Article

Mental Practice Enhances Surgical Technical Skills A Randomized Controlled Study

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Abstract

To assess the effects of mental practice on surgical performance. Increasing concerns for patient safety have highlighted a need for alternative training strategies outside the operating room. Mental practice (MP), "the cognitive rehearsal of a task before performance," has been successful in sport and music to enhance skill. This study investigates whether MP enhances performance in laparoscopic surgery. After baseline skills testing, 20 novice surgeons underwent training on an evidence-based virtual reality curriculum. After randomization using the closed envelope technique, all participants performed 5 Virtual Reality (VR) laparoscopic cholecystectomies (LC). Mental practice participants performed 30 minutes of MP before each LC; control participants viewed an online lecture. Technical performance was assessed using video Objective Structured Assessment of Technical Skills-based global ratings scale (scored from 7 to 35). Mental imagery was assessed using a previously validated Mental Imagery Questionnaire. Eighteen participants completed the study. There were no intergroup differences in baseline technical ability. Learning curves were demonstrated for both MP and control groups. Mental practice was superior to control (global ratings) for the first LC (median 20 vs 15, P = 0.005), second LC (20.5 vs 13.5, P = 0.001), third LC (24 vs 15.5, P < 0.001), fourth LC (25.5 vs 15.5, P < 0.001) and the fifth LC (27.5 vs 19.5, P = 0.00). The imagery for the MP group was also significantly superior to the control group across all sessions (P < 0.05). Improved imagery significantly correlated with better quality of performance (ρ 0.51–0.62, Ps < 0.05). This is the first randomized controlled study to show that MP enhances the quality of performance based on VR laparoscopic cholecystectomy. This may be a time- and cost-effective strategy to augment traditional training in the OR thus potentially improving patient care.

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... 3 In other surgical specialties, mental rehearsal has been demonstrated to reduce learning curves and improve skill transfer. 4,5 In novices and trainees, mental rehearsal has improved essential, foundational surgical skills, including laparoscopic suturing, clipping and cutting, and knot tying. 6,7 Among experts, mental rehearsal reduces intraoperative errors at critical stages of surgery. ...
... 6,7 Among experts, mental rehearsal reduces intraoperative errors at critical stages of surgery. 4 It has been used successfully in specialties such as gynecology, urology, and gastrointestinal surgery. 4,8,9 Furthermore, mental readiness in surgeons has been proven to be a greater contributor to surgical success than physical readiness. ...
... 4 It has been used successfully in specialties such as gynecology, urology, and gastrointestinal surgery. 4,8,9 Furthermore, mental readiness in surgeons has been proven to be a greater contributor to surgical success than physical readiness. 10 Mental rehearsal has been observed to reduce the perceived workload and physiological stress of an operation. ...
Article
Neurosurgeons can learn from High performance sport and this letter describes how and why?
... There are also surgery-specific imagery assessments, such as the Mental Imagery Questionnaire (MIQ), which is a measure of the quality and volume of surgeons' MI for laparoscopic surgery. 15,16 The dimensions of MI related to surgery include visual and kinesthetic sensory experiences, confidence to carry out a laparoscopic procedure, and perceived usefulness of engaging in MI preoperatively. In regards to objective assessments of MI control, mental rotation tests are the primary means to assess one's ability to spatially manipulate images. ...
... Participants then completed the MIQ, which has validity evidence previously published on assessing preoperative MI in junior and senior surgeons. 15,16 Users rate eight items related to their ability to imagine a surgical skill on a 7-point Likert scale ranging from 1-"Not at all" to 7-"Very", so higher scores reflect higher MI ability for the specified surgical task. Importantly, question four of the MIQ relates to how useful a previous activity (e.g., imagery use or physical performance of the task) was in preparing the user to perform the surgical task. ...
... Researchers have shown that the MIQ is sensitive to changes in surgical novices' MI ability resulting from an MI intervention, and the MIQ displayed a significantly positive correlation with surgical performance. 16 These findings indicate that the MIQ is an effective measure of surgery-specific MI ability, and higher surgical performance is associated with higher MIQ scores. The MIQ was adapted for MI for robotic IS with permission from the authors. ...
Article
Background Mental imagery (MI) aids skill acquisition, however, it is unclear to what extend MI is used by experienced surgeons. The purpose of this study was to assess differences in MI of participants with varying surgical expertise in robotic surgery. Methods Students, residents, and surgeons completed the Mental Imagery Questionnaire to assess MI for robotic suturing. Participants then completed robotic simulator tasks, and imagined performing robotic suturing while being assessed with electroencephalogram (EEG). Results Attending surgeons reported higher MI for robotic suturing, and EEG revealed higher neural activation during imagery of robotic suturing than other groups. Conclusions Experienced surgeons displayed higher MI ability for robotic suturing, and displayed higher cortical activity in the frontal and parietal areas of the brain, which is associated with more advanced motor imagery. MI appears to be a component of robotic surgery expertise.
... 21,22 Owing to the extensive evidence of positive effects of MP and MI, they are being translated into medical education and skill acquisition training. 5,39,[42][43][44][45][46][47] Imagery has been proposed to be a time and cost effective strategy to improve surgeons' confidence, knowledge and performance. 39,48 To date, most published works on MP and skill acquisition interventions lack details in methodology as well as having significant heterogeneity in study designs, participants and outcomes. ...
... Eleven studies recruited surgical residents, novice or experienced surgeons, or a combination of these who were familiar with the surgical techniques, having observed, assisted or performed the procedures previously. 39,42,43,57,59,60,62,63,[66][67][68] The remaining eight studies comprised medical or dental students who had little or no experience and were unfamiliar with the procedures. 55,56,58,61,64,65,69,70 Most of the studies also matched the participants to certain criteria and tested their baseline ability to ensure they were comparable with each other. ...
... 55,56,58,61,64,65,69,70 Most of the studies also matched the participants to certain criteria and tested their baseline ability to ensure they were comparable with each other. 42 Most of the trial designs were similar to each other, with testing before as well as after the intervention and learning of a surgical procedure. 39,42,43,[55][56][57][58][59][60]63,64,[66][67][68][69][70] All studies reported the use of some form of MP script. ...
Article
Full-text available
Introduction The traditional methods of surgical training through apprenticeship are evolving owing to time constraints and new models of surgical training. Surgical programmes have begun to encompass technological advances such as simulation technology and online courses to improve surgical skills in a safe environment. Simulation training is not universally available because of financial constraints. Mental practice (MP) and motor imagery (MI) is a form of mental rehearsal and simulation without the need for external inputs. It has been successful in sports and music, and is a time and cost effective strategy to improve skills. MP can be translated into surgical skill acquisition and the aim of this review was to provide a systematic narrative synthesis of the current literature to support the use of MP in surgical training. Methods A systematic search was conducted on PubMed and Google Scholar™ to identify studies published up to March 2020 on MP in surgical skill acquisition. Results Nineteen studies were included in the review. Thirteen demonstrated a significant improvement in the knowledge and performance of the participants in learning surgical skills after MP. There was improved confidence in surgical trainees after MP in three studies. Conclusions MP appears to be effective in aiding surgical skill acquisition and retention. There is lack of methodological rigour in the design and development of the mental script, which is an important component in MP. MP augments physical practice and is a viable strategy to enhance surgical training. However, further studies are required to demonstrate that these skills are transferable to clinical practice.
... Effect sizes for individual studies ranged from −0.09 9 to 1.80 SMD. 41 Furthermore, of the five studies included into the meta-analysis, only one study showed statistically significant results and a high effect size. 41 The effect size of the current study was considerably lower and more in line with the findings of the remaining four studies. ...
... 41 Furthermore, of the five studies included into the meta-analysis, only one study showed statistically significant results and a high effect size. 41 The effect size of the current study was considerably lower and more in line with the findings of the remaining four studies. 9,24,42,43 The observed point estimates and the effect sizes of the APSPT 29 at the retention test remained in favour of the MP groups. ...
... Malouin et al 46 report that the use of relaxation exercises may be associated with potential benefits such as increased concentration and attention, a more vivid mental imaging and an increased motor performance. Especially, the study of Arora et al 41 showed that MP was more effective than physical practice alone. This might be caused by their use of relaxation exercises prior to the MP. ...
Article
Full-text available
Introduction: Procedural skills are a central element in the education of physiotherapists. Procedural skills relate to the execution of a practical task. An educational intervention, which can be used to support skill acquisition of procedural skills, is mental practice (MP). Several studies have investigated the use of MP or imaging in medical education. This pilot study evaluated the application of MP on the acquisition of procedural skills in physiotherapy education. Methods: This pilot randomised controlled study recruited a convenience sample of 37 BSc physiotherapy student participants. Two different complex task procedures (transfer and vestibular rehabilitation) were trained during this study. Participants in both the transfer (task procedure 1) and the vestibular rehabilitation (task procedure 2) arm of the study were randomly assigned to either MP or no MP. Results: For the transfer task, median performance at post-acquisition testing showed a moderate effect size in favour of the group using MP (r: −0.3), but the findings were not statistically significant (P: 0.2). Similar results were found for the vestibular rehabilitation task (r: 0.29; P: 0.21). In addition, the self-reported confidence was higher in the MP group.
... 'Mental Training' has already been used successfully in the mediation of clinical skills and surgical training [17][18][19][20]. An influential study by Arora et al. [21] showed that participants who practiced with a standardized mental imaginary script showed greater improvements in learning laparoscopic cholecystectomies compared to a control group that participated in online lecture training. These results were supported by Immenroth et al., who demonstrated that mental rehearsal led to significantly better performance results compared to practical training in the mediation of laparoscopic cystectomies [19]. ...
... There is a great heterogeneity regarding the impact of 'Mental Training' in surgical education in the current literature. There are randomized and controlled studies that have shown that Mental Training led to significantly better performance results in the mediation of laparoscopic cystectomies [19,21]. However, not all studies that investigated 'Mental Training' in surgical education reported beneficial effects. ...
... 'Mental Training' has already been used successfully in the mediation of clinical skills and surgical training [17][18][19][20]. An in uential study by Arora et al. [21] showed that participants who practiced with a standardized mental imaginary script showed greater improvements in learning laparoscopic cholecystectomies compared to a control group that participated in online lecture training. These results were supported by Immenroth et al., who demonstrated that mental rehearsal led to signi cantly better performance results compared to practical training in the mediation of laparoscopic cystectomies [19]. ...
... In the present literature there is a great heterogeneity regarding the impact of 'Mental Training' in surgical education. There are randomized and controlled studies that have shown that Mental Training led to signi cantly better performance results in the mediation of laparoscopic cystectomies [19,21]. However, not all studies that investigated 'Mental Training' in surgical education reported bene cial effects. ...
Preprint
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Background: The correct performance of a structured facial examination presents a fundamental clinical skill to detect facial pathologies. However, many students are not adequately prepared in this basic clinical skill. Many argue that the traditional ‘See One, Do One’ approach is not sufficient to fully master a clinical skill. ‘Mental Training’ has successfully been used to train psychomotor and technical skills in sports and other surgical fields, but its use in Oral and Maxillofacial Surgery is not described. We conducted a quasi-experimental to determine if ‘Mental Training’ was effective in teaching a structured facial examination. Methods: 67 students were randomly assigned to a ‘Mental Training’ and ‘See One, Do One’ group. Both groups received standardized video instruction on how to perform a structured facial examination. The ‘See One, Do One’ group then received 60 minutes of guided physical practice while the ‘Mental Training’ group actively developed a detailed, stepwise sequence of the performance of a structured facial examination and visualized this sequence subvocally before practicing the skill. Student performance was measured shortly after (T1) and five to ten weeks (T2) after the training by two blinded examiners (E1 and E2) using a validated checklist. Results: Groups did not differ in gender, age or in experience. The ‘Mental Training’ group averaged significantly more points in T1 (pE1 = 0.00012; pE2 = 0.004; dE1 = 0.86; dE2 = 0.66) and T2 (pE1 = 0.04; pE2 = 0.008, dE1 = 0.37; dE2 = 0.64) than the ‘See One, Do One’ group. The intragroup comparison showed a significant (pE1 = 0.0002; pE2 = 0.06, dE1 = 1.07; dE2 = 0.50) increase in clinical examination skills in the ‘See One, Do One’ group, while the ‘Mental Training’ group maintained an already high level of clinical examination skills between T1 and T2. Discussion: ‘Mental Training’ is an efficient tool to teach and maintain basic clinical skills. In this study ‘Mental Training’ was shown to be superior to the commonly used ‘See One, Do One’ approach in learning how to perform a structured facial examination and should therefore be considered more often to teach physical examination skills.
... It involves inserting a catheter into a vein to administer intravenous therapy or to allow blood collection. There are potential septic risks for the patient [1], thus, learning how to insert a PVC reduces potential traumatic or infectious lesions and limits the risk of errors [2][3][4]. Medical techniques are learnt through training procedures. However, due to the short time allocated, and the amount of students involved, the training time is often limited. ...
... The main objective of the experiment was to study the effect of Motor imagery (MI) associated with actual practice on the ability to learn how to insert a PVC. We hypothesized that MI should improve learning and make the skills more effective after a four-session training period [3,7,16]. We first checked that the MI training sessions were adequately performed by assessing the MI vividness. ...
Article
Full-text available
Background The peripheral venous catheter is the most frequently used medical device in hospital care to administer intravenous treatment or to take blood samples by introducing a catheter into a vein. The aim of this study was to examine the effect of motor imagery associated with actual training on the learning of peripheral venous catheter insertion into a simulated venous system. Method This was a prospective monocentre study in 3rd year medical students. Forty medical students were assigned to the experimental group ( n = 20) performing both real practice and motor imagery of peripheral venous catheter insertion or to the control group ( n = 20) trained through real practice only. We also recruited a reference group of 20 professional nurses defining the benchmark for a target performance. Results The experimental group learned the peripheral venous catheter insertion faster than the control group in the beginning of learning phase ( p < 0.001), reaching the expected level after 4 sessions ( p = .87) whereas the control group needed 5 sessions to reach the same level ( p = .88). Both groups were at the same level at the end of the scheduled training. Conclusions Therefore, motor imagery improved professional motor skills learning, and limited the time needed to reach the expected level. Motor imagery may strengthen technical medical skill learning.
... 7,[12][13][14] More recently, cognitive training has demonstrated great promise as a cost-effective, efficacious training adjunct in several surgical specialties including general surgery, obstetrics and gynecology, otolaryngology, and vascular surgery. 12,[15][16][17][18] Although several methods of cognitive training exist, cognitive task analysis (CTA) and mental rehearsal (MR) are perhaps the most studied in the field of surgical training. CTA is a systematic process by which experts break down a complex task into discrete steps. ...
... 13,14 More recently, the utility of MR as a training technique has been established in numerous surgical specialties including general surgery, vascular surgery, obstetrics and gynecology, and otolaryngology. [15][16][17][18]37 For instance, Arora et al 18 observed novice surgeons doing simulated laparoscopic cholecystectomies using a virtual reality platform and found that participants who did 30 minutes of MR before each simulated procedure had superior technical performance and improved mental imagery compared with participants who viewed an online lecture. The incorporation of MR into orthopaedic surgery training, on the other hand, has lagged behind other surgical specialties. ...
Article
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Introduction: Over the past two decades, various factors have led to fewer opportunities for hands-on learning in the operating room among orthopaedic surgery trainees. Innovative training platforms using anatomic models, cadaveric specimens, and augmented reality have been devised to address this deficiency in surgical training, but such training tools are often costly with limited accessibility. Cognitive training is a low-cost training technique that improves physical performance by refining the way in which information is mentally processed and has long been used by professional athletes and world-class musicians. More recently, cognitive training tools have been developed for several orthopaedic surgery procedures, but the overall utility of cognitive training in orthopaedic surgery remains unknown. Methods: The purpose of this study was to review the existing literature regarding the use of cognitive training in orthopaedic surgery and to summarize the results of investigations comparing cognitive training tools with other methods of learning. To that effect, the PubMed and Embase databases were systematically reviewed for articles related to cognitive training in orthopaedic surgery. Results: Eleven publications met the inclusion criteria, including six randomized controlled trials. Cognitive task analysis and mental rehearsal were the most common forms of cognitive training identified. All 11 publications supported the use of cognitive training in orthopaedic surgery training. In the six randomized controlled trials, the utilization of cognitive training was associated with notably improved surgical performance and increased knowledge compared with traditional methods of learning. Discussion: Based on the limited evidence presented in this review, cognitive training represents a promising, low-cost adjunct to traditional orthopaedic surgery training. Further efforts should be directed at developing and evaluating additional cognitive training tools for orthopaedic surgery trainees.
... 'Mental Training' has already been used successfully in the mediation of clinical skills and surgical training [17][18][19][20]. An influential study by Arora et al. [21] showed that participants who practiced with a standardized mental imaginary script showed greater improvements in learning laparoscopic cholecystectomies compared to a control group that participated in online lecture training. These results were supported by Immenroth et al., who demonstrated that mental rehearsal led to significantly better performance results compared to practical training in the mediation of laparoscopic cystectomies [19]. ...
... There is a great heterogeneity regarding the impact of 'Mental Training' in surgical education in the current literature. There are randomized and controlled studies that have shown that Mental Training led to significantly better performance results in the mediation of laparoscopic cystectomies [19,21]. However, not all studies that investigated 'Mental Training' in surgical education reported beneficial effects. ...
Article
Full-text available
Background The correct performance of a structured facial examination presents a fundamental clinical skill to detect facial pathologies. However, many students are not adequately prepared in this basic clinical skill. Many argue that the traditional ‘See One, Do One’ approach is not sufficient to fully master a clinical skill. ‘Mental Training’ has successfully been used to train psychomotor and technical skills in sports and other surgical fields, but its use in Oral and Maxillofacial Surgery is not described. We conducted a quasi-experimental to determine if ‘Mental Training’ was effective in teaching a structured facial examination. Methods Sixty-seven students were randomly assigned to a ‘Mental Training’ and ‘See One, Do One’ group. Both groups received standardized video instruction on how to perform a structured facial examination. The ‘See One, Do One’ group then received 60 min of guided physical practice while the ‘Mental Training’ group actively developed a detailed, stepwise sequence of the performance of a structured facial examination and visualized this sequence subvocally before practicing the skill. Student performance was measured shortly after (T1) and five to 10 weeks (T2) after the training by two blinded examiners (E1 and E2) using a validated checklist. Results Groups did not differ in gender, age or in experience. The ‘Mental Training’ group averaged significantly more points in T1 (pE1 = 0.00012; pE2 = 0.004; dE1 = 0.86; dE2 = 0.66) and T2 (pE1 = 0.04; pE2 = 0.008, dE1 = 0.37; dE2 = 0.64) than the ‘See One, Do One’ group. The intragroup comparison showed a significant (pE1 = 0.0002; pE2 = 0.06, dE1 = 1.07; dE2 = 0.50) increase in clinical examination skills in the ‘See One, Do One’ group, while the ‘Mental Training’ group maintained an already high level of clinical examination skills between T1 and T2. Discussion ‘Mental Training’ is an efficient tool to teach and maintain basic clinical skills. In this study ‘Mental Training’ was shown to be superior to the commonly used ‘See One, Do One’ approach in learning how to perform a structured facial examination and should therefore be considered more often to teach physical examination skills.
... Incorporating speech recognition to initiate the checklist, and speech generation to guide the user through the process, should reduce tactile interaction and perhaps the number of individuals required. In one study, although 85% of checklist items were checked off as complete, review of the medical record revealed that only 54% of these tasks were actually completed [15]. Given the digital format of the Smart Checklist, we will have the ability to cross-reference timestamped checklist interactions with ground truth via activity logs and medical device logs including the OpenICE data log to determine the nature of checklist compliance, extending previous work from trauma resuscitation settings [16] into the cardiac OR. ...
Conference Paper
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Surgical processes are rapidly being adapted to address the COVID-19 pandemic, with changes in procedures and responsibilities being made to protect both patients and medical teams. These process changes put new cognitive demands on the medical team and increase the likelihood of miscommunication, lapses in judgment, and medical errors. We describe two process model driven cognitive aids, referred to as the Narrative View and the Smart Checklist View, generated automatically from models of the processes. The immediate perceived utility of these cognitive aids is to support medical simulations, particularly when frequent adaptations are needed to quickly respond to changing operating room guidelines.
... 24 Once all parts of the surgical procedure were covered to a level of competence, the full procedure was performed on high-fidelity synthetic simulation surgery eyes (PS-OS-010, Phillips Studio, Bristol, UK), 25 following a round of mental rehearsal. 31 The procedures were performed using Zeiss Stemi 305 microscopes (Carl Zeiss Microscopy, Jena, Germany). The microscopes were equipped with cameras and linked to a central router and local area network. ...
Article
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Background/Aim Glaucoma accounts for 8% of global blindness and surgery remains an important treatment. We aimed to determine the impact of adding simulation-based surgical education for glaucoma. Methods We designed a randomised controlled, parallel-group trial. Those assessing outcomes were masked to group assignment. Fifty-one trainee ophthalmologists from six university training institutions in sub-Saharan Africa were enrolled by inclusion criteria of having performed no surgical trabeculectomies and were randomised. Those randomised to the control group received no placebo intervention, but received the training intervention after the initial 12-month follow-up period. The intervention was an intense simulation-based surgical training course over 1 week. The primary outcome measure was overall simulation surgical competency at 3 months. Results Twenty-five were assigned to the intervention group and 26 to the control group, with 2 dropouts from the intervention group. Forty-nine were included in the final intention-to-treat analysis. Surgical competence at baseline was comparable between the arms. This increased to 30.4 (76.1%) and 9.8 (24.4%) for the intervention and the control group, respectively, 3 months after the training intervention for the intervention group, a difference of 20.6 points (95% CI 18.3 to 22.9, p<0.001). At 1 year, the mean surgical competency score of the intervention arm participants was 28.6 (71.5%), compared with 11.6 (29.0%) for the control (difference 17.0, 95% CI 14.8 to 19.4, p<0.001). Conclusion These results support the pursuit of financial, advocacy and research investments to establish simulation surgery training units and courses including instruction, feedback, deliberate practice and reflection with outcome measurement to enable trainee glaucoma surgeons to engage in intense simulation training for glaucoma surgery. Trial registration number PACTR201803002159198.
... However, mental rehearsal definitely would be a better way to review and practice the task efficiently without any risk. This would be an additional method to enhance the performance, an adjunct to physical practice as reported by the results of the previous studies on Virtual Realistic laparoscopic cholecystectomy and laporoscopic suturing training sessions [14,15]. A preliminary exposure to physical practice is required to form a template, which the participant can use as a reference to form a mental image. ...
Article
Full-text available
Introduction: Mentally Guided Imagery (MGI) has successfully been applied in sports for skill acquisition and performance enhancement. Despite the fact that athletes often use mental imagery as a part of their preparation, it has not been extensively explored as a learning technique in medical education. Few studies had highlighted mental imagery as a way to review and practice surgical skills efficiently. The present study aimed to assess the efficiency of intubation skills acquired through mental imagery in medical interns. Aim: To assess and compare the effect of Guided mental imagery and physical practice using mannequins on intubation technique among 40 medical Interns after seven days of training. Materials and Methods: The study was conducted in the Department of Emergency Medicine, Velammal Medical College and Hospital, Madurai over a period of seven days. Forty house surgeons were randomly divided into two groups. Group A (n=20) practiced MGI on intubation technique and Group B (n=20) practiced on mannequins one hour everyday for seven days. The performance of the students was assessed using a graded Objective Structured Clinical Examination (OSCE). Results: Results of Group A and Group B were analysed and compared statistically using paired and unpaired t-test. Though there was significant difference between the pre and post values in the MGI group (p
... The current well-known training method for UMIBS focuses on lecture-based learning (LBL), which means that teachers lead the class but students rarely have the opportunity to practice. 6,7 However, due to this lack of practice and clinical thinking during the training process, students cannot carry out clinical operations after watching the procedure, [8][9][10] and restrictions have prompted educators to seek alternative methods to teach medical knowledge and gain procedural experience. UMIBS is a highly practical subject; in response to its practical nature, it is imperative for medical educators to employ a simulation and teaching mode to practice operational ability. ...
Article
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Purpose: Traditional standardized training in ultrasound-guided minimally invasive breast surgery (UMIBS) focused on lecture-based learning (LBL) resulted in students' insufficient analysis, limited spatial visual conversion ability, and poor practical application. This study examined the effects of the step-by-step (SBS) method combined with a simulation model in UMIBS education. Subjects and methods: A total of 84 residents participated in this study. The residents were divided into the SBS group (experience group, n=42) and the LBL group (control group, n=42), and the same teacher taught the two groups to ensure a comparable result. Based on the pork simulation model, two experts evaluated student performance scores, and the total time taken by each student was also counted. The participants were surveyed with 7 questions after the training, and each answer was assigned a score of 1, 2 or 3 to compare the participants' satisfaction. Results: The average value of the surgical skills for SBS group were significantly higher than LBS group, which was 82.8±4.4 and 72.7±4.0 (t=4.27, P<0.001), the time spend of neoplasm localization by the experience group was significantly less than the control group, which was 17.9±1.6 and 20.9±1.2 secs, (t=1.58, P<0.001), and there were significant differences in puncture accuracy and excision integrity between the two groups (P<0.05). In addition, the results of the questionnaire survey showed that learning interest, surgical ability and satisfaction were better in the SBS group than in the LBS group (P<0.05), and there were no significant differences in clinical thinking and learning pressure between the two groups. Conclusion: The SBS teaching method may help to improve the surgical skills and learning interest, as well as reduce adverse reactions and cultivate clinical thinking of the students in UMIBS training. Future studies could consider multicenter clinical research to further confirm the practicality of this teaching method and reduce the risk of deviation.
... In addition, mental practice may improve subsequent surgical performance 6 . Evidence regarding the impact of mental practice on the surgical skills of experts is non-existent, as comparative studies have thus far recruited only medical students [7][8][9][10][11][12] and surgical trainees [13][14][15] . ...
Article
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Background It was hypothesized that preparing for a surgical procedure, taking into account individual patient characteristics, may facilitate the procedure and improve surgical quality. The aim of this study was to compare different case-specific, preoperative mental rehearsal methods before minimally invasive rectal cancer surgery. Methods In this RCT, patients were allocated in a 1 : 1 : 1 : 1 ratio to four groups: systematic mental rehearsal (SMR) using MRI scans; SMR and three-dimensional (3D) virtual models; SMR and synthetic 3D printed models; and routine practice (control group). Surgeons operating on all but the control group underwent mental rehearsal with the visual aids, including axial MRI scans of the pelvis, interactive 3D virtual models reconstructed from axial MRIs, and synthetic models, manufactured by 3D printing. Operations were video-recorded and assessed by two experts blinded to allocation using two validated scores, the Competency Assessment Tool (CAT) and Objective Clinical Human Reliability Analysis (OCHRA). The primary outcome of the study was surgical performance, measured by the CAT. Results Forty-nine patients were randomized and allocated to the four groups. There were 12 participants in each of the control, MRI and SMR, and virtual and SMR groups, whereas the SMR using physical models and simulation group included 13. No difference was observed between groups in median CAT scores (control 30.50, MRI 34.25, virtual 31.75, physical 34.00; P = 0.748, partial η2 <0.001, where pη2 is indicative of effect size) or OCHRA scores (anterior, posterior, right and left lateral planes, transection P>0.200, pη2 =0.052–0.088). Time spent not performing dissection was significantly shorter for the SMR with MRI group than for the control (57.5 versus 42 respectively; P < 0.001, pη2 =0.212). Conclusion Mental rehearsal did not affect CAT and OCHRA scores of consultant surgeons. Reference number: ISRCTN 75603704 (https://www.isrctn.com).
... In the naturalization phase, students perform consistently and with ease while perfecting their own model. They can integrate multiple tasks and may be asked to perform them in a shorter period to increase their speed (Arora et al., 2011). ...
Article
Task trainer simulators are often used in medical programs for bachelor’s degree students when teaching procedural skills. They provide the opportunity to practice dangerous maneuvers that students are not ready to perform on real patients yet. The rise of technology has vastly expanded the availability of these devices for use in teaching. To develop a protocol that would account for the complexities of psychomotor learning, based on student progress, and improve training quality, we designed a protocol for the bachelor’s degree program in dentistry. We justify the key elements of the proposal and explain the full working protocol.
... The role of human factors in surgery has led to interest in the application of psychological techniques to surgical performance, reflected by more than 1000 publications on this topic in surgical journals, mostly in the past decade 9 . Many studies have shown benefits of mental practice 10 , with a meta-analysis 11 of RCTs demonstrating enhancement in surgical skills. ...
Article
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Background: Despite the acknowledgement of human factors, application of psychological methods by surgeons to improve surgical performance is sparse. This may reflect the paucity of evidence that would help surgeons to use psychological techniques effectively. There is a need for novel approaches to see how cognitive training might be used to address these challenges. Methods: Surgical trainees were divided into intervention and control groups. The intervention group received training in surgical cognitive simulation (SCS) and was asked to apply the techniques while working in operating theatres. Both groups underwent procedure-based assessment based on the UK and Ireland Intercollegiate Surgical Curriculum Programme (ISCP) before the training and 4 months afterwards. Subjective evaluations of SCS application were obtained from the intervention group participants. Results: Among 21 participants in the study, there was a statistically significant improvement in 11 of 16 procedure-based assessment domains (P < 0.050) as well as a statistically significant mean reduction in time to complete the procedure in the intervention group (-15.98 versus -1.14 min; P = 0.024). Subjectively, the intervention group experienced various benefits with SCS, especially in preoperative preparedness, intraoperative focus, and overall performance. Conclusion: SCS training has a statistically significant impact in improving surgical performance. Subjective feedback suggests that surgeons are able to apply it in practice. SCS may prove a vital adjunct for skill acquisition in surgical training.
... p < .01; Arora et al., 2011). All other studies reported no significant relation between mental imagery and behavior (all ps > .77; ...
Article
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Mental simulation of future scenarios is hypothesized to affect future behavior, but a large and inconsistent literature means it is unclear whether, and under what conditions, mental simulation can change people’s behavior. A meta-analysis was conducted to synthesize the effects of mental simulation on behavior and examine under what conditions mental simulation works best. An inclusive systematic database search identified 123 (N = 5685) experiments comparing mental simulation to a control group. After applying a multilevel random effects model, a statistically-reliable positive effect of Hedges’ g=0.49 [95% CI 0.37; 0.62], which was significantly different than zero. Using a taxonomy to identify different subtypes of mental simulation (along two dimensions, class [process, performance, outcome] and purpose [whether an inferior, standard, superior version of that behavior is simulated]), it was found that superior simulations garnered more reliable beneficial effects than inferior simulations. These findings have implications for integrating theories of how mental simulations change behavior, how mental simulations are classified, and may help guide professionals seeking evidence-based and cost-effective methods of changing behavior.
... 'See' involves the use of visualisation exercises and mental practice. Previous research has shown that mental rehearsal improves the performance of technical skills in healthcare (Hall, 2002;Arora et al, 2011;Lorello et al, 2016) and may perhaps also aid relaxation (Willis, 2019). ...
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Managing a complex scene and a critically unwell patient at the same time is a challenge for any paramedic, in terms of both personal preparation and crew resource management. While modern paramedicine requires new solutions to situated challenges, a good starting point is to review existing frameworks to seek ways of maximising the safety of the care delivered by paramedics. This paper provides a synthesis of the theoretical egg-timer model of disparity combined with a practical framework called the zero point survey as cohesive tools for operational paramedics to optimise their performance while experiencing high-stress situations. This synthesis provides a valuable aide mémoire for strategies to improve personal performance, leadership and teamworking in relation to the care of a critically unwell patient. Such models fit within current practice, and have the potential to lead to safer paramedic care through the practical application of human factors theory, with team management skills and psychological interventions to improve patient outcomes.
... Action-imagery practice (AIP, also mental practice or motorimagery practice) is the repetitive use of motor imagery with the intention to improve action-execution (Driskell et al., 1994;Simonsmeier et al., 2020). As an alternative to action-execution practice (AEP), AIP has been shown to improve performance in various fields, such as surgery (Arora et al., 2011), music (Coffman, 1990), sports (Guillot et al., 2010), and rehabilitation (Page, 2010). Compared to a non-practice control group, AIP is often followed by performance improvements, although to a lesser degree than AEP (Driskell et al., 1994;Ladda et al., 2021;Simonsmeier et al., 2020;Toth et al., 2020). ...
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Action-imagery practice (AIP) is often less effective than action-execution practice (AEP). We investigated whether this is due to a different time course of learning of different types of sequence representations in AIP and AEP. Participants learned to sequentially move with one finger to ten targets, which were visible the whole time. All six sessions started with a test. In the first four sessions, participants performed AIP, AEP, or control-practice (CP). Tests involved the practice sequence, a mirror sequence, and a different sequence, which were performed both with the practice hand and the other (transfer) hand. In AIP and AEP, movement times (MTs) in both hands were significantly shorter in the practice sequence than in the other sequences, indicating sequence-specific learning. In the transfer hand, this indicates effector-independent visual-spatial representations. The time course of the acquisition of effector-independent visual-spatial representations did not significantly differ between AEP and AIP. In AEP (but not in AIP), MTs in the practice sequence were significantly shorter in the practice hand than in the transfer hand, indicating effector-dependent representations. In conclusion, effector-dependent representations were not acquired after extensive AIP, which may be due to the lack of actual feedback. Therefore, AIP may replace AEP to acquire effector-independent visual-spatial representations, but not to acquire effector-dependent representations.
... Due to the often lack of time resources, the important last step "Teach one" is often omitted or takes part without supervision in everyday clinical practice. Because of the increased awareness for patient safety today, many argue that this teaching method is passé because students are unable to safely perform a medical procedure after seeing it only once [4][5][6]. ...
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Background: Teaching complex motor skills at a high level remains a challenge in medical education. Established methods often involve large amounts of teaching time and material. The implementation of standardized videos in those methods might help save resources. In this study, video-based versions of Peyton's '4-step Approach' and Halsted's 'See One, Do One' are compared. We hypothesized that the video-based '4-step Approach' would be more effective in learning procedural skills than the 'See One, Do One Approach'. Methods: One-hundred-two naïve students were trained to perform a structured facial examination and a Bellocq's tamponade with either Halsted's (n = 57) or Peyton's (n = 45) method within a curricular course. Steps 1 (Halsted) and 1-3 (Peyton) were replaced by standardized teaching videos. The performance was measured directly (T1) and 8 weeks (T2) after the intervention by blinded examiners using structured checklists. An item-analysis was also carried out. Results: At T1, performance scores significantly differed in favor of the video-based '4-step Approach' (p < 0.01) for both skills. No differences were found at T2 (p < 0.362). The item-analysis revealed that Peyton's method was significantly more effective in the complex subparts of both skills. Conclusions: The modified video-based version of Peyton's '4-step Approach' is the preferred method for teaching especially complex motor skills in a large curricular scale. Furthermore, an effective way to utilize Peyton's method in a group setting could be demonstrated. Further studies have to investigate the long-term learning retention of this method in a formative setting.
... Both types of knowledge are essential to acquire before a resident can actually practice, leading to the manta 'never the first time on a patient' [3]. Thus, technology assistance in training has been an important challenge for addressing several related issues ranging from patient safety to economic considerations. ...
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Improving surgical training by means of technology assistance is an important challenge that aims to directly impact surgical quality. Surgical training includes the acquisition of two categories of knowledge: declarative knowledge (i.e. ‘knowing what’) and procedural knowledge (i.e. ‘knowing how’). It is essential to acquire both before performing any particular surgery. There are currently many tools for acquiring procedural knowledge, such as simulators. However, few approaches or tools allow a trainer to formalize and record surgical declarative knowledge, and a trainee to have easy access to it. In this paper, we propose an approach for structuring surgical declarative knowledge according to procedural knowledge and based on surgical process modeling. A dedicated software application has been implemented. We evaluated the concept and the software usability on two procedures with different medical populations: endoscopic third ventriculostomy involving 6 neurosurgeons and preparation of a surgical table for craniotomy involving 4 scrub nurses. The results of both studies show that surgical process models could be a well-adapted approach for structuring and visualizing surgical declarative knowledge. The software application was perceived by neurosurgeons and scrub nurses as an innovative tool for managing and presenting surgical knowledge. The preliminary results show that the feasibility of the proposed approach and the acceptability and usability of the corresponding software. Future experiments will study impact of such an approach on knowledge acquisition.
... Mental imagery has been shown to significantly improve the acquisition and execution of technical skills (Epstein, 1980;Driskell et al., 1994;Bohan et al., 1999), has been implicated as important in surgical skills development (Bathalon et al., 2005;Arora et al., 2011) as well as in the development of palpation skills (Esteves and Spence, 2013). Similarly, spatial ability, its importance, and its apparent malleability as a trait (Baenninger and Newcombe, 1989;Hoyek et al., 2009;Lufler et al., 2012) have been widely discussed within the anatomy education literature (e.g., Garg et al., 2001Garg et al., , 2002Guillot et al., 2007;Hegarty et al., 2008;Lufler et al., 2012;Vorstenbosch et al., 2013;Nguyen et al., 2014;Sweeney et al., 2014;Berney et al., 2015;Delisser and Carwardine, 2017;Gutierrez et al., 2017;Loftus et al., 2017). ...
Article
Despite the uncontested importance of anatomy as one of the foundational aspects of undergraduate veterinary programs, there is still limited information available as to what anatomy knowledge is most important for the graduate veterinarian in their daily clinical work. The aim of this study was therefore to gain a deeper understanding of the role that anatomy plays in first opinion small animal veterinary practice. Using ethnographic methodologies, the authors aimed to collect rich qualitative data to answer the question “How do first opinion veterinarians use anatomy knowledge in their day‐to‐day clinical practice?” Detailed observations and semi‐structured interviews were conducted with five veterinarians working within a single small animal first opinion practice in the United Kingdom. Thematic analysis was undertaken, identifying five main themes: Importance; Uncertainty; Continuous learning; Comparative and dynamic anatomy; and Communication and language. Anatomy was found to be interwoven within all aspects of clinical practice however veterinarians were uncertain in their anatomy knowledge. This impacted their confidence and how they carried out their work. Veterinarians described continually learning and refreshing their anatomy knowledge in order to effectively undertake their role, highlighting the importance of teaching information literacy skills within anatomy curricula. An interrelationship between anatomy use, psychomotor and professional skills was also highlighted. Based on these findings, recommendations were made for veterinary anatomy curriculum development. This study provides an in‐depth view within a single site small animal general practice setting: further work is required to assess the transferability of these findings to other areas of veterinary practice.
... Mental practice, defined as the cognitive rehearsal of a skill without gross physical movement, 3 has been shown to be an effective method of learning and maintaining complex physical skills in medicine. 4 The goal of mental practice is to generate mental representations of the skill being practised, which has been shown to be as effective as additional physical practice for selected surgical skills. 5 The mental practice process has typically involved a period of relaxation, followed by the recitation of a standardized script, which includes visual, kinesthetic, and cognitive cues to facilitate the generation of rich mental representations of the procedure. ...
Article
The coronavirus disease 2019 (COVID-19) pandemic presents challenges to the effective use of personal protective equipment, including equipment shortages, staff unfamiliarity, and physical distancing. Mental practice has been used as an alternative learning strategy in medicine for the development of technical skills. We developed educational materials with the aim of using mental practice to overcome these challenges and increase provider skill and confidence with the use of personal protective equipment. A mental practice script integrating cognitive, kinesthetic, and visual cues with a list of procedural steps was created and iteratively refined. To allow the use of this tool by providers unfamiliar with the principles of mental practice, accompanying explanatory materials were created and disseminated widely through the Free Open Access Medical education (FOAMed) community. By creating easily accessible resources to facilitate effective mental practice, providers may be able to increase their skill and comfort with the procedure while conserving personal protective equipment and respecting physical distancing guidelines.
... The operating room was clearly not a safe environment for such experiential learning to occur. 16 Simulation provides a viable and valid alternative for technical skill acquisition in a controlled, safe environment with no harm to the patient, especially at the early part of the learning curve. It allows proficiency based curricula to be delivered, enabling structured training in the form of knowledge base, task deconstruction, laboratory environment training and skills transfer, with valid and reliable measures of assessment. ...
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Annually, an estimated 234 million major surgical operations occur worldwide, with concomitant seven million complications and one million deaths. It is now well established that technical competence is necessary, but not sufficient for modern surgical practice and outcomes. Breakdown in non-technical skills has been attributed as a key root cause for near misses and patient harm in the operating room. This article discusses the multi-faceted skills-set that is necessary for the modern surgeon to succeed and for optimal patient outcomes. This includes technical skills, non-technical skills, with a focus on key CanMEDS framework domains, including leadership, communication, evidence-based surgery and mentorship.
... 9 Because of the positive effects of MP and MI, they are used in both medical education and skill acquisition training. [10][11][12][13][14][15][16][17] Imagery has been proposed to be a time and cost-effective strategy to improve trainees' confidence, knowledge and performance. 10,18 The mind can simulate diverse sensations and experiences. ...
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Introduction: Motor imagery and mental practice are important for the acquisition and mastery of surgical skills. The success of this technique relies on the use of a well-developed mental script. In this study, we shared how we developed a mental script for basic micro suturing training by using a low-fidelity rubber glove model. Methods: This study applied the design and development research framework. Five expert surgeons developed a mental script by performing a cognitive walkthrough to repair a vertical opening in a rubber glove model, followed by hierarchical task analysis. A draft script was created, and its face and content validity assessed with a checking-back process. Twenty-eight surgeons used the Mental Imagery Questionnaire (MIQ) to assess the validity of the final script. Results: The process of developing the mental script is detailed. The assessment by the expert panel showed the mental script had good face and content validity. The mean overall MIQ score was 5.2±1.1 (standard deviation), demonstrating the validity of generating mental imagery from the mental script developed in this study for micro suturing in the rubber glove model. Conclusion: The methodological approach described in this study is based on a design and development research framework to teach surgical skills. This model is inexpensive and easily accessible, addressing the challenges of reduced opportunities to practise surgical skills. However, although motor skills are important, the surgeon's other non-technical expertise is not addressed with this model. Thus, this model should act as one surgical training approach, but not replace it.
... Simulation and mental rehearsal (19) are further interventions that aim to develop surgeon stress tolerance and facilitate improved performance when confronted with real-life stressful stimuli in theatre (3,20). However, the results of these trials largely comprise small cohorts of participants and demonstrate modest improvement in subjective and objective markers of stress (21)(22)(23). More recently, studies incorporating functional neuroimaging of surgeons under stress have sought to investigate the neural correlates between temporal stress and surgical performance. ...
Chapter
Intraoperative temporal demand (TD) precipitates technical skill deterioration in surgical novices and is associated with attenuated prefrontal cortex (PFC) activity. Transcranial direct-current stimulation (tDCS) may augment PFC activation, thereby reducing subjective stress and improving technical skill under TD. In this randomized double-blind trial, forty surgical novices performed time-pressured simulated laparoscopic tasks across three phases: before (“pre”), during (“online”), and after (“post”) either active or sham stimulation of the PFC. Primary outcomes were self-reported measures of surgery-specific workload. Objective measures of technical performance were also recorded. Intervention groups comprised similar baseline demographics and skill levels (p>0.05). Only active tDCS significantly reduced perceived TD (p=0.01), whereas perceived task complexity reduced with sham (p=0.02). Following intervention, the tDCS group were 5% and 7.5% more likely to complete peg-transfer and pattern-cutting tasks within time, respectively (p=0.273). Our findings suggest that non-invasive prefrontal stimulation may offset perceived temporal stress in surgery, facilitating improved technical performance.
... There are few studies that have evaluated the value of MI in surgical learning. A review of the literature published in 2015 identified 9 randomized control studies over reported randomized control studies [31][32][33][34][35][36][37][38][39][40][41]. Five of them objectified a beneficial effect of MI on the learning of surgical technical skills while four studies were negative. ...
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Objective Mental imagery (MI) has long been used in learning in both fields of sports and arts. However, it is restrictively applied in surgical training according to the medical literature. Few studies have evaluated its’ feasibility and usefulness. The aim of this study is to assess the impact of mental imagery on surgical skills learning among novice’s surgeons. Material and methods In this pilot prospective randomized comparative study; we recruited 17 residents and interns of surgery education curriculum. They were all included in their first semester of the curricula. Two groups were randomly designed. Group (a) including “Mental Imagery” volunteers ( n = 9) which benefited from a mental imagery rehearsal exercise prior to physical practice, while the control group (b) ( n = 8) didn’t underwent any MI process prior to surgery practice. Each participant of both groups was invited to perform an intestinal hand-sewn anastomosis on bovine intestine. Each procedure was evaluated and analyzed according to 14 qualitative criteria while each criterion was scored 0, 1 or 2 respectively assigned to the gesture was not acquired, gesture was performed with effort, or mastered gesture. The final score is 28 for those who master all 14 gestures. A non-parametric statistical comparison between the both studied groups was performed. Results Both groups of surgery students demonstrated equivalent age, sex ratio, laterality, and surgical experience. The mean overall score is significantly higher in the MI group (a) (17.78; SD = 2.42) compared to the control group (b) (10.63, SD = 2.85). However, advanced analysis of individual assessment items showed significant statistical difference between both groups only in 6 out of 14 assessed items. Conclusion Indeed, mental imagery will not be able to substitute the traditional learning of surgery for novice surgeons; it is an important approach for improving the technical skills acquisition and shortening the physical learning.
Article
Objective Mental skills training (MST) in surgical education varies greatly in quality and outcomes. This systematic review assessed the effectiveness of MST on surgical trainee performance in simulated and operating room (OR) settings. Design We searched PubMed/MEDLINE, EMBASE, and PsycINFO for randomized controlled trials using Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Peer-reviewed studies published in the English language between January 1, 2000 and March 1, 2020 were considered for inclusion. Articles that did not study surgical residents, assess surgical performance as an outcome, or report findings were excluded. Study characteristics, methodologies, and outcomes were qualitatively analyzed. Grading of Recommendations, Assessment, Development and Evaluations (GRADE) was used to measure the quality of the studies, and the Oxford quality scoring system for risk of bias ratings. Results Seven randomized controlled trials met study inclusion criteria; interventions were mental practice, relaxation exercises, action observation, and Mindfulness-Based Stress Reduction. Targeted interventions based on mental practice, relaxation exercises, and MBSR significantly improved surgical performance in four (57%) studies. Risk of bias was low for all included studies, and quality of evidence was moderate for both simulated and OR performance. Conclusions Mental practice, relaxation, and mindfulness training improved simulation and OR performance for surgical residents. There was insufficient evidence to support other MST interventions or the intermediate- and long-term efficacy of MST.
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Importance: Cataracts account for 40% of cases of blindness globally, with surgery the only treatment. Objective: To determine whether adding simulation-based cataract surgical training to conventional training results in improved acquisition of surgical skills among trainees. Design, setting, and participants: A multicenter, investigator-masked, parallel-group, randomized clinical educational-intervention trial was conducted at 5 university hospital training institutions in Kenya, Tanzania, Uganda, and Zimbabwe from October 1, 2017, to September 30, 2019, with a follow-up of 15 months. Fifty-two trainee ophthalmologists were assessed for eligibility (required no prior cataract surgery as primary surgeon); 50 were recruited and randomized. Those assessing outcomes of surgical competency were masked to group assignment. Analysis was performed on an intention-to-treat basis. Interventions: The intervention group received a 5-day simulation-based cataract surgical training course, in addition to standard surgical training. The control group received standard training only, without a placebo intervention; however, those in the control group received the intervention training after the initial 12-month follow-up period. Main outcomes and measures: The primary outcome measure was overall surgical competency at 3 months, which was assessed with a validated competency assessment rubric. Secondary outcomes included surgical competence at 1 year and quantity and outcomes (including visual acuity and posterior capsule rupture) of cataract surgical procedures performed during a 1-year period. Results: Among the 50 participants (26 women [52.0%]; mean [SD] age, 32.3 [4.6] years), 25 were randomized to the intervention group, and 25 were randomized to the control group, with 1 dropout. Forty-nine participants were included in the final intention-to-treat analysis. Baseline characteristics were balanced. The participants in the intervention group had higher scores at 3 months compared with the participants in the control group, after adjusting for baseline assessment rubric score. The participants in the intervention group were estimated to have scores 16.6 points (out of 40) higher (95% CI, 14.4-18.7; P < .001) at 3 months than the participants in the control group. The participants in the intervention group performed a mean of 21.5 cataract surgical procedures in the year after the training, while the participants in the control group performed a mean of 8.5 cataract surgical procedures (mean difference, 13.0; 95% CI, 3.9-22.2; P < .001). Posterior capsule rupture rates (an important complication) were 7.8% (42 of 537) for the intervention group and 26.6% (54 of 203) for the control group (difference, 18.8%; 95% CI, 12.3%-25.3%; P < .001). Conclusions and relevance: This randomized clinical trial provides evidence that intense simulation-based cataract surgical education facilitates the rapid acquisition of surgical competence and maximizes patient safety. Trial registration: Pan-African Clinical Trial Registry, number PACTR201803002159198.
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Reports such as Each Baby Counts and the Confidential Enquiry into Maternal Deaths and Morbidity increasingly recognise that human factors contribute to significant events such as hypoxic ischaemic encephalopathy and maternal deaths. Loss of situational awareness (SA) has been implicated in at least 50% of such cases. A clinician’s SA involves information gathering, comprehension of data in real time and developing the crucial skills to project ahead and anticipate potential errors and threats. Good communication and shared mental models are important to maximise team SA in theatre, clinic and the labour ward.
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Excellent resuscitation requires technical skills and knowledge, but also the right mindset. Expert practitioners must master their internal affective state, and create the environment that leads to optimal team performance. Leaders in resuscitation should use structured approaches to prepare for resuscitation, and psychological skills to enhance their performance including mental rehearsal, positive self-talk, explicit communication strategies, and situational awareness skills. Postevent recovery is equally important. Providers should have explicit plans for recovery after traumatic cases, including developing resilience and self-compassion. Experts in resuscitation can improve their performance (and that of their team) by consciously incorporating psychological skills into their armamentarium.
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The present work is the first study that assess long run change after motor learning. The study’s main objective was to evaluate the short to medium-term impact of motor imagery (MI) and action observation (AO) on motor learning of a sequence of thumb-opposition tasks of increasing complexity. We randomly assigned 45 participants to an AO, MI, or placebo observation (PO) group. A sequence of 12 thumb-opposition tasks was taught for 3 consecutive days (4 per day). The primary outcome was accuracy. The secondary outcomes were required time and perfect positioning. The outcomes were assessed immediately after the intervention and at 1 week, 1 month and 4 months postintervention. Regarding the primary outcome, AO group had significantly higher accuracy than the MI or PO group until at least 4 months (p < 0.01, d> 0.80). However, in the bimanual positions, AO was not superior to MI at 1 week postintervention. Regarding secondary outcomes, AO group required less time than the MI group to remember and perform the left-hand and both-hand gestures, with a large effect size (p < 0.01, d> 0.80). In terms of percentage of perfect positions, AO group achieved significantly better results than the MI group until at least 4 months after the intervention in the unimanual gestures (p < 0.01, d> 0.80) and up to 1 month postintervention in the bimanual gestures (p= 0.012, d= 1.29). AO training resulted in greater and longer term motor learning than MI and placebo intervention. If the goal is to learn some motor skills for whatever reason (e.g., following surgery or immobilization.), AO training should be considered clinically.
Article
IntroductionThe aim of residency is to acquire medical skills and abilities. One didactic model is “Peyton’s four-step approach”. The aim of the present study was to develop and evaluate a modified Peytonian approach for group interactions. The aim was to develop a course for the acquisition of practical skills and training assistants in suture techniques for urology.MethodsA prospective study was conducted with a total of 38 participants and 6 tutors. In a modified four-step Peytonian approach, various suturing and knotting techniques were taught in a structured manner. Tutors evaluated the procedural activity using observation sheets. In addition, the learning method was evaluated by the participants and the tutors at the end of the course. In order to check the long-term learning success, a renewed survey of the participants was conducted after 6 months.Results80% of the participants rated the modified teaching method as useful and 83% of the tutors rated the procedural implementation as good. Fluid movement sequences were difficult independent of the technique taught. After 6 months, the participants significantly improved their procedural skills in all techniques that were taught.Conclusion This paper defines a four-step Peyton-based approach to teaching practical skills such as suturing and knotting used in urological training. The modified teaching method improved practical skills used in urology. This method should be considered in continuing education to promote self-confidence and increase the competence in surgical skills.
Article
OBJECTIVE The operating theatre (OT) is an important learning environment. Trainees face barriers to learning in the OT that may reduce meaningful educational interactions. The impact of these barriers on the intraoperative learning experience of trainees and the strategies that they employ to overcome them are not known. This qualitative study aimed to describe the intraoperative learning experiences of senior general surgery trainees in Australia and their strategies to optimize learning in the OT. DESIGN, SETTING, PARTICIPANTS The authors developed a semi-structured interview guide based on published literature. Purposive sampling was used to identify a representative group of general surgery trainees in Australia, who were interviewed in a private setting with audio recordings deidentified for verbatim transcription and analysis. Thematic analysis was conducted using an interpretivist approach to produce a coding framework. RESULTS Ten trainees participated in the study. Themes were divided into external and internal barriers to learning, promoters of effective learning and actions to facilitate learning. External barriers included cultural neglect of an important issue, with inadequate prioritization of teaching and a lack of structure for intraoperative learning. From this, we identified the theme of missed opportunities. Internal barriers included difficulties in developing assertiveness required to address these issues and a failure to adequately plan for learning, with reliance on the mentor to initiate. Actions to facilitate learning were rarely employed by trainees, as most were unaware of strategies to maximize intraoperative learning. CONCLUSIONS Trainees find the barriers to learning in the OT difficult to address and are not well acquainted with strategies that may allow them to maximize their learning.
Article
Objective: To demonstrate the feasibility of implementing a competency-based education (CBE) curriculum within a general surgery residency program and to evaluate its effectiveness in improving resident skill. Summary background data: Operative skill variability affects residents and practicing surgeons and directly impacts patient outcomes. CBE can decrease this variability by ensuring uniform skill acquisition. We implemented a CBE laparoscopic cholecystectomy (LC) curriculum to improve resident performance and decrease skill variability. Methods: PGY-2 residents completed the curriculum during monthly rotations starting in July 2017. Once simulator proficiency was reached, residents performed elective LCs with a select group of faculty at three hospitals. Performance at curriculum completion was assessed using LC simulation metrics and intraoperative OPRS scores and compared to both baseline and historical controls, comprised of rising PGY-3 s, using a two-sample Wilcoxon rank-sum test. PGY-2 group's performance variability was compared with PGY-3 s using Levene's Robust Test of Equality of Variances; p < 0.05 was considered significant. Results: 21 residents each performed 17.52 ± 4.15 consecutive LCs during the monthly rotation. Resident simulated and operative performance increased significantly with dedicated training and reached that of more experienced rising PGY-3 s (n = 7) but with significantly decreased variability in performance (p = 0.04). Conclusions: Completion of a CBE rotation led to significant improvements in PGY-2 residents' LC performance that reached that of PGY-3 s and decreased performance variability. These results support wider implementation of CBE in resident training.
Chapter
Over the past several decades, simulation has been introduced as a tool for surgical training. Simulation has several advantages compared to traditional training in the live patient setting, most importantly ensuring patient safety. Simulation has been developed using a variety of training platforms ranging from physical simulation to virtual reality simulation. Surgical simulation allows for development and maintenance of surgical skills that translate to the live patient setting. Simulation also has the added benefit of allowing trainees to have adequate exposure to less commonly performed surgical tasks and procedures. The most widely utilized application of surgical simulation to date has been in minimally invasive surgery. In addition to the role in education and training, simulation is beginning to be utilized as a method to demonstrate proficiency for credentialing and certification purposes. As simulation continues to gain acceptance in the surgical training community, additional uses and applications will emerge.
Thesis
Einleitung Platzwunden im Gesicht machen nahezu ein Drittel aller Platzwunden in der Notaufnahme aus (Singer et al., 2006). Diese werden zum Großteil nicht von Plastischen Chirurginnen und Chirurgen versorgt (Lee, Cho, et al., 2015), weshalb eine gute Grundausbildung junger Ärztinnen und Ärzte unabdingbar ist. Eine gängige Lehrmethode zur Vermittlung praktischer Fertigkeiten ist der konventionelle Ansatz „see one, do one“, welcher oft als unzureichend bewertet wird (Zahiri et al., 2015). Hingegen sind für die Vierschrittmethode nach Peyton zahlreiche Vorzüge dokumentiert (Herrmann-Werner et al., 2013; Krautter et al., 2015). Anhand eines eigens entwickelten Gesichtsmodells aus Silikon wurden beide Lehrmethoden im Hinblick auf ihren Lernerfolg bezüglich kommunikativer Fähigkeiten und handwerklicher Fertigkeiten, die Verankerung im Langzeitgedächtnis, die Dauer des Eingriffs sowie eine korrekte prozedurale Abfolge beim Versorgen von Gesichtswunden überprüft. Material und Methoden Zum Zeitpunkt der Teilnahme an der Studie befanden sich die Studierenden (n=20 bei einer Power von 0,8) entweder im Praktischen Jahr (11./12. Fachsemester) (n=10) oder im Blockpraktikum (10. Fachsemester) (n=10). Ausschlusskriterium war eine bereits selbstständig durchgeführte ambulante Naht im Gesichtsbereich. Die Kohorte der konventionellen Methode als Kontrollgruppe (KG) und die der Peyton Methode als Experimentalgruppe (EG) wurden mittels Video-Tutorial angeleitet, bevor sie die Naht in Lokalanästhesie am Gesichtsmodell durchführten. Nach 7 Tagen erfolgte die Operation ein zweites Mal ohne Anleitung. Die Operationen wurden gefilmt und durch drei verblindete Bewertende anhand der Skalen „Instrumentengebrauch“, „Umgang mit dem Gewebe“, „Knappe Versäumnisse und Fehler“ sowie „Qualität des Endergebnisses“ des Competency Assessment Tools (CAT) bewertet (1 = Anfänger/in bis 4 = Erfahrene/r), welche wiederum in 12 Items eingeteilt waren (Miskovic et al., 2013). Die Berechnung der Unterschiede bezog handwerkliche Fertigkeiten, die Verankerung im Langzeitgedächtnis, die Kommunikation sowie Unterschiede zwischen den Ausbildungsständen ein. Zusätzlich wurde das Einhalten des korrekten prozeduralen Ablaufes überprüft, sowie die Zeit zur Durchführung gemessen und zwischen den Lehrmethoden verglichen. Zur Validierung des CAT wurde die Reliabilität der Skalen und die Interrater-Reliabilität berechnet. Ergebnisse Sowohl die Reliabilität der Skalen als auch die Interrater-Reliabilität zeigten zufriedenstellende Ergebnisse. Bezüglich der Unterschiede auf Skalenebene zeigte die EG im Vergleich zur KG signifikant bessere Ergebnisse für die Mittelwerte aller vier Skalen (p < 0,05). Diese Ergebnisse bestätigten sich auch bei der Analyse einzelner Items. Bei Betrachtung der Unterschiede zwischen den OP Tagen zeigte sich bei der EG ein signifikanter Zuwachs der Leistung (p < 0,05). Bezüglich der kommunikativen Fähigkeiten berechnete sich für eines der beiden zugehörigen Items eine Überlegenheit der EG (p < 0,05). Bei detaillierter Betrachtung des Ausbildungsstandes ließ sich ein insgesamt besseres Abschneiden der Studierenden im Praktischen Jahr verglichen zu jenen im Blockpraktikum feststellen. Außerdem hielt die Kohorte der EG signifikant häufiger eine korrekte prozedurale Abfolge ein (p < 0,05) und benötigte deskriptiv weniger Zeit zur Durchführung der Prozedur. Fazit Die Peyton-Methode zeigte sich der konventionellen Methode im Hinblick auf das Erlernen einer Gesichtsnaht sowohl in der Qualität als auch in Bezug auf das Durchführen der Schritte in korrekter Reihenfolge überlegen. Zudem gibt es Evidenz, dass die Peyton Methode eine Verankerung des Gelernten im Langzeitgedächtnis fördert und die Durchführungsgeschwindigkeit erhöht. Die Ergebnisse sprechen somit für den Einsatz der Peyton Methode beim Erlernen komplexer chirurgischer Fähigkeiten. Ausblick Zukünftig könnte die feste Integration der Peyton Methode in das Curriculum die ärztliche Ausbildung verbessern. Insbesondere im Hinblick auf nachhaltiges und (Zeit-) effizientes Lernen besteht weiterer Forschungsbedarf. Außerdem wären weitere Untersuchungen zum Erlernen von Kommunikation mittels Vierschrittmethode nach Peyton wünschenswert.
Article
Operative video has great potential to enable instant replays of critical surgical decisions for training and quality review. Recently, artificial intelligence (AI) has shown early promise as a method of enabling efficient video review, analysis, and segmentation. Despite the progress with AI analysis of surgical videos, more work needs to be done to improve the accuracy and efficiency of AI-driven video analysis. At a recent consensus conference held on July 10–11, 2020, 8 research teams shared their work using AI for surgical video analysis. Four of the teams showcased the utility of wearable technology in providing objective surgical metrics. Data from these technologies were shown to pinpoint important cognitive and motor actions during operative tasks and procedures. The results support the utility of wearable technology to facilitate efficient and accurate video analysis and segmentation.
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Introduction: Health professionals are expected to consistently perform to a high standard during a variety of challenging clinical situations, which can provoke stress and impair their performance. There is increasing interest in applying sport psychology training using performance mental skills (PMS) immediately before and during performance. Methods: A systematic review of the main relevant databases was conducted with the aim to identify how PMS training (PMST) has been applied in health professions education and its outcomes. Results: The 20 selected studies noted the potential for PMST to improve performance, especially for simulated situations. The key implementation components were a multimodal approach that targeted several PMS in combination and delivered face to face delivery in a group by a trainer with expertise in PMS. The average number of sessions was 5 and of 57 minutes duration, with structured learner guidance, an opportunity for practice of the PMS and a focus on application for transfer to another context. Conclusion: Future PMST can be informed by the key implementation components identified in the review but further design and development research is essential to close the gap in current understanding of the effectiveness of PMST and its key implementation components, especially in real-life situations.
Article
Background: The aim is to develop and test the utility of an event-initiated, team-based check list to optimize the response to bleeding during laparoscopic HPB surgery. Methods: To build a checklist for managing bleeding events, we conducted a systematic review. Using nominal group technique (NGT), a checklist consisting of four domains was developed. Following team-based training of anesthesia and surgical staff, the checklist was implemented. HPB cases before and after implementation of the checklist were compared for adverse outcomes, bleeding complications, and transfusions. Results: NGT identified four domains: Communicate Control, Expose, and Repair under which the checklist was organized. Supplemental Video for a detailed review of how each domain was applied to a specific case example. We compared 169 HPB cases before to 53 cases after implementation. We found a significant decrease in mean EBL (from 518 ± 852.8 to 151.5 ± 221.7 ml (P = 0.001)) for cases performed after implementation of the checklist and a trends toward less volume of pRBC transfused (2.7 ± 2.5 vs 2.3 ± 1.7 units/per patient, P = 0.611) and transfusion rates (22% vs 11%, P = 0.703). Conclusion: An event-initiated, team-based response to an adverse bleeding event during laparoscopic HPB surgery correlates with positive effects on bleeding management, and transfusion rates.
Chapter
Surgery should be safe for both patients and providers. There are numerous strategies to optimize intraoperative patient safety. This chapter will cover patient positioning and radiation safety given their importance in the surgical management of incontinence. Surgeons should also be safe in their workplace, and the high rates of work-related musculoskeletal pain and injury in vaginal surgeons suggest that there is room for improvement. Various strategies can improve surgical ergonomics and prevent pain, including alterations in the physical environment, surgeon-specific activities, and workstation optimization.Peak surgical performance requires both excellent technical and nontechnical skills (e.g., communication, decision-making, and leadership). Improvement opportunities abound for individual surgeons interested in performance optimization. These include technical coaching to improve surgical technique or instruction in mental practice or stress management techniques. Understanding the performance implications of hypoglycemia and fatigue can prompt practical lifestyle change. Encouraging institutions to invest in team training and develop skills in crisis management can save lives when inevitable emergencies occur.KeywordsPatient safetyRadiation safetySurgical patient positioningSurgical ergonomicsMusculoskeletal painNontechnical skillsSurgeonPerformance
Thesis
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It is assumed that imagined and executed actions are based on similar mechanisms because they take approximately the same amount of time, follow the same motor principles, and involve similar brain areas. In motor imagery and motor execution, internal models (e.g. forward models) are supposed to predict the action consequences on the actor and the environment. The predictive mechanisms in motor imagery were investigated in two series of experiments. In Series 1, cognitive factors and bimanual principles influenced motor imagery and motor execution similarly. In Series 2, deviations from optimal performance were observed in motor imagery and motor execution. However, predictions showed fewer deviations from optimal performance than actual performance, regardless whether predictions were based on motor imagery or motor execution. Further, the action consequences were similarly influenced by expertise in motor imagery and motor execution. The findings strengthen the assumption of similar mechanisms in motor imagery and motor execution. Most likely, a simulation of the action takes place in motor imagery that predicts the action consequences. This prediction may be based on forward models. The observed results enhance the understanding of the mechanisms of motor imagery and contribute to a solid theoretical and empirical basis for applications of motor imagery in mental practice.
Article
Background Since the transition of surgical robot systems into the medical field, physicians have had to develop new dexterity skills. The ideal learning environment for robotic surgery has yet to be discovered. Virtual-reality (VR) simulation is a possible safe and economic method. In VR-simulator training human feedback is hardly used, an alternative may be found in video revision. The purpose of this study is to investigate whether adding video review to VR-simulation-based training in novice physicians improves their ability to complete a complex robot task. In addition, the secondary goal is to investigate whether the skills learned on the robotic simulator can be transferred to a real robotic system. Methods 40 participants, medical students and, medical-PhD candidates, from one university hospital, were included. Baseline dexterity skills were measured through completion of a vesico-urethral anastomosis on a VR-robot simulator and the DaVinci robot. Participants were randomized into a video and control group. The video group practiced skills on the robot simulator with intermediate video revision, whereas the control group had intermediate pause instead. Post-intervention dexterity skills were measured using the same exercises as the baseline tests. Results No significant differences were found in baseline performance. Post-intervention results on the VR-simulator show that the video group commits significantly fewer injuries to the urethra and sutures at a greater optimal depth. The control group was significantly faster, had less camera travel, and had their instruments less out of view. On the DaVinci robot, participants in both groups performed significantly faster and had better GEARS-score after the training sessions on the VR simulator. Conclusions Video revision significantly improves the quality of robotic skills in novice surgeons on the VR-simulator, though at the expense of time. Furthermore, both groups demonstrated enhanced skills on the DaVinci robot after training sessions, which advocates the transferability of skill.
Article
Emotional regulation is increasingly gaining acceptance as a means to improve well-being, performance, and leadership across high-stakes professions, representing innovation in thinking within the field of surgical education. As one part of a broader cognitive skill set that can be trained and honed, emotional regulation has a strong evidence base in high-stress, high-performance fields. Nevertheless, even as Program Directors and surgical educators have become increasingly aware of this data, with emerging evidence in the surgical education literature supporting efficacy, hurdles to sustainable implementation exist. In this white paper, we present evidence supporting the value of emotional regulation training in surgery and share case studies in order to illustrate practical steps for the development, adaptation, and implementation of emotional regulation curricula in three key developmental contexts: basic cognitive skills training, technical skills acquisition and performance, and preparation for independence. We focus on the practical aspects of each case to elucidate the challenges and opportunities of introducing and adopting a curricular innovation into surgical education. We propose an integrated curriculum consisting of all three applied contexts for emotional regulation skills and advocate for the dissemination of such a longitudinal curriculum on a national level.
Chapter
The operative environment remains suboptimal for the development of surgical skills. Simulation training provides a possibility of becoming familiar with the instruments and procedures and being trained in a calm and consequence-free environment. The currently available training models include dry laboratories with inanimate bench models, wet laboratories with animal and cadaveric models and virtual reality (VR) simulators. Over the last 2 decades, inanimate bench models and VR simulators have been extensively assessed and validated for technical and non-technical skill acquisition. Overall, these training systems facilitate the development and improvement of initial competencies in the endoscopic procedure. The URO Mentor™ VR simulator remains the most popular model due to its easy installation and use, integrated immediate feedback option, and the possibility of training in various procedures. However, the system has a high purchasing cost, limiting its acceptance by a significant number of centers. On the other hand, low-cost alternatives have also been tested to provide efficient training. Recently, laparoscopic and endoscopic skills training have been standardised in Europe. There is still, however, a lack of large-scale data on curriculum-based training. New, well-designed studies can increase the interest in surgical training and facilitate its integration into the residency training programs.KeywordsSimulation; trainingUrethro-cystoscopyUreteroscopyVirtual realityKidney calculiURSRIRS
Article
Objective The resident-attending dyad influences the intraoperative training of surgery residents. To better understand the role of trainees within the dyad, we hypothesized there is a measurable concept of “teachability,” a combination of the trainee's observed skills and behaviors with their performance. This study aims to define teachability and identify discrete intraoperative behaviors that contribute to this concept. We posit that residents who are active learners as demonstrated by asking questions, proposing next steps, and initiating purposeful actions have higher teachability. Design, Setting, Participants Previously recorded videos from 26 laparoscopic inguinal hernia repairs performed by two PGY-5 general surgery residents at a Midwest tertiary care center were qualitatively reviewed for intraoperative behaviors. A summative content analysis identified behaviors associated with increased teachability and improved operative performance assessment scores. Results Average frequencies of intraoperative behaviors for resident 1 and 2 (R1 and R2) were not significantly different, although R2 asked more medical knowledge and technical questions. While the rate of attending feedback was similar for both residents (x=3.82 vs 3.40, p=0.646), R1 consistently incorporated feedback (x=2.27 vs 0.40, p=0.001) whereas R2 needed frequent prompting (x=2.45 vs 1.55, p=0.239). R1 scored higher in all but one operative performance assessment category, including overall performance (x=4.17 vs 2.93, p=0.007), but R2 had a larger magnitude of overall improvement (+1 vs +2). Conclusions Teachability is a dynamic component of the resident-attending dyad. While intraoperative active learning behaviors do not appear to be associated with teachability, asking questions may increase the magnitude of improvement in performance. Most importantly, the ability to incorporate intraoperative feedback in real time seems to be a critical aspect of teachability and warrants further research.
Book
The human imagination manifests in countless different forms. We imagine the possible and the impossible. How do we do this so effortlessly? Why did the capacity for imagination evolve and manifest with undeniably manifold complexity uniquely in human beings? This handbook reflects on such questions by collecting perspectives on imagination from leading experts. It showcases a rich and detailed analysis on how the imagination is understood across several disciplines of study, including anthropology, archaeology, medicine, neuroscience, psychology, philosophy, and the arts. An integrated theoretical-empirical-applied picture of the field is presented, which stands to inform researchers, students, and practitioners about the issues of relevance across the board when considering the imagination. With each chapter, the nature of human imagination is examined – what it entails, how it evolved, and why it singularly defines us as a species.
Article
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Mental practice is the cognitive rehearsal of a task prior to performance. Although most researchers contend that mental practice is an effective means of enhancing performance, a clear consensus is precluded because (a) mental practice is often defined so loosely as to include almost any type of mental preparation and (b) empirical results are inconclusive. A meta-analysis of the literature on mental practice was conducted to determine the effect of mental practice on performance and to identify conditions under which mental practice is most effective. Results indicated that mental practice has a positive and significant effect on performance, and the effectiveness of mental practice was moderated by the type of task, the retention interval between practice and performance, and the length or duration of the mental practice intervention.
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This paper focuses on the potential of mental simulation (mentally rehearsing an action to enhance performance) as a useful contemporary educational method. By means of a meta-review, it is examined which conditions impede or facilitate the effectiveness of mental simulation (MS). A computer search was conducted using Ovid PsycINFO. Reviews, meta-reviews, or meta-analyses published between 1806 and 2006 were included. The current paper presents the results of ten publications in which about 630 studies on mental simulation or mental practice are reviewed. According to the analyses, conditions that influence the effect of MS are the type of skill practiced, personal factors, time per trial, amount of trials, and instructional procedures. Based on these insights, it is reflected upon in which areas MS would be functional with regard to contemporary educational demands, such as for emotional, behavioral, and (other) complex cognitive tasks.
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To assess the effect of virtual reality training on an actual laparoscopic operation. Prospective randomised controlled and blinded trial. Seven gynaecological departments in the Zeeland region of Denmark. 24 first and second year registrars specialising in gynaecology and obstetrics. Proficiency based virtual reality simulator training in laparoscopic salpingectomy and standard clinical education (controls). The main outcome measure was technical performance assessed by two independent observers blinded to trainee and training status using a previously validated general and task specific rating scale. The secondary outcome measure was operation time in minutes. The simulator trained group (n=11) reached a median total score of 33 points (interquartile range 32-36 points), equivalent to the experience gained after 20-50 laparoscopic procedures, whereas the control group (n=10) reached a median total score of 23 (22-27) points, equivalent to the experience gained from fewer than five procedures (P<0.001). The median total operation time in the simulator trained group was 12 minutes (interquartile range 10-14 minutes) and in the control group was 24 (20-29) minutes (P<0.001). The observers' inter-rater agreement was 0.79. Skills in laparoscopic surgery can be increased in a clinically relevant manner using proficiency based virtual reality simulator training. The performance level of novices was increased to that of intermediately experienced laparoscopists and operation time was halved. Simulator training should be considered before trainees carry out laparoscopic procedures. ClinicalTrials.gov NCT00311792.
Article
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Surgery has become an integral part of global health care, with an estimated 234 million operations performed yearly. Surgical complications are common and often preventable. We hypothesized that a program to implement a 19-item surgical safety checklist designed to improve team communication and consistency of care would reduce complications and deaths associated with surgery. Between October 2007 and September 2008, eight hospitals in eight cities (Toronto, Canada; New Delhi, India; Amman, Jordan; Auckland, New Zealand; Manila, Philippines; Ifakara, Tanzania; London, England; and Seattle, WA) representing a variety of economic circumstances and diverse populations of patients participated in the World Health Organization's Safe Surgery Saves Lives program. We prospectively collected data on clinical processes and outcomes from 3733 consecutively enrolled patients 16 years of age or older who were undergoing noncardiac surgery. We subsequently collected data on 3955 consecutively enrolled patients after the introduction of the Surgical Safety Checklist. The primary end point was the rate of complications, including death, during hospitalization within the first 30 days after the operation. The rate of death was 1.5% before the checklist was introduced and declined to 0.8% afterward (P=0.003). Inpatient complications occurred in 11.0% of patients at baseline and in 7.0% after introduction of the checklist (P<0.001). Implementation of the checklist was associated with concomitant reductions in the rates of death and complications among patients at least 16 years of age who were undergoing noncardiac surgery in a diverse group of hospitals.
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To demonstrate that virtual reality (VR) training transfers technical skills to the operating room (OR) environment. The use of VR surgical simulation to train skills and reduce error risk in the OR has never been demonstrated in a prospective, randomized, blinded study. Sixteen surgical residents (PGY 1-4) had baseline psychomotor abilities assessed, then were randomized to either VR training (MIST VR simulator diathermy task) until expert criterion levels established by experienced laparoscopists were achieved (n = 8), or control non-VR-trained (n = 8). All subjects performed laparoscopic cholecystectomy with an attending surgeon blinded to training status. Videotapes of gallbladder dissection were reviewed independently by two investigators blinded to subject identity and training, and scored for eight predefined errors for each procedure minute (interrater reliability of error assessment r > 0.80). No differences in baseline assessments were found between groups. Gallbladder dissection was 29% faster for VR-trained residents. Non-VR-trained residents were nine times more likely to transiently fail to make progress (P <.007, Mann-Whitney test) and five times more likely to injure the gallbladder or burn nontarget tissue (chi-square = 4.27, P <.04). Mean errors were six times less likely to occur in the VR-trained group (1.19 vs. 7.38 errors per case; P <.008, Mann-Whitney test). The use of VR surgical simulation to reach specific target criteria significantly improved the OR performance of residents during laparoscopic cholecystectomy. This validation of transfer of training skills from VR to OR sets the stage for more sophisticated uses of VR in assessment, training, error reduction, and certification of surgeons.
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Objective: This approach provides the basis of our research program, which aims to expand operative assessment beyond patient factors and the technical skills of the surgeon; to extend assessment of surgical skills beyond bench models to the operating theater; to provide a basis for assessing interventions; and to provide a deeper understanding of surgical outcomes. Summary background data: Research into surgical outcomes has primarily focused on the role of patient pathophysiological risk factors and on the skills of the individual surgeon. However, this approach neglects a wide range of factors that have been found to be of important in achieving safe, high-quality performance in other high-risk environments. The outcome of surgery is also dependent on the quality of care received throughout the patient's stay in hospital and the performance of a considerable number of health professionals, all of whom are influenced by the environment in which they work. Methods: Drawing on the wider literature on safety and quality in healthcare, and recent papers on surgery, this article argues for a much wider assessment of factors that may be relevant to surgical outcome. In particular, we suggest the development of an "operation profile" to capture all the salient features of a surgical operation, including such factors as equipment design and use, communication, team coordination, factors affecting individual performance, and the working environment. Methods of assessing such factors are outlined, and ethical issues and other potential concerns are discussed.
Article
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The purpose of this study was to test the effects of varying the amount of physical practice and mental imagery rehearsal on learning basic surgical procedures. Using a sample of 65 second-year medical students, 3 randomized groups received either: (1) 3 sessions of physical practice on suturing a pig's foot; (2) 2 sessions of physical practice and 1 session of mental imagery rehearsal; or (3) 1 session of physical practice and 2 sessions of imagery rehearsal. All participants then performed a surgery on a live rabbit in the operating theater of a veterinary college under approved conditions. Analysis of variance was applied to pre- and post-treatment ratings of surgical performance. Physical practice followed by mental imagery rehearsal was statistically equal to additional physical practice. Initial physical practice followed by mental imagery rehearsal may be a cost-effective method of training medical students in learning basic surgical skills.
Article
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The aim of the present study was to examine self-reported psychological states and physiological responses (heart rate) experienced during different motivational general imagery scenarios. Forty competitive athletes wore a standard heart rate monitor and imaged five scripts (mastery, coping, anxiety, psyching up, and relaxation). Following each script, they reported their state anxiety and self-confidence. A significant increase in heart rate from baseline to imagery was found for the anxiety, psyching-up, and coping imagery scripts. Furthermore, the intensity of cognitive and somatic anxiety was greater and perceived as being more debilitative following the anxiety imagery script. The findings support Lang's (1977, 1979) proposal that images containing response propositions will produce a physiological response (i.e., increase heart rate). Moreover, coping imagery enabled the athletes to simultaneously experience elevated levels of anxiety intensity and thoughts and feelings they perceived as helpful.
Article
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Although surgeons and athletes frequently use mental imagery in preparing to perform, mental imagery has not been extensively researched as a learning technique in medical education. A mental imagery rehearsal technique was experimentally compared with textbook study to determine the effects of each on the learning of basic surgical skills. Sixty-four Year 2 medical students were randomly assigned to 2 treatment groups in which they undertook either mental imagery or textbook study. Both groups received the usual skills course of didactic lectures, demonstrations, physical practice with pigs' feet and a live animal laboratory. One group received additional training in mental imagery and the other group was given textbook study. Performance was assessed at 3 different time-points using a reliable rating scale. Analysis of variance on student performance in live rabbit surgery revealed a significant interaction favouring the imagery group over the textbook study group. The mental imagery technique appeared to transfer learning from practice to actual surgery better than textbook study.
Article
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For many patients, a successful clinical outcome depends on having a well performed technical procedure. Crucial for surgeons, technical competence is becoming an important element of training for many hospital based specialists: interventional radiologists, cardiologists, gastroenterologists, endovascular therapists, and others. “See one, do one” is no longer appropriate for educating health professionals to perform complex procedures. Graduated independence, the hallmark of the approach to teaching procedural skills, is being challenged by concerns for patients’ safety, the skyrocketing complexity of procedures, and a diminishing work week for trainees. Finding the balance between patients’ safety and doctors’ training will require a more structured approach to our skills curriculum, including continuous assessment of skills, constructive feedback, and provision of opportunities for deliberate practice in the teaching environment.This paper aims to provide an evidence based algorithm for procedural skills training. It focuses on teaching technical skills, which are just one component of a successful procedure—others are clinical judgment, communication, and team work.
Article
Research examining imagery use by athletes is reviewed within the context of an applied model for sport. The model conceptualizes the sport situation, the type of imagery used, and imagery ability as factors that influence how imagery use can affect an athlete. Three broad categories of imagery effects are examined: (a) skill and strategy learning and performance, (b) cognitive modification, and (c) arousal and anxiety regulation. Recommendations are offered for the operationalization and measurement of constructs within the model, and suggestions are provided for how the model may guide future research and application. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
Procedures are an important component of the practice of medicine. Students and residents must be trained to perform procedures safely and well. Simultaneously, we must seek consensus on what procedures should be taught, and we must develop better, safer techniques to teach them. Finally, we must develop objective measures of initial and continuing competency for those who perform procedures. We must try to overcome the “turf” battles in this area and focus on what is best for patients, students, and residents.
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ProblemThere has been a recent upsurge of research interest in cognitive sport psychology or the scientific study of mental processes (e.g., mental imagery) in athletes. Despite this interest, an important question has been neglected. Specifically, is research on cognitive processes in athletes influential outside sport psychology, in the “parent” field of cognitive psychology or in the newer discipline of cognitive neuroscience?ObjectivesThe purpose of this paper is to explore the theoretical significance of research on expertise, attention and mental imagery in athletes from the perspective of cognitive psychology and cognitive neuroscience.MethodFollowing analysis of recent paradigm shifts in cognitive psychology and cognitive neuroscience, a narrative review is provided of key studies on expertise, attention and mental imagery in athletes.Results and conclusionsThis paper shows that cognitive sport psychology has contributed significantly to theoretical understanding of certain mental processes studied in cognitive psychology and cognitive neuroscience. It also shows that neuroscientific research on motor imagery can benefit from increased collaboration with cognitive sport psychology. Overall, I conclude that the domain of sport offers cognitive researchers a rich and dynamic natural laboratory in which to study how the mind works.
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To determine whether skills acquired by simulation-based training transfer to the operative setting. The fundamental assumption of simulation-based training is that skills acquired in simulated settings are directly transferable to the operating room, yet little evidence has focused on correlating simulated performance with actual surgical performance. A systematic search strategy was used to retrieve relevant studies. Inclusion of articles was determined using a predetermined protocol, independent assessment by 2 reviewers, and a final consensus decision. Only studies that reported on the use of simulation-based training for surgical skills training, and the transferability of these skills to the operative setting, were included. Ten randomized controlled trials and 1 nonrandomized comparative study were included in this review. In most cases, simulation-based training was in addition to normal training programs. Only 1 study compared simulation-based training with patient-based training. For laparoscopic cholecystectomy and colonoscopy/sigmoidoscopy, participants who received simulation-based training before undergoing patient-based assessment performed better than their counterparts who did not receive previous simulation training, but improvement was not demonstrated for all measured parameters. Skills acquired by simulation-based training seem to be transferable to the operative setting. The studies included in this review were of variable quality and did not use comparable simulation-based training methodologies, which limited the strength of the conclusions. More studies are required to strengthen the evidence base and to provide the evidence needed to determine the extent to which simulation should become a part of surgical training programs.
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Distributed simulation (DS) is the concept of high-fidelity immersive simulation on-demand, made widely available wherever and whenever it is required. DS provides an easily transportable, self-contained 'set' for creating simulated environments within an inflatable enclosure, at a small fraction of the cost of dedicated, static simulation facilities. High-fidelity simulation is currently confined to a relatively small number of specialised centres. This is largely because full-immersion simulation is perceived to require static, dedicated and sophisticated equipment, supported by expert faculty. Alternatives are needed for healthcare professionals who cannot access such centres. We propose that elements of immersive simulations can be provided within a lightweight, low-cost and self-contained setting which is portable and can therefore be accessed by a wide range of clinicians. We will argue that mobile simulated environments can be taken to where they are needed, making simulation more widely available. We develop the notion that a simulation environment need not be a fixed, static resource, but rather a 'container' for a range of activities and performances, designed around the needs of individual users. We critically examine the potential of DS to widen access to an otherwise limited resource, putting flexible, 'just in time' training within reach of all clinicians. Finally, we frame DS as a 'disruptive innovation' with potential to radically alter the landscape of simulation-based training.
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Safe surgical practice requires a combination of technical and nontechnical abilities. Both sets of skills can be impaired by intra-operative stress, compromising performance and patient safety. This systematic review aims to assess the effects of intra-operative stress on surgical performance. A systematic search strategy was implemented to obtain relevant articles. MEDLINE, EMBASE, and PsycINFO databases were searched, and 3,547 abstracts were identified. After application of limits, 660 abstracts were retrieved for subsequent evaluation. Studies were included on the basis of predetermined inclusion criteria and independent assessment by 2 reviewers. In all, 22 articles formed the evidence base for this review. Key stressors included laparoscopic surgery (7 studies), bleeding (4 studies), distractions (4 studies), time pressure (3 studies), procedural complexity (3 studies), and equipment problems (2 studies). The methods for assessing stress and performance varied greatly across studies, rendering cross-study comparisons difficult. With only 7 studies assessing stress and surgical performance concurrently, establishing a direct link was challenging. Despite this shortfall, the direction of the evidence suggested that excessive stress impairs performance. Specifically, laparoscopic procedures trigger greater stress levels and poorer technical performance (3 studies), and expert surgeons experience less stress and less impaired performance compared with juniors (2 studies). Finally, 3 studies suggest that stressful crises impair surgeons' nontechnical skills (eg, communication and decision making). Surgeons are subject to many intra-operative stressors that can impair their performance. Current evidence is characterized by marked heterogeneity of research designs and variable study quality. Further research on stress and performance is required so that surgical training and clinical excellence can flourish.
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Assessment of surgical competence is a priority; however little is known about surgeons' perceptions of competence. We investigated components of competence and adequacy of training in achieving them. Using questionnaires, Surgical Attendings and trainees rated the importance of 7 CanMEDS roles that define a competent surgeon (Medical Expert; Communicator; Collaborator; Manager; Health Advocate; Scholar; Professional) and whether training enabled them to achieve competency in each role. Ninety-two of 125 questionnaires (74%) were completed. Junior trainees attributed lower importance to the roles of Manager, Communicator, Collaborator, and Professional than senior trainees or Attendings. No surgeon stated that they had achieved competency in every role. Trainee surgeons do not appreciate the importance of all the roles required of a competent surgeon and current training does not ensure competence in all roles. These gaps must be addressed to develop surgeons able to provide the highest quality of care.
Article
The rate of death was 1.5% before the checklist was introduced and declined to 0.8% afterward (P = 0.003). Inpatient complications occurred in 11.0% of patients at baseline and in 7.0% after introduction of the checklist (P
Article
Concerns for patient safety have accelerated the need for alternative training strategies outside the operating room. Mental practice (MP: the use of mental imagery to rehearse a task symbolically before performance) has been used successfully in sports and music to enhance skill. This study aimed to develop and validate a MP training strategy for laparoscopic surgery. A cognitive "walk through" was conducted for a laparoscopic cholecystectomy (LC) to identify key visual, cognitive, and kinesthetic cues for the procedure. This was used to develop a MP training protocol featuring an "MP script" to enhance mental imagery of a LC. The script was validated by asking each subject to rehearse mentally a LC within 30 min. Ability to practice this procedure mentally was assessed before and after MP training with a modified version of a validated questionnaire (minimum score, 8; maximum score, 56). The study was completed by 20 subjects (10 experienced surgeons >100 LCs, 10 novice surgeons <10 LCs). Reliability testing of the questionnaire gave it a Cronbach alpha of 0.984 (n = 20) before MP training and 0.879 (n = 20) after MP training, indicating internal consistency. The construct validity of the questionnaire is supported by the fact that the experienced surgeons scored higher on all the questions than the novices both before and after training. Significant improvement in global imagery score after MP was shown by both experienced (48 before MP vs. 53 after MP; p = 0.007) and novice (15 before MP vs. 42 after MP; p = 0.005) surgeons, suggesting both face and content validity. This is the first study to develop and validate MP as a novel training approach for laparoscopic surgery. Mental practice may be a time- and cost-effective strategy that improves surgeons' ability to visualize themselves performing a LC, increasing both their knowledge and confidence.
Article
Early evidence is promising, but integration with existing systems is key Surgery was traditionally learnt by repeated practice on patients. Trainee surgeons were exposed to innumerable operative cases over many years, with supervision tailored to their needs. This provided experience in coping with a wide range of operative approaches and complications, and it balanced trainees’ levels of experience with the demands of the procedure. This process has changed radically in recent years. Minimally invasive surgical techniques have led to fast track and ambulatory surgery; service targets and reductions in working time have reduced training opportunities for young doctors; and strong ethical imperatives have made it unacceptable for novices to learn “on patients.”1 Traditional approaches are therefore no longer tenable. How then should surgeons learn their craft? In the linked randomised controlled trial (doi: 10.1136/bmj.b1802), Larsen and colleagues assess the effect of virtual reality training on surgical performance in laparoscopic surgery.2 Simulation offers obvious benefits, especially in mastering counterintuitive techniques such as minimal access surgery. Sophisticated virtual reality simulators can provide anatomically realistic recreations of many operations, …
Article
A conceptual three-level framework is presented for understanding the aims, scope and potential outcomes of simulation in healthcare contexts. At the first level, micro-simulation aims at honing basic technical skills of individual clinicians. At the second level, meso-simulation aims to train clinicians to work more effectively and efficiently as part of a clinical team. At the third level, macro-simulation aims toassess organisational fitness fo r purpose at large scale. We discuss HOSPEX as an exemplar macro-simulation and argue for needs- and evidence-based implementation of simulation-based training at micro, meso and macro levels.
Article
A new approach to testing operative technical skills, the Objective Structured Assessment of Technical Skill (OSATS), formally assesses discrete segments of surgical tasks using bench model simulations. This study examines the interstation reliability and construct validity of a large-scale administration of the OSATS. A 2-hour, eight-station OSATS was administered to 48 general surgery residents. Residents were assessed at each station by one of 48 surgeons who evaluated the resident using two methods of scoring: task-specific checklists and global rating scales. Interstation reliability was 0.78 for the checklist score, and 0.85 for the global score. Analysis of variance revealed a significant effect of training for both the checklist score, F(3,44) = 20.08, P <0.001, and the global score, F(3,44) = 24.63, P <0.001. The OSATS demonstrates high reliability and construct validity, suggesting that we can effectively measure residents' technical ability outside the operating room using bench model simulations.
Article
The "fulcrum effect" of the body wall on surgical instrument manipulation is a major hurdle for novice endoscopic surgeons. Virtual reality training has not previously been evaluated as a means to overcome this problem. 16 participants with no experience of endoscopy were required to make multiple defined incisions under laparoscopic laboratory conditions within 2-minute periods. Half of the subjects were randomized to receive initial training on the Minimally Invasive Surgical Trainer, Virtual Reality (MIST VR) computer programme. Participants with MIST VR training made significantly more correct incisions (P = 0.0001) than the control group on test trial 1, and even after extended practice by both groups (P = 0.0001). They were also significantly more likely to actively use both hands to perform the endoscopic evaluation task (P = 0.01). Virtual reality training represents a potential, viable solution for junior endoscopists, for overcoming the "fulcrum effect", in a replicable, safe learning environment which allows objective and reliable quantification of skill levels by trainers.
Article
This study examined the impact of virtual reality (VR) surgical simulation on improvement of psychomotor skills relevant to the performance of laparoscopic cholecystectomy. Sixteen surgical trainees performed a laparoscopic cholecystectomy on patients in the operating room (OR). The participants were then randomized to receive VR training (ten repetitions of all six tasks on the Minimally Invasive Surgical Trainer-Virtual Reality (MIST-VR)) or no training. Subsequently, all subjects performed a further laparoscopic cholecystectomy in the OR. Both operative procedures were recorded on videotape, and assessed by two independent and blinded observers using predefined objective criteria. Time to complete the procedure, error score and economy of movement score were assessed during the laparoscopic procedure in the OR. No differences in baseline variables were found between the two groups. Surgeons who received VR training performed laparoscopic cholecystectomy significantly faster than the control group (P=0.021). Furthermore, those who had VR training showed significantly greater improvement in error (P=0.003) and economy of movement (P=0.003) scores. Surgeons who received VR simulator training showed significantly greater improvement in performance in the OR than those in the control group. VR surgical simulation is therefore a valid tool for training of laparoscopic psychomotor skills and could be incorporated into surgical training programmes.
Article
Increasing constraints on the time and resources needed to train surgeons have led to a new emphasis on finding innovative ways to teach surgical skills outside the operating room. Virtual reality training has been proposed as a method to both instruct surgical students and evaluate the psychomotor components of minimally invasive surgery ex vivo. The performance of 100 laparoscopic novices was compared to that of 12 experienced (>50 minimally invasive procedures) and 12 inexperienced (<10 minimally invasive procedures) laparoscopic surgeons. The values of the experienced surgeons' performance were used as benchmark comparators (or criterion measures). Each subject completed six tasks on the Minimally Invasive Surgical Trainer-Virtual Reality (MIST-VR) three times. The outcome measures were time to complete the task, number of errors, economy of instrument movement, and economy of diathermy. After three trials, the mean performance of the medical students approached that of the experienced surgeons. However, 7-27% of the scores of the students fell more than two SD below the mean scores of the experienced surgeons (the criterion level). The MIST-VR system is capable of evaluating the psychomotor skills necessary in laparoscopic surgery and discriminating between experts and novices. Furthermore, although some novices improved their skills quickly, a subset had difficulty acquiring the psychomotor skills. The MIST-VR may be useful in identifying that subset of novices.
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Learning surgical skills involves both fine and gross motor skills, and necessitates performance in stressful situations. This environment is similar to the environment in which an athlete performs. Mental imagery has been used successfully in training athletes of all levels of proficiency and enhances both motor skills and motivational skills of performing under stress. The literature of using mental imagery to train surgeons is limited to the teaching of simple surgical skills, but shows promise as another tool to teach technical skills.
Article
Objective: To examine how surgical skills are taught and evaluated in obstetrics-gynecology residency programs in the United States.Methods: A questionnaire was mailed to the directors of all 266 residency programs in the United States and to second contact names at 51 sites. Directors were asked to evaluate how surgical skills are taught and evaluated and to rate the importance of specific techniques and procedures for residents at given points in resident training.Results: Two hundred twenty-three surveys were returned (70%), representing 203 of 266 programs (76%). Among responding programs, 99% reported teaching surgical skills in operating rooms, 88% in lectures, 68% with bench procedures, and 54% with animal surgery. Twenty-nine percent indicated they had formal surgical skills curricula. A significantly higher percentage of those programs with formal curricula used animal surgery laboratories (81% versus 42%, P < .001) and were more likely to conduct formal skills assessments (88% versus 69%, P = .005) than programs without formal curricula. Overall, 74% of programs evaluated surgical skills. Of those, 56% reported using subjective faculty evaluations, 12% written evaluations (eg, checklists), 4% written and oral assessments, and 1% a test. Regardless of formal curricula, there was much agreement in respondents’ ratings of 60 different skills and procedures as “essential,” “important,” “nice to know,” or “unimportant.”Conclusion: Most programs teach surgical skills in the operating room and through lectures. Only 29% of reporting programs provide formal surgical curricula. Evaluation of surgical skills is usually done by subjective evaluation, a technique with unknown validity and poor reliability.
Article
To develop an evidence-based virtual reality laparoscopic training curriculum for novice laparoscopic surgeons to achieve a proficient level of skill prior to participating in live cases. Technical skills for laparoscopic surgery must be acquired within a competency-based curriculum that begins in the surgical skills laboratory. Implementation of this program necessitates the definition of the validity, learning curves and proficiency criteria on the training tool. The study recruited 40 surgeons, classified into experienced (performed >100 laparoscopic cholecystectomies) or novice groups (<10 laparoscopic cholecystectomies). Ten novices and 10 experienced surgeons were tested on basic tasks, and 11 novices and 9 experienced surgeons on a procedural module for dissection of Calot triangle. Performance of the 2 groups was assessed using time, error, and economy of movement parameters. All basic tasks demonstrated construct validity (Mann-Whitney U test, P < 0.05), and learning curves for novices plateaued at a median of 7 repetitions (Friedman's test, P < 0.05). Expert surgeons demonstrated a learning rate at a median of 2 repetitions (P < 0.05). Performance on the dissection module demonstrated significant differences between experts and novices (P < 0.002); learning curves for novice subjects plateaued at the fourth repetition (P < 0.05). Expert benchmark criteria were defined for validated parameters on each task. A competency-based training curriculum for novice laparoscopic surgeons has been defined. This can serve to ensure that junior trainees have acquired prerequisite levels of skill prior to entering the operating room, and put them directly into practice.