Visuo-Spatial Tests and Surgery
There have been a spate of studies over decades looking at visuo-spatial abilities and how they might relate to surgery. Historically, studies attempted to correlate higher levels of visuo-spatial abilities with better technical performance in surgical trainees. The idea was that these visuo-spatial measures could be used to select trainees that would later make good surgeons.1 This is problematic for multiple reasons.
First, this assumes that spatial skills are fixed traits. They are not.2 In a meta-analysis of over 200 studies, Uttal et al found that spatial skills are malleable across the lifespan. Even more important, these skills are trainable. How does one train these skills? Primarily by performing spatial tasks—even just taking repeated tests of spatial abilities led to signficant improvements in the control groups.
So selecting surgical trainees based on pre-existing visuo-spatial skills is short sighted, and promotes an inappropriately fixed mindset regarding surgical abilities and potential.3
Second, this assumes that spatial skills (as assessed in traditional psychometric tests) actually matter for surgery. While common sense alone would make one question exactly how much relevance ability at tasks like card rotation, paper folding, or cube comparison actually matter when it comes to performing a surgery, we have actual evidence that this is not the case.
If psychometric spatial skills mattered for surgery, then expert surgeons should be far better at these spatial skills tests than trainees. This is not the case.4-6 When studied, the psychometrically determined spatial skills of expert surgeons are similar to or lower than medical students.
Several studies have looked at the spatial abilities of surgical novices and reported that novices with higher levels of spatial skills are able to pick up complicated surgical tasks more quickly than their peers.1,4,7 This suggests that there may be some partial overlap between the abilities required to perform well on spatial skills tests and the ability to perform a new surgical task, but this difference rapidly disappears with experience. As early as residency, but certainly for attending surgeons, spatial ability stops correlating with ability.4,6,8
This is not surprising, given the trainability of spatial skills described above, and the extensive practice that surgical training involves.
Third, these psychometric tests purport to measure some sort of general “spatial ability”, but we know that expertise, and even specifically, perceptual expertise, are domain specific.9,10 Expert radiologists are no better than laypeople at Where’s Waldo.11
So why would a general marker of spatial ability matter for a highly-specific domain such as surgery?
So general psychometric spatial skills tests should not be used to select surgical trainees, and probably shouldn’t be involved much at all in surgical training.
And yet, learning to see is a major component of surgical training. Cope et al call this “sensory semiosis”—the ability to convert the visual and haptic stimuli in the OR into an accurate mental map of the anatomy in front of you.12 Like other visual/spatial skills, this should be trainable. And we clearly don’t do a perfect job, otherwise 97% of bile duct injuries wouldn’t be related to errors in perception.13
We need to heed the advice of perceptual learning researcher Philip Kellman (and Eleanor Gibson long before him), and move the study of perception away from sterile psychometrics and back into the real world.10 After all, what is the relevance of visuo-spatial skills to surgery if not to allow for the accurate and fluent perception of the operative field?
Perceptual learning (PL) is specifically designed to teach the learner how to extract information from rich, multidimensional stimuli such as the operative field. A full explanation is beyond the scope of this post, but PL basically involves repeated exposure to novel stimuli, training the eye to recognize previously hidden invariant patterns within the noise of a complex visual field. It is essentially how surgeons learn to recognize anatomy now (see it over and over again in the operating room), but on hyperdrive. In the same amount of time it takes to do a single operation, one can attempt to identify the cystic duct 1000s of times across 100s of operations.
Old school, fixed, general psychometric measures of spatial skill have limited application to surgical training. But surgical training could benefit from novel methods to train domain-specific visual and spatial abilities, using tools such as perceptual learning and operative videos. These tools already have a great deal of scientific support behind them—they just need to be tested, and then actually implemented, in surgical training.
Citations
1 Wanzel, Kyle R, Stanley J Hamstra, Dimitri J Anastakis, Edward D Matsumoto, and Michael D Cusimano. “Effect of Visual-Spatial Ability on Learning of Spatially-Complex Surgical Skills.” The Lancet 359, no. 9302 (January 19, 2002): 230–31. https://doi.org/10.1016/S0140-6736(02)07441-X.
2 Uttal, David H, Nathaniel G Meadow, Elizabeth Tipton, Linda L Hand, Alison R Alden, Christopher Warren, and Nora S Newcombe. “The Malleability of Spatial Skills: A Meta-Analysis of Training Studies,” 2013, 51.
3 Dweck, C. S. (2006). Mindset: The new psychology of success. New York: Random House.
4 Wanzel, Kyle R, Stanley J Hamstra, Marco F Caminiti, Dimitri J Anastakis, Ethan D Grober, and Richard K Reznick. “Visual-Spatial Ability Correlates with Efficiency of Hand Motion and Successful Surgical Performance.” Surgery 134, no. 5 (November 1, 2003): 750–57. https://doi.org/10.1016/S0039-6060(03)00248-4.
5 Francis, N. K., G. B. Hanna, A. B. Cresswell, F. J. Carter, and A. Cuschieri. “The Performance of Master Surgeons on Standard Aptitude Testing.” American Journal of Surgery 182, no. 1 (July 2001): 30–33. https://doi.org/10.1016/s0002-9610(01)00652-3.
6 Keehner, Madeleine M, Frank Tendick, Maxwell V Meng, Haroon P Anwar, Mary Hegarty, Marshall L Stoller, and Quan-Yang Duh. “Spatial Ability, Experience, and Skill in Laparoscopic Surgery.” The American Journal of Surgery 188, no. 1 (July 1, 2004): 71–75. https://doi.org/10.1016/j.amjsurg.2003.12.059.
7 Abe, Takashige, Nicholas Raison, Nobuo Shinohara, M. Shamim Khan, Kamran Ahmed, and Prokar Dasgupta. “The Effect of Visual-Spatial Ability on the Learning of Robot-Assisted Surgical Skills.” Journal of Surgical Education 75, no. 2 (March 1, 2018): 458–64. https://doi.org/10.1016/j.jsurg.2017.08.017.
8Stefanidis, Dimitrios, James R. Korndorffer, F. William Black, J. Bruce Dunne, Rafael Sierra, Cheri L. Touchard, David A. Rice, Ronald J. Markert, Peter R. Kastl, and Daniel J. Scott. “Psychomotor Testing Predicts Rate of Skill Acquisition for Proficiency-Based Laparoscopic Skills Training.” Surgery 140, no. 2 (August 1, 2006): 252–62. https://doi.org/10.1016/j.surg.2006.04.002.
9 Ericsson, K. Anders, and Tyler J. Towne. “Expertise.” WIREs Cognitive Science 1, no. 3 (2010): 404–16. https://doi.org/10.1002/wcs.47.
10 Kellman, Philip J., and Patrick Garrigan. “Perceptual Learning and Human Expertise.” Physics of Life Reviews 6, no. 2 (June 2009): 53–84. https://doi.org/10.1016/j.plrev.2008.12.001.
11 Nodine, C. F., and E. A. Krupinski. “Perceptual Skill, Radiology Expertise, and Visual Test Performance with NINA and WALDO.” Academic Radiology 5, no. 9 (September 1998): 603–12. https://doi.org/10.1016/s1076-6332(98)80295-x.
12 Cope, Alexandra C. MRCS, Stella Mavroveli, Jeff Bezemer, George B. FRCS Hanna, and Roger FRCS Kneebone. “Making Meaning From Sensory Cues: A Qualitative Investigation of Postgraduate Learning in the Operating Room.” Academic Medicine 90, no. 8 (August 2015): 1125–31. https://doi.org/10.1097/ACM.0000000000000740.
13 Way, Lawrence W., Lygia Stewart, Walter Gantert, Kingsway Liu, Crystine M. Lee, Karen Whang, and John G. Hunter. “Causes and Prevention of Laparoscopic Bile Duct Injuries: Analysis of 252 Cases from a Human Factors and Cognitive Psychology Perspective.” Annals of Surgery 237, no. 4 (April 2003): 460–69. https://doi.org/10.1097/01.SLA.0000060680.92690.E9.