Learning and mastering surgical skills is often seen as a combination of innate talent and long hours of practice. However, this traditional view has been largely challenged by the theory of deliberate practice developed by Dr. K. Anders Ericsson, and more recently applied concretely in the surgical field by clinical researchers such as Pr. Philippe Liverneaux.
A renowned surgeon and researcher in the field of microsurgery and robotic surgery, the
In this article, we will explore the fundamental principles of deliberate practice, drawing not only on the work of the
Deliberate practice: a solid theoretical framework
According to Dr. Ericsson Ericsson, deliberate practice is a form of intensive, thoughtful training, structured to maximize skill gains. It rests on several essential pillars:
- A clear and precise objective: Each training session must be designed around mastering a specific aspect of the skill.
- Immediate feedback: Errors need to be identified and corrected in real time, so that the technique can be adjusted immediately.
- Stepping out of your comfort zone: Effective learning occurs when the practitioner strives to go beyond his or her current limits.
- Repetition and continuous adjustment: Repetition is essential, but it must always be accompanied by adjustment based on feedback.
These principles differ from simple “naive practice” (or automatic repetition), which consists of reproducing a gesture without feedback or a precise goal. Deliberate practice transforms every act into an opportunity for improvement.
Pr. Liverneaux to deliberate surgical practice
Le Pr. Philippe Liverneaux, pionnier de la chirurgie robotique et de la microchirurgie (cf “Cycle Santé 2021 | L’avenir de la microchirurgie passe-t-il par la robotique ?“, a été l’un des premiers à intégrer formellement la théorie de la pratique délibérée dans l’enseignement chirurgical. Son approche se fonde sur l’idée que les chirurgiens peuvent améliorer leurs compétences non seulement par la répétition d’interventions réelles, mais aussi par des exercices hautement ciblés et structurés dans des environnements simulés ou avec des outils technologiques avancés.
1. Microsurgical simulation and robotics: Environments for optimized deliberate practice
Pr. Liverneaux has developed microsurgery training programs incorporating high-fidelity simulators and virtual reality devices. These tools make it possible to recreate complex operations and perform ultra-precise gestures without endangering patients.
In these environments, repetition becomes an asset. For example, microsurgery students can practice suturing vessels just a few millimeters in diameter, or reconnecting severed nerves under a microscope. Robotics, a field in which Pr. Liverneaux has worked extensively in, offers unprecedented precision and enables fine-tuned assessment of the surgeon’s performance, thanks to the data collected by robotic systems. These tools also provide immediate feedback on the precision of gestures and the effectiveness of techniques, thus respecting one of the fundamental principles of deliberate practice.
Pr. Liverneaux has also shown that these simulators not only allow errors to be corrected more quickly, but also enable more substantial progress to be made in less time. Unlike unsupervised practice, where errors can become habits that are difficult to correct, simulation in a deliberate practice setting allows us to focus on specific objectives such as reducing tremors or improving manual dexterity.
2. Structured learning based on targeted repetition
Pr. Liverneaux’s work shows that breaking down surgical skills into specific micro-tasks is a key element of deliberate practice. In surgery, certain critical steps, such as opening tissue or placing fine sutures, are more difficult to master than others. By focusing on these specific tasks, surgeons can improve faster than by simply training to perform complete procedures.
In this context, Prof. Liverneaux proposes a step-by-step training program, in which each phase of the surgical procedure is isolated and repeated to perfection. In reconstructive microsurgery, for example, the surgeon can focus solely on vascularization of the flaps, a key gesture, before moving on to other, more complex parts of the procedure. This type of segmentation enables rapid mastery of critical skills, before integrating these micro-skills into more complex procedures.
3. The central role of feedback in surgical education
Another important element in Pr. Liverneaux’s work is the emphasis placed on immediate, detailed feedback. Thanks to augmented reality systems and robotic simulators, surgeons can obtain real-time information on their performance: the angle of instruments, the force applied or the quality of sutures are precisely measured.
In addition, mentoring remains central to surgical training. Pr. Liverneaux argues that direct feedback from an expert after each training session ensures that mistakes are corrected immediately, and do not become bad habits. He has also set up review programs, where surgeons view recordings of their performance to identify areas for improvement themselves, thus reinforcing their learning.
4. The importance of getting out of your comfort zone: Managing complex scenarios
Pr. Liverneaux also advocates that even experienced surgeons should regularly practice difficult or unusual scenarios. In his training centers, surgeons in training are confronted with simulations of rare or complex cases, such as emergency situations or unexpected complications (such as haemorrhage or nerve damage).
These simulations not only develop technical skills, but also reinforce stress management and rapid decision-making, two crucial aspects of surgical practice. The ability to step out of one’s comfort zone, while remaining in a safe learning environment, promotes faster learning and greater resilience.
The challenges and limitations raised by Pr. Liverneaux
Although Pr. Liverneaux’ work shows enormous potential for surgical training, there are still a number of challenges to be overcome.
- The cost of technology and infrastructure
The high-fidelity simulators and robotic tools used in deliberate practice represent a significant financial investment. Training establishments must have the resources to acquire and maintain these technologies. What’s more, learning to use these technologies requires time and specialized supervision.
- The need to create a feedback culture
Although immediate feedback is a pillar of deliberate practice, there is still resistance in some surgical circles to establishing a culture of systematic feedback. Some surgeons, especially those with more experience, may be reluctant to accept constant criticism, even if it is constructive. The work of Pr. Liverneaux’s work shows, however, that feedback is essential for optimal learning.
- Fatigue and time management
Integrating deliberate practice into an already busy schedule can be a challenge, especially for young surgeons juggling long on-call hours and other clinical responsibilities. It is therefore crucial to optimize training time to allow for regular deliberate practice sessions, even in a tight schedule.
- The need to engage a surgical expert
A surgical expert needs to be able to dedicate himself to analyzing and debriefing other surgeons. This analysis is often long and tedious, but should be simplified in the years to come with the development of specific artificial intelligence (this will be the subject of another article). It is also important that the surgeon analyzing and commenting on the surgeries is an expert recognized by his or her peers, and that the “learners” are committed to improving their own practice if this innovative teaching technique is to bear fruit.
The work of Pr. Philippe Liverneaux is making a major contribution to the application of the principles of deliberate practice in the field of surgery. By integrating advanced technologies such as robotic simulation and virtual reality, he has created a surgical training framework that enables rapid and thorough mastery of technical and cognitive skills. Prof. Liverneaux’s approach shows that targeted repetition, accompanied by precise and immediate feedback, can develop highly skilled surgeons, capable of handling complex situations with calm and precision. This concept is now being developed, in clinical practice, for osteosynthesis surgeries, where the need for analysis is greater because the number of metrics (these surgeries do not use robots) going back to the evaluator is much smaller. We have therefore created an evaluation system that is the least subjective possible (this will be the subject of a future article).
Although this approach has its challenges, particularly in terms of cost and feedback culture, the benefits in terms of improving surgical skills are clear: it significantly reduces the time on the learning curve for surgical techniques. By combining Dr. Ericsson’s theory of deliberate practice with Dr. Ericsson’s practical innovations, the benefits are clear. Ericsson’s theory of deliberate practice and Dr. Liverneaux Liverneaux, surgery enters a new era of more rigorous and effective training, paving the way for sustainable surgical excellence.
Pour poursuivre le sujet, vous pouvez consulter l’article “Skylab : L’innovation au service de la formation chirurgicale dans le bassin ligérien“
