Applying Deliberate Practice to Plastic Surgery Residency Training

Purpose: To assess the impact of K. A. Ericsson's theory of deliberate practice¹ on resident education by evaluating procedure times of breast reconstruction utilizing transverse rectus abdominis myocutaneous (TRAM) flaps.

Methods: TRAM flap breast reconstruction cases with resident participation at the Moffitt Cancer Center from 2009-2011 were retrospectively reviewed.  Residents were trained according to the deliberate practice didactic model over their four-month rotations and were trained along a continuum of increasing resident independence.^{2, 3, 4} Operative times were assessed and categorized into the 1^st, 2^nd, 3^rd, and 4^th months of the rotation to determine improvement in operating room efficiency.

Results:  A total of 75 cases (n=75) met inclusion criteria.  The median procedure duration for the 1^st, 2^nd, 3^rd, and 4^th months was 5.63 hrs, 5.17 hrs, 4.93 hrs, and 4.80 hrs, respectively.  While the decline in procedure time during the four-month intervals was not statistically significant (p=0.2440), the correlation coefficient for operative times for these same cases was significant (r=‐0.25, p=0.048).

Conclusions: This study marks the first application in the surgical literature of the theory of deliberate practice to a complex skill set.  The data shows a decrease in operative times over each month interval of the residents' rotations.  Further evaluation is warranted to determine whether this didactic model can be formalized and potentially accelerate the acquisition of the complex skill set required for breast reconstruction. 

Table:

Procedure Duration of TRAM Cases
Statistical Variable	Month 1	Month 2	Month 3	Month 4	P Value
Number of Cases	n = 17	n = 21	n = 16	n = 21	p = 0.2440
Mean Procedure Duration (Hours)	6.16	5.21	5.20	5.24
Standard Deviation	1.80	1.44	0.98	1.39
Median Procedure Duration (Hours)	5.63	5.17	4.93	4.80
Procedure Duration Range (Hours)	4.2 – 11.6	2.8 – 7.5	3.2 – 6.7	3.6 – 7.6

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