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Address rehearsal

Harnett, Miriam J.P.; Shorten, George D.

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European Journal of Anaesthesiology: October 2011 - Volume 28 - Issue 10 - p 675-677
doi: 10.1097/EJA.0b013e3283457d12

The Accreditation Council for Graduate Medical Education, which is responsible for the accreditation of post-MD medical training programmes within the United States, has defined six categories of core clinical competencies: medical knowledge, clinical care, interpersonal and communication skills, professionalism, practice-based learning and systems-based practice. This categorisation reflects and defines what it means to be a doctor in the 21st century. In the developed world, medical education, training and licensure has changed to accommodate this broad, demanding view of what constitutes the competent clinician. Of the six domains, patient benefit or health gain emanates directly from clinical care. However, implementation of the European Working Time Directive and other factors have curtailed the number of clinical learning opportunities available to trainees today.1,2 The frequency of these opportunities is an important determinant of how much and how well a trainee learns, in particular for procedural skills.3

Simulation offers a partial solution to this problem: a solution because it offers a safe means by which trainees may enhance their clinical performance,4,5 but partial because simulation-based training is often expensive and time-consuming, and the improvements observed in the simulated environment may not ‘transfer’ to the real world. For procedural skills, there are particular benefits to simulator-based training through deliberate practice and mastery learning.6 Simulation technology is also used routinely for assessment of procedural skills.7 In addition to training and assessment, simulators may offer more direct benefits to patient care by enabling a clinician to ‘warm-up’ and to rehearse a procedure shortly before doing it ‘for real’.

Warm-up is defined as ‘the act or process of warming up for a contest, by light exercise or practice’. The desirable effect of warm-up on physical activity is well recognised, but there are additional benefits of warm-up such as improvement in cognitive skills which allows better focus on the task being undertaken. Warm-up has been shown to be an effective strategy in ballet and tennis as it enhances performance and decreases energy requirements and muscular injuries as well as the time needed to complete the task. Warm-up may provide the opportunity to practise management of problems, which arise during the procedure. Warm-up also appears to decrease the anxiety of practitioners.8

Virtual reality training devices are an increasingly attractive educational option; the running costs are small and, once bought, the devices are available for repeated use and to enable training in repeatable skills. There may be a potential application in their use as a form of warm-up, just before undertaking the ‘real’ (i.e. clinical) procedure. This may allow for the benefits of simulation-based training to improve patient care directly at its point of delivery. The currently available surgical literature supports a number of hypotheses.

  1. Performing a preoperative warm-up exercise before a surgical procedure can improve operative performance.
  2. Improvement appears to occur as a result of both psychomotor and cognitive skill enhancement.
  3. The improvements are independent of the experience of the surgeon; there is no point on the learning curve after which warm-up is not helpful.

Kahol et al.9 have demonstrated a decrease in operating time and incidence of errors by warming up for 15 min before performing a procedure, using exercises designed to target relevant psychomotor and cognitive skills. This warm-up greatly enhanced proficiency during the follow-up procedure. The effect enhanced the performance of novices and experts alike. This is a convincing demonstration that warming up before a demanding activity can enhance performance.

Calatayud et al.10 demonstrated a beneficial effect of a 15-min warm-up on laparoscopic performance in the operating theatre by surgeons who received a preprocedure warm-up using a virtual reality simulator. There was a significant improvement in skill levels over a relatively short period.

These preliminary findings are important in demonstrating an effect with great potential for benefit to patients that extends to surgical and non-surgical procedures. They also pose important new questions.

  1. Does experience moderate the magnitude of a warm-up effect (i.e. will a resident benefit more than an expert)?
  2. What duration of warm-up is optimal and how soon before the procedure should it be carried out?
  3. Should a preoperative warm-up period be required before every procedure?

As answers to these questions emerge, it is conceivable that preprocedure warm-up may become standard practice.

Rehearsal is defined as ‘a practice or trial performance of a play or other work for later public performance’. This differs from training in that it implies that a certain level of proficiency has already been achieved through prior practice. Rehearsal can be regarded as a final ‘run-through’ or a session of specific practice before a planned performance.

Although the concept of rehearsing a specific task is new within the medical field, this is not the case in other high-stake industries. In the fields of music and sport, professional performers routinely rehearse for specific upcoming events. Rehearsal is an integral part of military preparation. The term ‘mission rehearsal’ refers to the practice of specific combat scenarios or military tasks before they are carried out on the battlefield. Apart from acting as an excellent tool to train members of the team, it offers an effective planning opportunity and facilitates assessment of the feasibility of strategic plans.

Over the past 5 years, rapid advances in simulation technology combined with a demand for increased patient safety11 have led to a growing interest in virtual reality simulation as a training tool to prepare physicians for complex procedures without risk to patients. This concept of rehearsal is beginning to appear in the medical literature as a novel way in which simulation can be used to improve procedural performance and patient safety. Patient-specific procedure rehearsal refers to rehearsal of the procedure in a simulated setting using patient-specific data, prior to performing the intervention on the patient. Virtual reality simulation training to proficiency has been recommended in the certification process for carotid stenting. Cates et al.12 have demonstrated that rehearsal for carotid stenting can be performed with currently available virtual reality simulation technology. Willaert et al.13 have demonstrated that a virtual reality rehearsal is a feasible preparatory tool for carotid artery stenting. Operators can practise without risk using an accurate model of the patient's anatomy.

Potential applications of warm-up and/or rehearsal to anaesthetic practice exist for novices, experienced trainees and trained specialists. For novices, the potential exists to warm up on a spinal anaesthetic simulator, for example, MedCAP,14 prior to performing a spinal anaesthetic or to warm up on a variety of ‘intubating mannequin heads’ prior to airway management. More experienced trainees may benefit from warm up of a very specific part of a skill set such as maintaining the needle ‘in plane’ at all times during an ultrasound-guided regional anaesthesia block. For consultants or other independent practitioners, the role of warm-up may be influenced by changes in legislation and regulations. For instance, as a result of the Irish Medical Practitioners Act 2007, ‘it is the duty of the Medical Council to satisfy itself as to the ongoing maintenance of professional competence of registered medical practitioners’ and ‘doctors should have their competence reassessed and reaffirmed periodically’. Experienced practising specialists may welcome the opportunity to ‘warm up’ for a procedure that they perform infrequently or at irregular intervals (e.g. ultrasound-guided central venous catheter insertion).

So what of the future? The effects of a global move to competence based training - recently addressed in an editorial by Van Gessel,15 the requirement for lifelong learning and the maintenance of proficiency in procedural skills, and the development of superior forms of simulator which render patient specific datasets, make both “warm up” and rehearsal feasible adjuncts to doctors’ performance. Whether that is justified will depend on the extent to which real patient benefit is demonstrated for one or other over the next 3–5 years. This information will inform two long contentious debates.

  1. Does the learning effect achieved with simulation-based training transfer to the real world?
  2. At what point in (re)training is it ethically sound for a practitioner to perform procedures on patients?

The potential of warm-up and rehearsal to improve performance of medical procedural skills is evident. Before this potential translates into real patient benefit, specific questions need to be answered. Anaesthesiologists may choose to await the answers provided by others, answer the questions themselves or, best of all, reshape the questions.


G.S. is principal investigator for the project MedCAP, funded by the European Commission: LDV/LLP/TOI/2007/IRL-513.


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© 2011 European Society of Anaesthesiology