Surgical expertise in neurosurgery: integrating theory into practice

: The development of technical skills is a major goal of any neurosurgical training program. Residency programs in North America are focused on achieving an adequate level of training to produce technically competent surgeons. The training requirements and educational environments needed to produce expert surgeons are incompletely understood. This review explores the theoretical implications of training technical skills to expertise rather than competency in a complex field such as neurosurgery. First, the terms technical expertise and technical competency are defined. Definitions of these qualities are lacking in all surgical specialties. Second, the assessment of technical skills of neurosurgeons are investigated using an expert performance approach. This approach entails the design of tasks that can capture the level of expertise in a reproducible manner. One method to accomplish this involves the use of novel simulators with validated performance metrics. Third, the training of technical skills using simulation is studied in the optic of developing training curricula that would target the development of expertise rather than simple competency. Such curricula should include objective assessments of technical skills, appropriate feedback, and a distributed schedule of deliberate practice. Implementing a focus on the development of expertise rather than simple competency in surgical performance will lead to innovative developments in the field of neurosurgical education. Novel technologies, such as simulation, will play important roles in the training of future expert surgeons, and focused technical skills curricula with a sound theoretical basis should guide the development of all such programs.