Go to watch a tennis match, and you will see the players warming up and practicing their strokes. Observe how Tiger Woods thinks about his shot and practices his swing prior to stepping up to the tee. Highly skilled individuals in every profession routinely rehearse and practice prior to performance. In this way their performance is honed, refined, and optimized. However, compare this with surgery where the concept of rehearsal prior to an operation is almost foreign. Time is spent between cases rushing to the ward to see other patients, or absorbed in the other issues surrounding patient care. As we have already established that surgery is even more of a cognitive specialty than a technical one, surely time spent considering your decision-making could make a difference to surgical performance. This was exactly the effect shown in studies that demonstrated how mental rehearsal prior to a task translated into superior physical performance in surgery. In this way Touch Surgery can also be used for surgical rehearsal, and therefore directly affect performance.

Touch Surgery Development

Touch Surgery was founded by four surgeons, who are dedicated to improving the surgical training process. The ultimate aims of Touch Surgery are to raise the standards of surgical care globally, utilizing cutting edge, affordable, and accessible technology.

The team is currently involved with building an academically validated curriculum of surgery and interventional medicine that will be able to be used worldwide, so that physicians from around the globe will have access to the expertise and training from leaders within their fields. To this end, Touch Surgery is reaching out to academic institutions and hospital groups to collaborate in developing content for an open surgical education platform.

The medical device industry will also be involved heavily with this process, as surgical education now is incomplete without learning about current tools and devices which are used in operating rooms every single day. Furthermore, Touch Surgery provides a cost effective means of safe introduction of devices and real time evaluation of surgeon education.

Surgeons will be able to use validated Touch Surgery assessment tools to receive real-time feedback, identify areas for attention, and develop their own personalized surgical training pathway to shorten their learning curve to expertise. Surgical training systems will be able to have an overview of a surgeon’s development, and ensure that proficiency is reached and maintained in a quantifiable and standardized manner. Hospitals will be able to use this system to understand surgical performance, and mitigate risk with early identification of problem areas and actionable data, which will become even more critical as systems move towards pay-by-performance reimbursement strategies.

Although there is a lot of work to be done before such a situation exists, the marriage of new technologies and attention to cognitive performance in surgery will allow the rapid development of new surgical training solutions that can transform surgical training and care as we know it.

About the Authors

Andre Chow is a General Surgical Resident with an academic background in Surgical Care quality, Data Analysis and Tissue Engineering. Jean Nehme is a Plastic Surgical Resident with an honors degree in Surgical Simulation and Training. Together with the team at Touch Surgery they share a desire to improve the practice of surgery worldwide using cutting edge and affordable technology. You can contact the team at and


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