Kognitivno ohranjanje kirurških spretnosti v času COVID-19 epidemije

The COVID-19 pandemic: Cognitive training for the prevention of skill decay in non-performing orthopaedic surgeons

by Robi Kelc, et al.


Surgical tasks are prone to skill decay. During unprecedented circumstances, such as the COVID-19 pandemic, many orthopaedic surgeons are not performing specific surgical procedures for an uncertain period of time. Not being able to execute regular surgical tasks or use surgical simulators, skill decay can be prevented with regular mental practice, a scientifically proven skill acquisition and retaining tool. The paper describes different theories on cognitive training answering the question on how it works and offers a brief review of its application in surgery. Additionally, practical recommendations are proposed for performing mental training while not performing surgical procedures.


Surgical tasks combine many gross and fine motoric actions in a strict time frame, demanding a high degree of accuracy. As such, surgical skills usually present with a flat learning curve, especially if minimally invasive. However, once acquired, surgical skills are prone to decay, especially after a period of non-use [20, 24]. Other important risk factors affecting decay are time pressure and the quality of the job performed [30], both being vital components of surgical performance.

During special circumstances, such as an epidemic, many orthopaedic surgeons are being relocated to working environments away from their field of expertise, thereby not performing specific surgical procedures for a period of time. Not being able to perform regular surgical tasks or use surgical simulators, the prevention of skill decay can be achieved through regular mental practice, a scientifically proven skill acquisition and retaining tool.

Mental practice or imagery, a form of cognitive training is a symbolic rehearsal of a physical activity in the absence of any gross muscular movements [19]. It is widely implemented in sports where it has long been used with success in enhancing the performance of elite athletes [17] and in certain other areas, such as aviation[8], professional music, and surgery. All these fields share crucial similarities, such as the importance of technical skills, performance under stressful conditions, and aiming for perfection without making mistakes. Mental practice improves a variety of different motor skills in sports, as well as acquisition, physical strength [23] and technique performance [26], hence its application in surgery is not only scientifically justified but also of common sense.

It is believed that experienced subjects may benefit more from mental practice on physical tasks because of the requisite schematic knowledge to imagine an accurate and a precise outcome associated with the imagined performance [18]. For example, experienced athletes have better visualizing abilities and employ more structured mental practice session in comparison to novice [6]. However, mental practice has recently gained on popularity also regarding novice surgeons, surgical trainees and medical students learning new surgical techniques. Cognition, integration and automation are typical steps in learning new surgical skills [9], the first one or two being most decay-susceptible and therefore a subject of interest for mental practice as a retaining tool.

In this article a brief theoretical background of cognitive training is provided, followed by its application in surgery and surgical education. Finally, recommendations are provided for novice and expert surgeons for performing cognitive training while not performing for a long or uncertain period of time.

Theoretical basis for cognitive training

The motor system has been hypothesised to be a part of a cognitive network including a variety of psychological activities. During cognitive training and real-life motor tasks, similar neural paths are being activated. In musicians, a close relationship between motor imagery and motor action has been described, for example changes in corticospinal activity with the same muscles involved in both circumstances [5].

There are different theories on why mental practice improves motor skills [28]. The psychoneuromuscular theory proposes that mental training causes similar activation pattern of muscles as actual movements [11]. The symbolic learning theory postulates that symbols are coding the sequence of movements [21]. The repetitions of symbolic components of the movement pattern facilitates execution of an actual motor pattern [7]. A more recent theory suggests that motor imagery and motor performance are functionally equivalent, thereby suggesting that in both the same underlying neural structures and mechanisms are involved [12].

Cognitive training in surgery

Surgery as a medical specialty containing complex psychomotor and cognitive tasks is without any doubt a subject of skill decay when tasks are not being performed for a certain period [1]. It is not only a question of one’s interest but also a surgeon’s duty to master the skills and retain them. In times of unprecedented conditions, such as recent COVID-19 epidemic, many elective surgical procedures are begin cancelled, orthopaedic being among the first on the list. Novice surgeons and surgical trainees usually find themselves in cognitive and integrational phases of learning thus being especially vulnerable for the decay of their skills which can happen after a short retention interval [25]. On such occasions, cognitive training can be of critical importance as it has been proven to enhance knowledge of a procedure, flow of an operation and preparedness for the task [13].

There are numerous techniques of cognitive training. At a novice level, cognitive task analysis (CTA) training has been shown to be the most effective, a method by which experts are used to construct a teaching program for novices by intuitive knowledge and thought processes [27, 29]. CTA has recently been proven to be an effective technique in hip arthroplasty, where its use resulted in shorter procedure time, decrease in the number of errors and increase in accuracy of acetabular cup orientation [14]. However, CTA requires a mentor to be present, which is probably inaccessible in an epidemic situation. In this case, other techniques of cognitive training, such as external observative and subvocal training are also potentially useful. In the former, a surgeon is an observer of a skill that is to be learned whereas in the latter a visual image is being called up by a surgeon through external or self-talk [10].

Cognitive training is not beneficial for novice surgeons only. The most experienced surgeons report going over the procedures in “their mind’s eye” and consider mental readiness the most important type of preparation, followed by technical and physical readiness [22]. It has been shown that in experts not only the same regions of the brain are being engaged during visual imagery as in novices, but also additional regions are recruited suggesting that the pattern of activation moves from frontal parts at the beginning of the process to posterior parts responsible for retrieval of domain specific knowledge around the final expertise stage [2]. While cognitive specific skills tend to be the focus of novice subjects who are learning specific movements, cognitive general skills are usually used more by experts that link the skills together. Additionally, experts often use motivational and arousal techniques to enhance overall performance by setting specific goals and managing stress and relaxation [15, 16].

Recommendations for surgeons

Cognitive training in combination with physical training impacts performance to a greater extent than physical training only. In the absence of specific elective surgical procedures, cognitive training is the only skill acquisition and retaining tool that can and should be used constantly. The literature suggests that mental practice should be brief and focused and should be optimally carried out for 20 minutes in a singular session, since extended mental practice may lead to loss of concertation  [3, 4].

Training by observation

For mental practice to be effective, the subject must be familiar with the surgical procedure prior to the imagery session [4]. It is not useful for one to mentally practice a complex procedure, if the individual is not familiar with the procedure and its flow. In such a situation, external observational training should be performed first. This could be realized through observation of recordings from trusted sources (i.e. VuMedi, clips from industrial educational websites, YouTube with well-known surgeons performing, etc.), surgical technique guides and textbooks. Observing a recording can be followed only by listening to its audio component and visualizing the procedure instead of watching it.

Subvocal imagery

Subvocalization is a natural process of internal speech typically made when reading. In terms of surgical training, visual images are recalled by an internal self-talk [10]. This type of training represents not only a possible next step of external observative training but also a practical way of performing mental imagery training for more experienced surgeons. Especially novice surgeons should pay attention to every detail in a systematic manner (i.e. patient positioning before shoulder arthroscopy, trocar insertion, opening of the water inflow valve, rotating the optics, identify intra-articular structures etc.), whereas more experienced surgeons can focus more on a specific difficult step (i.e. placing stitches to a cuff tear and performing a specific knot).

Ideomotoric training

Ideomotoric training technique implies the movement patterns imagined several times, visualized and verbalized by a highly trained expert to facilitate a procedure execution 30. The subject visualizes movements from the inner perspective, imagining him or herself performing the procedure [10]. To include motivational and arousal components of cognitive training, the sensory aspects of the procedures should be included as much as possible. One should recall the atmosphere in the operating theatre such as the team, temperature, light, and even background music and the sounds produced by the anaesthetic machine. Furthermore, the trainee should try to feel the tactile properties of instruments and tissues (i.e. visualize the PDS suture and how tricky it is to catch it with a tissue grasper in a narrow space or the challenging passage of the endobutton in cortical ACL fixation). Additionally, potential intra-operative complications and their management (i.e. displacement of implants after using all-inside meniscal devices or suture anchor pull-out after tying a knot in rotator cuff repair) are not to be left out.


In extraordinary conditions, such as recent COVID-19 pandemic, orthopaedic specific surgical skills are prone to decay as elective procedures are being widely cancelled. Cognitive training has been shown to be an effective tool for performance improvement when performed alone or in combination with motor training under ordinary situation. In case of limited access to actual performance, mental practice seems to be reasonable if not mandatory for novice and experienced surgeons. Not only would such training prevent surgical skill decay but probably also lower the anticipatory anxiety level once returning back to the operating theatre.


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