The psychomotor domain focuses on the necessary neuromuscular and motor coordination aspects of acquiring a technical skill. One recognized taxonomy [22] of this domain describes the following five levels: Imitation—observing and repeating the action; Manipulation—responding to verbal instructions; Precision-practice—high level of accurate independent performance; Articulation—completes skill sequentially and consistently; Naturalization—demonstrates skill automatically without need for guidance. Further details on the psychomotor principles are discussed below.

The affective domain involves the emotional response and desire for satisfaction in good performance of a skill and an appreciation of its clinical significance (e.g., a lifesaving chest decompression procedure in a tension pneumothorax patient). A major part of this affective process is the motivation from the teacher (extrinsic motivation) as a positive role model. This motivation, which initially is extrinsic, ideally becomes intrinsic when the student internally values the skill and no longer requires the extrinsic motivation of the teacher to enhance his own learning. The process begins with “receiving” when, at the appropriate moment, the student consciously notes the concept being taught and follows this with an appropriate, hopefully positive, response. This leads to embracing the concept with an emotional valuing, followed by internalization and permanent change in the student’s reaction to the concept or skill being taught (Fig. 38.2) This is known as Krathwohl’s taxonomy of the affective domain [20]. A key element of this process is the recognition of “the teachable moment” when the student is most eager to observe and be receptive to the teacher’s efforts. The effective teacher creates a receptive positive environment as a role model and stimulator of intrinsic motivation. This self-motivation then leads to development of the higher levels of the affective domain such as “characterization by value.” This progression along the affective domain is not accomplished by command but is stimulated by a highly motivated, sensitive teacher, acting as a role model.

All three domains of learning complement each other in the acquisition of technical skills. For instance, the cognitive aspect allows understanding of the anatomy, physiology, and indications for performing the skill; the psychomotor aspect focuses on the physical details of accomplishing the skill and performing it proficiently; while the affective component stimulates intrinsic motivation and emphasizes the value of the skill in the clinical management of a patient. As opposed to mere physical acquisition of a skill, the other domains lead to more complete learning. This may not make the skill easier to learn but the student, sensitized to the clinical significance of the skill through the affective component, is more likely to expend effort and energy to acquire a skill which may be difficult rather than abandon that skill merely because of its level of difficulty. Learning is often defined in terms of these three domains or “learning set” as the process of acquiring knowledge (cognitive), attitudes (affective), and skills (psychomotor). Teaching is then defined as the provision of opportunities for acquiring these three components of the learning set.

Understanding the sequential steps in psychomotor skills development is essential for the instructor to effectively plan the teaching, to evaluate and recognize progress, provide remediation and determine when the skill is achieved at the desired level. As indicated above, learning occurs when the student achieves new levels in the three domains. This requires a preliminary assessment of the student’s level of achievement (e.g., Postgraduate Year (PGY)) that will guide further development in these three domains.

Several taxonomies of the psychomotor domain have been described [22, 23] with proposed methods for teaching technical skills. After reviewing these, George and Doto [24] have presented a stepwise approach to skills teaching. This has been adopted by the Advanced Trauma Life support program [25] which is the internationally recognized training program for trauma resuscitation and which includes a physician instructor training component. These sequential steps are:

Students frequently have difficulty acquiring skills which we are trying to teach. Intuitively, an approach which allows analysis of the cause of poor performance should facilitate the remediation process. Awareness of the steps in psychomotor skills development serves as a diagnostic framework for identifying the cause of the student’s deficiency and allows a rational strategy for remediation. The approach begins with identifying the level at which the student is experiencing difficulty starting with the Conceptualization step and sequentially examining all the other steps outlined above. For instance, if the student has a good grasp of the Conceptualization step (broad view, anatomic landmarks, etc.) then a search is made for possible deficiencies in the Visualization step (i.e., has the student ever seen the task performed? If not, the student should be provided the opportunity to visualize the skill before moving further along the skills development steps). Each step is approached in a similar manner and deficiencies corrected as they are identified.

At the Practice step, one of the most difficult deficiencies to remediate is habitual incorrect performance of a skill because the skill was taught and/or learned incorrectly and the student has no appreciation of the reason for the performance being considered poor. Unlearning of an incorrectly “imprinted” skill can be very challenging but if the student is willing to consider the change after agreeing that the performance is incorrect then one must begin at the Conceptualization level and patiently work forward through the different levels to achieve remediation.

Another difficulty which may be identified in the Practice step is physical neurosensory/neuromotor discoordination. This may require the expertise of a kinesiologist [27, 28] with the help of appropriate equipment to analyze fine motor movements and hopefully correct identified deficiencies.

The recognized steps in formulating a teaching/learning experience with the student, including the teaching of surgical skills are: identify the changes in the “learning set” that are required; develop strategies for producing those changes and evaluate the change or lack thereof. Feedback is perhaps the most important component of this evaluative process and is crucial to successful teaching in general but particularly so in the teaching of surgical skills [29].