Original communication| Volume 143, ISSUE 1, P140-145, January 2008

Implicit motor learning in surgery: Implications for multi-tasking

Published:November 30, 2007DOI:


      Implicitly learned motor skills are characterized by minimal conscious knowledge of the movements involved and stable performance despite stress, fatigue, or multi-tasking. In contrast, explicitly learned motor skills are characterized by conscious knowledge of the movements and performance that tends to be less stable under stress, fatigue, and multi-tasking. We examined the acquisition of a basic surgical skill in three observational learning treatment conditions designed to accomplish implicit or explicit motor learning. We then tested performance in conditions that emulated multi-tasking in the operating theater. Our intention was to elaborate current understanding of implicit and explicit processes that underpin observational learning in the surgical environment.


      Thirty-six novice adults were assigned randomly to an observation-only, an instructed-observation, or a guided-observation treatment condition, in which they learned to perform a suturing and knot-tying task in a Learning Phase. Their performance during multi-tasking was then assessed objectively by motion analysis during a Test Phase.


      In the Learning Phase, performance improved equally in the treatment conditions throughout learning, with participants using fewer hand movements and completing the task more quickly. Participants in the observation-only and the guided-observation treatment condition, however, reported significantly less movement-related knowledge than participants in the instructed-observation condition. In the Test Phase, participants in the instructed-observation condition exhibited slower completion times and more hand movements when they were required to multi-task, whereas in the observation-only and the guided-observation treatment condition, participants showed stable performance.


      A surgical skill that is learned by observation alone or by observation accompanied by guidance to reduce the number of errors that are committed tends to be learned implicitly and to have stable performance during multi-tasking. The efficacy of observation for acquiring technical skills implies that, at least for some skills, verbal instructions may not be necessary.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Schmidt R.A.
        Motor Learning and Performance.
        Human Kinetics, Champaign, Illinois1991
        • Custers E.J.
        • Regehr G.
        • McCulloch W.
        • Peniston C.
        • Reznick R.K.
        The effects of modeling on learning a simple surgical procedure: See one, do one or see many, do one?.
        Adv Health Sci Educ. 1999; 14: 123-143
        • Wanzel K.R.
        • Ward M.
        • Reznick R.K.
        Teaching the surgical craft: From selection to certification.
        Curr Prob Surg. 2002; 39: 573-660
        • Howard J.R.
        • Mutter S.A.
        • Howard D.V.
        Serial pattern learning by event observation.
        J Exp Psychol: Learn Mem Cogn. 1992; 18: 1029-1039
        • Willingham D.B.
        Implicit motor sequence learning is not purely perceptual.
        Mem Cognit. 1999; 27: 561-572
        • Kirk R.M.
        Teaching the craft of operative surgery.
        Ann R Coll Surg Eng. 1996; 78: 25-28
        • Masters R.S.W.
        Knowledge, knerves and know-how: The role of explicit versus implicit knowledge in the breakdown of a complex motor skill under pressure.
        Brit J Psychol. 1992; 83: 343-358
        • Masters R.S.W.
        • Law J.
        • Maxwell J.
        Implicit and explicit learning in interceptive actions.
        in: Davids K. Savelsbergh G. Bennett S. van der Kamp J. Interceptive actions in sport: information and movement. Routledge, London2002: 126-143
        • Masters R.S.W.
        • Maxwell J.P.
        Implicit motor learning, reinvestment and movement disruption: What you don’t know won’t hurt you?.
        in: Williams A.M. Hodges N.J. Skill acquisition in sport: research, theory and practice. Routledge, London2004: 207-228
        • Hamdorf J.
        • Hall J.C.
        Acquiring surgical skills.
        Brit J Surg. 2000; 87: 28-37
        • Cohen A.
        • Ivry R.
        • Keele S.
        Attention and structure in sequence learning.
        J Exp Psychol: Learn Mem Cogn. 1990; 16: 17-30
        • Frensch P.A.
        • Wenke D.
        • Rünger D.
        A secondary tone-counting task suppresses expression of knowledge in the serial reaction task.
        J Exp Psychol: Learn Mem Cogn. 1999; 25: 260-274
        • Jiminéz L.
        • Méndez C.
        Which attention is needed for implicit sequence learning?.
        J Exp Psychol: Learn Mem Cogn. 1999; 25: 236-259
        • Mulligan N.W.
        Attention and implicit memory tests: The affects of varying attentional load on conceptual priming.
        Mem Cognit. 1997; 25: 11-17
        • Hardy L.
        • Mullen R.
        • Jones G.
        Knowledge and conscious control of motor actions under stress.
        Brit J Psychol. 1996; 87: 621-636
        • Maxwell J.P.
        • Masters R.S.W.
        • Kerr E.
        • Weedon E.
        The implicit benefit of learning without errors.
        Q J Exp Psychol. 2001; 54A: 1049-1068
        • Poolton J.
        • Masters R.S.W.
        • Maxwell J.P.
        The relationship between initial errorless learning conditions and subsequent performance.
        Hum Movement Sci. 2005; 24: 362-378
        • Poolton J.M.
        • Masters R.S.W.
        • Maxwell J.P.
        Passing thoughts on the evolutionary stability of implicit motor behaviour: Performance retention under physiological fatigue.
        Conscious Cogn. 2007; 16: 456-468
      1. Masters RSW, Poolton JM, Maxwell JP. Stable implicit motor processes despite aerobic locomotor fatigue. Conscious Cogn. In press.

        • Masters R.S.W.
        • MacMahon K.M.A.
        • Pall P.S.
        Implicit motor learning in Parkinson’s disease.
        Rehabil Psychol. 2004; 49: 79-82
        • Hall J.C.
        • Ellis C.
        • Hamdorf J.
        Surgeons and cognitive processes.
        Brit J Surg. 2003; 90: 10-16
        • Wetzel C.M.
        • Kneebone R.L.
        • Woloshynowych M.
        • Nestal D.
        • Moorthy K.
        • Kidd J.
        • Darzi A.
        The effects of stress on surgical performance.
        Am J Surg. 2006; 191: 5-10
        • Yule S.
        • Flin R.
        • Paterson-Brown S.
        • Maran N.
        Non-technical skills for surgeons in the operating room: A review of the literature.
        Surgery. 2006; 139: 140-149
        • Baddeley A.
        • Wilson B.A.
        When implicit learning fails: Amnesia and the problem of error elimination.
        Neuropsychologia. 1994; 32: 53-68
        • Singer R.N.
        To err or not to err: A question for the instruction of psychomotor skills.
        Rev Educ Res. 1977; 47: 479-498
        • Aggarwal R.
        • Grantcharov T.P.
        • Darzi A.
        Framework for systematic training and assessment of technical skills.
        J Am Coll Surg. 2007; 204: 697-705
        • Perkins N.
        • Starkes J.L.
        • Lee T.D.
        • Hutchison C.
        Learning to use minimal access surgical instruments and 2-dimensional remote visual feedback: How difficult is the task for novices?.
        Adv Health Sci Educ. 2002; 7: 117-131
        • Starkes J.L.
        • Payk B.A.
        • Hodges N.J.
        Developing a standardized test for the assessment of suturing skill in novice microsurgeons.
        Microsurg. 1998; 18: 19-22
        • Taffinder N.
        • Smith S.
        • Mair J.
        • Russell R.
        • Darzi A.
        Can a computer measure surgical precision?.
        Surg Endosc. 1999; 13: 81
        • Datta V.
        • Mackay S.
        • Mandalia M.
        • Darzi A.
        The use of electromagnetic motion tracking analysis to objectively measure open surgical skill in the laboratory-based model.
        J Am Coll Surgeons. 2001; 193: 479-485
        • Bann S.
        • Kwok K.-F.
        • Lo C.-Y.
        • Darzi A.
        • Wong J.
        (2003). Objective assessment of technical skills of surgical trainees in Hong Kong.
        Brit J Surg. 2003; 90: 1294-1299
        • Baddeley A.D.
        The capacity for generating information by randomisation.
        Q J Exp Psychol. 1966; 18: 119-129
        • Beckers S.
        • Fries M.
        • Bickenbach J.
        • Derwall M.
        • Kuhlen R.
        • Rossaint R.
        Minimal instructions improve the performance of laypersons in the use of semiautomatic and automatic external defibrillators.
        Crit Care. 2005; 9: 110-116
        • Vinter A.
        • Perruchet P.
        Implicit motor learning through observational training in adults and children.
        Mem Cognit. 2002; 30: 256-261
        • Calderhead J.
        Teachers’ beliefs and knowledge.
        in: Berliner D.C. Calfee R.C. Handbook of Educational Psychology. Simon & Schuster MacMillan, New York1996: 702-729
        • McLeod P.
        • Meagher T.
        • Steinert Y.
        • Schuwirth L.
        • McLeod A.
        Clinical teachers’ tacit knowledge of basic pedagogic principles.
        Med Teach. 2004; 26: 23-27
        • McLeod P.
        • Steinert Y.
        • Meacher T.
        • Schuwirth L.
        • Tabatabai D.
        • McLeod A.H.
        The acquisition of tacit knowledge in medical education: learning by doing.
        Med Educ. 2006; 40: 146-149