Defining Essential Skills

Rank

Surgeons [10] n = 101

Mean score (1–5)

Residents [9] n = 67

Mean score (1–5)

Surgeons-residents n = 195 [11]

Mean score (1–5)

Anatomical knowledge

3.86^a

Anatomical knowledge

4.4

Anatomical knowledge

4.63^b

Triangulation/depth perception

3.34^a

Spatial perception

4.3

Triangulation

4.43^b

Spatial perception

2.77^a

Triangulation/ depth perception

4.2

Spatial perception

4.29^b

Manual dexterity

2.86^a

Manual dexterity

4.2

Tactile sensation

4.00^b

Tactile sensation

2.05^a

Tactile sensation

3.7

Manual dexterity

3.85^b

^aSignificantly different (p < 0.001) [10]

^bSignificantly different (p < 0.001) [11]

Table 5.2

Ranking of important specific skills for a trainee to possess prior to performing in operating room

Rank	Surgeons [10] n = 101	Mean score (1–5)	Residents [9] n = 67	Mean score (1–5)	Surgeons-residents n = 195 [11]	Mean score (1–5)
1	Precise portal placement	4.7^a	Triangulating the tip of the probe with a 30° scope	4.6	Precise portal placement	4.56^b
2	Triangulating the tip of the probe with a 30° scope	4.6^a	Precise portal placement	4.5	Triangulating the tip of the probe with a 30° scope	4.41^b
3	Identification of lateral and medial compartment	4.4^a	Identification of lateral compartment	4.4	Insertion of the arthroscope	4.23^b
4	Identification of notch, ACL, and PCL	4.3^a	Identification of posterolateral compartment	4.4	Patient positioning	4.29^b
5	Insertion of the arthroscope	4.2^a	Shaving of synovium, cartilage, and meniscus	4.4	Entry of all compartments	4.24^b

^aSignificantly different (p < 0.001) [10]

^bSignificantly different (p < 0.001) [11]

Table 5.3

Results of the ESSKA survey

Specific skills	Priority level	Rank	Median	Mean
Sterility	Level 1^a	1	5	4.6
Knowledge of pathology	Level 1^a	2	5	4.37
Patient positioning	Level 1^a	3	5	4.33
Preparation before the start of the operation	Level 1^a	4	5	4.3
Knowledge of equipment	Level 1^a	5	4	4.2

Level 1: high level priority

^aItems with p < 0.001

In all three surveys, knowledge on anatomy of the knee joint is ranked as priority number one, with tactile sensation and manual dexterity less important skills to possess (Table 5.1). Analysis of more specific arthroscopic skills as presented in Table 5.2 and does indicate precise portal placement as one of the priority skills to possess which has tactile sensation as important cue as surgeons need to palpate the area where the portal is made. Table 5.2 also highlights triangulation and identification as important skills to possess, which can be very well trained in a simulated setting as is discussed in the chapters to come. Notice that the residents feel that they should also be trained in using the shaver. This can be explained by the fact that it requires additional complex instrument handling with activation of the shaver being combined with precise placement of the shaver tip, avoidance of damaging the arthroscope lense, and verification of correct tissue removal. This could be a typical example of experts being so used to this skill and perform it without thinking of all steps that need to be taken, that they have forgotten the initial complexity of this skill.

Also detailed results of the ESSKA survey are presented in Table 5.3, as they indicate the top five of equally important surgical skills with a preferred level of priority, which have a noticeable emphasis on knowledge, such as knowledge on sterility of pathology, and of equipment. Also these skills can be very well trained in a simulated digital e-learning environment away from the patient with assessment of the trainees competency been taken place before continuation of training in the operating room (see Chap. 9).

5.3 Translating Skills in Measurable Learning Objectives

Some theories on human behavior can assist the translation of the general description of an arthroscopic skill (e.g., triangulation or shaving) into a learning objective or set of learning objectives that can be monitored and assessed objectively. Both the Rasmussen model of human behavior and the Fitts and Posner model of learning psychomotor skill are introduced [12, 13].

To start with the Rasmussen model, this model distinguishes three levels of behavior: skill-based, rule-based, and knowledge-based.

5.3.1 Skill-Based Behavior

Skill-based behavior represents behavior that takes place without conscious control. An example of such behavior in everyday life is cycling or tying your shoe laces. Analogous to this, basic psychomotor skills that are required to perform arthroscopy is triangulation or shaving. Since these actions take place without conscious control once mastered, it can be difficult for trainers to explain how to perform these actions as they “literally” do not need to think about that action. See for example the difference in priority ranking between experts and residents in Table 5.2, where shaving is ranked in the top five by the residents.

5.3.2 Rule-Based Behavior

Rule-based behavior is represented by task execution that is based on prescribed rules or procedures. An example of this behavior is stopping your car when the traffic light is red [12]. The red light is the sign that triggers the rule which is stopping the car. Applied to arthroscopy, an example of rule-based behavior is the recognition of the pathology. Once this task is executed, the next step is triggered, which in this case is the appropriate intervention.

5.3.3 Knowledge-Based Behavior

Knowledge-based behavior is the highest level of complexity of human behavior, which is seen in unfamiliar situations that require a complete analysis of the situation and for which prescribed rules do not apply. The overall goal is known, but several scenarios are mentally evaluated from which one is selected. Applied to arthroscopy, this type of behavior is triggered in case an uncommon complication is encountered or when standard equipment cannot be used to execute the intended intervention (e.g., the patient is a child).

Considering the Rasmussen model, skilled-based behavior targets actual instrument handling, which is best trained by actual performance of these actions in a standardized simulated environment [14, 15]. Some rule-based skills can be trained as well in simulated environments. This depends on the fidelity level and the extensiveness of exercises and pathology that are offered by the simulators (see Chaps. 6 and 7). Notice that quite some ruled based and knowledge-based behavior does not require actual instrument handling but rather correct decision-making. This could also be trained in an e-learning environment with patient cases that are illustrated by medical images and arthroscopic videos (see Chap. 9). Eventually, competency in knowledge-based behavior is what defines a “good surgeon,” and this requires the integration of cognitive skills with the actual instrument handling in real-life situations [8]. To assess this, a more holistic approach of assessment is needed for example by using Global rating Scales as is presented in Chap. 10.

5.3.4 Model of Learning Psychomotor Skills

To train the psychomotor skills that are specifically required for basic skills in arthroscopy, the model of learning psychomotor skills can be applied [13], which consists of three stages:

5.3.4.1 Cognitive Stage

In the cognitive stage, tasks are well-defined and appropriate consecutive actions are listed that are needed to accomplish the task goals. This stage usually interacts with the knowledge of the trainee. In other words, one must have enough theoretical information to complete the cognitive stage. Characteristic of this stage is that the trainee must think about the execution of each action before doing so, which results in slow and intermittent actions.

5.3.4.2 Associative Stage

Once the cognitive stage is accomplished, the trainee can focus on the details of the actions to achieve task completion. In this transient associative stage, the required actions are split into simple sensorimotor skills and smooth transition between these skills is exercised. This results in reducing the time consumed for thinking about the action, but actions are not fluent yet.

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