Surgical simulation applications have been largely limited to the acquisition and assessment of technical skills. Current teaching and assessment of surgical judgment is nonsystematic and prone to error. Interest in methods to enhance the acquisition and assessment of knowledge-based (judgment) skills for intraoperative decision making has led to the application of cognitive task analysis (CTA) and human error assessment to facilitate this process. CTA-based delineation of the steps and hazards of a surgical procedure creates a structured process to teach and assess expert surgical judgment and improves trainees' operative planning, hazard recognition, error prevention, and error recovery when coupled with low-fidelity, synthesized simulation models for open and laparoscopic surgery. Web-based simulation applications facilitate curricular learning (rules-guided skills), allow cognitive rehearsal of procedures, and are accessible independent of location and time. Simulation applications that facilitate the assessment and learning of expert intraoperative judgment should include a consensus-derived outline based on CTA of the operative steps and potential points of risk for each surgical procedure; the ability to detect the situational awareness of the performer and the options considered to avoid error at critical steps; an assessment (scoring) of options considered or attempted; immediate evaluation feedback to inform improved performance; and a program of deliberate practice in which progressively more challenging scenarios can be introduced, based on the trainee's demonstrated skills. High-fidelity simulators currently lack these essential components, and future simulation-assisted teaching and assessment of surgical judgment skills are likely to employ low-fidelity simulators coupled to Web-based instruction.
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