As surgical educators, we have seen significant changes occurring in surgery over the past decade, which have had significant impact on the way we train surgeons. Financial constraints, medico-ethical issues of learning new procedures while treating patients, and greater restrictions on the number of hours a resident can work in a week, have all had an impact on opportunities for residents to learn their skills in the operating room [1–3]. As a result, we can no longer rely on the operating room as the sole teaching venue for surgical residents. The authors of this review have focussed on studies looking at factors influencing training and maintaining ureteroscopic skills. They have identified, critiqued and assigned levels of evidence scores based on quality of study design. The learning factors identified integrate well with existing psychomotor frameworks, such as one proposed by Fitts and Posner [4], where acquisition of new skills occurs in three phases: cognitive (steps are learned, movement is erratic), integrative (movements become smoother) and autonomous (procedures flow with little cognitive input). The learning curve of acquiring new skills can be accelerated by using bench, virtual reality, animal and cadaveric models, especially during the cognitive and integrative step. In theory, ‘competence’ can be achieved upon completion of residency. The autonomous phase, may not be achieved until further into independent practice. And finally, to become the expert or master, may require another 10 years of ‘perfect practice’ based on Ericsson’s theory on expertise [5]. It is possible, that ‘proficiency’ could be achieved, in <50 cases, with the appropriate use of a training model and curriculum that stresses and teaches the critical constructs necessary for successful ureteroscopy. It is encouraging to see such interest in surgical education research. It will be a matter of time before we are able to attest to a residents’‘competence’ using valid and reliable high-stakes technical skills assessment tools.


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  • 1
    Bridges M, Diamond DL. The financial impact of teaching surgical residents in the operating room. Am J Surg 1999; 177: 2832
  • 2
    Cook M, Irby D, Sullivan W, Ludmerer KM. American medical education 100 years after Flexner report. N Engl J Med 2006; 355: 133944
  • 3
    Carlin AM, Gasevic E, Shepard AD. Effect of the 80-hour work week on resident operative experience in general surgery. Am J Surg 2007; 193: 3269
  • 4
    Fitts PM, Posner MI. Human Performance. Belmont: Brooks/Cole, 1967
  • 5
    Ericsson KA. The acquisition of expert performance: an introduction to some of the issues. In EricssonKA ed., The Road to Excellence: the Acquisition of Expert Performance in the Arts and Sciences, Sports, and Games, Mahwah: Lawrence Erlbaum Associates, 1996: 150