The optimal frequency of endoscopic skill labs for training and skill retention on suturing: a randomized controlled trial

Surgery and technical skill decay

BACKGROUND

An increasing number of surgical trainees are taking time out of clinical training for research, parental leave or other interests. A comprehensive review was carried out to evaluate the current evidence on whether and how such time results in surgical skill decay.

METHODS

A PubMed, Embase, Web of Science, and Cochrane Library search was performed using the phrase: ("skills decay" OR "skills fade") AND "surgery." All relevant literature was analyzed and summarized.

RESULTS

A total of 41 relevant articles were identified. The skills that are most adversely affected by time out of training are technical operative skills and, within those, speed and accuracy in operations. Factors that affect skill decay include the complexity of the task itself, the degree of overlearning (i.e., the skill of the surgeon prior to time out of training) and the retention interval (i.e., the length of time for which the trainee is out of training and whether or not spaced practice is carried out). The articles suggest that simulation may be of assistance in mitigating skill decay; however, this has yet to be fully investigated.

CONCLUSIONS

As an increasing number of surgical trainees are taking time away from clinical training for academic research, higher degrees, parental leave, or other interests, further research is required to investigate how to mitigate the resulting surgical skill decay, potentially through the use of simulation.

Biotissue Curriculum Translates to Performance in the Operating Room for Gastrojejunostomy and Hepaticojejunostomy in Robotic Pancreaticoduodenectomy

OBJECTIVE

Robotic simulation training curricula aim to aid surgeons in attaining robotic operating room proficiency, but the crossover success remains to be examined.

DESIGN

A retrospective cohort study grading robotic biotissue training models and intraoperative anastomotic videos. The curriculum included deliberate practice of inanimate drills of a hepaticojejunostomy (HJ) and gastrojejunostomy (GJ). Videos were blindly reviewed, and performance was evaluated by time, errors, and Objective Structured Assessment of Technical Skills (OSATS). Spearman's correlation coefficients (ρ) were calculated for prior experience, biotissue performance, and intraoperative performance.

SETTING

University of Pittsburgh Medical Center from 2014 to 2018.

PARTICIPANTS

Thirty-one surgical oncology fellows participated in the 5-step proficiency-based robotic training curriculum for robotic pancreaticoduodenectomy.

RESULTS

Fellows completed an average of 5.1 ± 3.7 HJ and 4.3 ± 3.3 GJ on biotissue. More practice on biotissue correlated with greater improvement on both times to complete an anastomosis (ρ = -0.51) and errors (ρ = -0.45). Average errors on biotissue GJ and longer time on the last attempt correlated with lower average intraoperative GJ OSATS (ρ = -0.64; ρ = -0.66). More errors on the last biotissue GJ correlated with longer average intraoperative GJ time (ρ = 0.58). Errors on the first and average biotissue HJ errors correlated with lower OSATS for the intraoperative HJ (ρ = -0.74; ρ = -0.80).

CONCLUSIONS

Performance on biotissue correlated with intraoperative performance. Results suggest the importance deliberate practice to achieve surgical proficiency.

Distributed training vs. massed practice for surgical skills training-a systematic review

BACKGROUND

Surgical skills training is often conducted using a massed approach. However, using a distributed training schedule may have benefits and increase skill retention. This study aimed to review the evidence for distributed training vs. massed training and recommend how surgical training should be scheduled.

METHODS

A systematic review was performed in three databases (MEDLINE, Web of Science, and EMBASE). Two authors screened the articles for inclusion according to the eligibility criteria. Data were extracted for each article, including general information, intervention, outcome, etc. A qualitative synthesis was performed, and the Medical Education Research Study Quality Instrument (MERSQI) was used to assess the methodological quality.

RESULTS

Of 12,088 potential studies screened, 28 were included in the final synthesis. Nineteen of the studies directly compared a distributed and a massed schedule, and thirteen studies combined the massed vs. distributed with various distributed training schedules or only investigated different types of distributed schedules. Of the 19 studies which compared distributed and massed training, 15 found a positive effect of distributed training, and no studies found massed training to be superior. Of the 13 that compared different types of distributed schedules, 6 found a positive effect for one of the distributed schedules, while the remaining 7 studies found no difference between the various training schedules. Only 1 of the 28 studies examined training during different times of the day.

CONCLUSION

Distributed training is superior to massed training. The optimal distributed schedule seems to be with shorter intervals between sessions. The recommended schedule is one session per day, lasting a maximum of 2 h.

The effect of duration between sessions on microperimetric biofeedback training in patients with maculopathies

Aim of this study was to explore the optimal training interval and times of microperimetric biofeedback training (MBFT) in maculopathies. Twenty-nine patients with maculopathies were divided into two groups: daily training (Group A) or alternate daily training (Group B). Both groups underwent 15 MBFT sessions. We compared the BCVA, reading speed, and fixation stability at baseline, after 5, 10, 15 sessions. After 15 sessions of MBFT, all visual parameters in both groups improved. There was a significant increase in BCVA after 5 sessions in both groups (P=0.016, and P<0.001 respectively), but Group A showed further improvement after 10 sessions (P<0.001). Regarding reading speed, Group A showed significant improvement from baseline after 15 sessions(P=0.020), Group B improved significantly after 5 sessions (P=0.047) and continued to improve after 10 sessions (P=0.030). Additionally, P1 and LgBCEA of Group A significantly improved after 10 sessions (P=0.001, and P=0.001 respectively), while Group B significantly improved after 5 sessions (P=0.002, and P<0.001 respectively). There was no significant difference in visual outcomes between the two groups (P>0.05) except LgBCEA (P=0.046) after 15 sessions. We concluded that the both MBFT frequencies are effective at improving vision and quality of life in patients with maculopathies. The alternate daily training group showed less time-dependent of improvement in all parameters and a greater benefit in fixation stability. Ten sessions are the optimal number of treatment sessions for alternate daily training.

No difference between using short and long intervals for distributed proficiency-based laparoscopy simulator training: a randomized trial

BACKGROUND

Simulation-based training is increasingly used to acquire basic laparoscopic skills. Multiple factors can influence training, e.g., distributed practice is superior to massed practice in terms of efficiency. However, the optimal interval between training sessions is unclear. The objective of this trial was to investigate if shorter intervals between sessions are more efficient than longer intervals during proficiency-based laparoscopy simulator training.

METHODS

A randomized simulation-based trial where medical students (n = 39) were randomized to proficiency-based training with either 1-2 days (intervention group) or 6-8 days (control group) between training sessions. Both groups practiced a series of basic tasks and a procedural module until proficiency level on the LapSim® simulator. Both groups were given instructor feedback upon request. After reaching proficiency, participants were invited back for a retention test 3-5 weeks later and practiced the same tasks to proficiency again.

RESULTS

The mean time to reach proficiency during training was 291 (SD 89) and 299 (SD 89) min in the intervention and control group, respectively (p = 0.81). During the retention test, the mean time to reach proficiency was 94 (SD 53) and 96 (SD 39) minutes in the intervention and control groups, respectively (p = 0.91).

CONCLUSION

We found no difference whether practicing with shorter intervals or longer intervals between training sessions when examining time to proficiency or retention.

A spaced retraining schedule with 2-day interval improves the acquisition and retention of simulation-based basic arthroscopic skills

PURPOSE

To compare the effect of three differently spaced retraining schedules (1-day, 2-day, and 1-week intervals) on the acquisition of basic arthroscopic skills and skill retention after 3 months.

METHODS

Thirty orthopaedic residents without arthroscopic experience were enrolled in a double-blind, randomised, parallel-controlled trial. Spaced retaining schedules were divided into massed training and retraining phases. Participants were required to obtain perfect scores in all tasks on the simulator in the massed training phase, followed by a pretest to evaluate the training effect. During the retraining phase, participants were randomly assigned to Groups A (1-day interval), B (2-day interval) or C (1-week interval). A posttest was used to evaluate the effect of different retraining patterns. Follow-up evaluations were conducted at 1 week, 1 month and 3 months after the completion of spaced retraining schedules to measure skill retention. One-way ANOVA and paired-sample t tests were used for statistical analysis.

RESULTS

Significant between-group differences in diagnostic arthroscopy (137.0 ± 24.8 vs. 140.1 ± 21.3 vs. 175.3 ± 27.4 s, P(A-C) = 0.005, P(B-C) = 0.010) and loose body removal (193.1 ± 33.9 vs. 182.0 ± 32.1 vs. 228.7 ± 42.9 s, P(B-C) = 0.025) completion times were observed. No significant differences were found in other posttest metrics. An assessment of skill retention after the 3-month follow-up (Evaluation 3) showed significant differences in diagnostic arthroscopy completion time (202.5 ± 53.3 vs. 172.0 ± 27.2 vs. 225.5 ± 42.1 s, P(B-C) = 0.026). No significant differences were found in other Evaluation 3 metrics.

CONCLUSION

The 2-day retraining schedule was the most effective for the acquisition and retention of basic arthroscopic skills and could be integrated into arthroscopic skills curricula. After a 3-month follow-up, residents who followed this schedule showed better skill retention than those who followed the 1-week interval schedule.

LEVEL OF EVIDENCE

Level I.

Assessing Endoscopic Suture Performance of Gynecology and Obstetrics Residents Following Methodic Training

OBJECTIVE

 To evaluate the performance of residents in gynecology and obstetrics before and after practicing laparoscopic sutures, to establish when the training shows the best results, in addition to comparing whether being in different years of residency influences this progression.

METHODS

 A prospective cohort study involving 32 medical residents evaluated with a pretest to establish their previous knowledge in laparoscopic suture. This test consisted of knotting two wires, one made of polypropylene and the other of polyglactin, with a blocking sequence of five semi-knots. We set a 30-minute limit to complete the task. Then, the residents held four training meetings, focusing on suture, Gladiator rule, knot, and symmetries, in addition to executing blocking sequences. A second test to establish progress was performed.

RESULTS

 Regarding the time spent to make the stiches using polyglactin wire, a statistically significant time improvement (p < 0.01) was observed, with a 10.67-minute pretraining median (mean 12.24 minutes) and a 2.53-minute posttraining median (mean 3.25 minutes). Regarding the stitches with polypropylene wire, a statistically significant time improvement (p < 0.05) was also observed, with a 9.38-minute pretraining median (mean 15.43 minutes) and a 3.65-minute posttraining median (mean 4.54 minutes). A total of 64.2% of the residents had been able to make the knot with polypropylene previously. One hundred percent were able to complete the task in the posttest.

CONCLUSION

 Model training using the Gladiator rule for laparoscopic suture improves the knotting time with statistically similar performance, regardless of the year of residency, after systematic training.

Towards best practice in developing motor skills: a systematic review on spacing in VR simulator-based psychomotor training for surgical novices

OBJECTIVE

Repeated practice, or spacing, can improve various types of skill acquisition. Similarly, virtual reality (VR) simulators have demonstrated their effectiveness in fostering surgical skill acquisition and provide a promising, realistic environment for spaced training. To explore how spacing impacts VR simulator-based acquisition of surgical psychomotor skills, we performed a systematic literature review.

METHODS

We systematically searched the databases PubMed, PsycINFO, Psychology and Behavioral Sciences Collection, ERIC and CINAHL for studies investigating the influence of spacing on the effectiveness of VR simulator training focused on psychomotor skill acquisition in healthcare professionals. We assessed the quality of all included studies using the Medical Education Research Study Quality Instrument (MERSQI) and the risk of bias using the Cochrane Collaboration's risk of bias assessment tool. We extracted and aggregated qualitative data regarding spacing interval, psychomotor task performance and several other performance metrics.

RESULTS

The searches yielded 1662 unique publications. After screening the titles and abstracts, 53 publications were retained for full text screening and 7 met the inclusion criteria. Spaced training resulted in better performance scores and faster skill acquisition when compared to control groups with a single day (massed) training session. Spacing across consecutive days seemed more effective than shorter or longer spacing intervals. However, the included studies were too heterogeneous in terms of spacing interval, obtained performance metrics and psychomotor skills analysed to allow for a meta-analysis to substantiate our outcomes.

CONCLUSION

Spacing in VR simulator-based surgical training improved skill acquisition when compared to massed training. The overall number and quality of available studies were only moderate, limiting the validity and generalizability of our findings.

Laparoscopy training status in India and a review of the current resident skill standards

Context:

The aim was to identify the current training standard of laparoscopy skills among the urology residents.

Aims:

This paper presents the residents’ subjective perception of their laparoscopy skills and evidence of an objective assessment of their actual skills.

Settings and Design:

An online survey was mailed, and completed by urology residents in training. The residents’ perception of laparoscopy training received, exposure to laparoscopy procedures, and training facilities were queried. The assessment was done on the skill levels of the residents presenting at an annual training program.

Subjects and Methods:

103 residents responded to the online survey and 115 residents were assessed at the training program.

Statistical Analysis Used:

Discrete data were compared using the t-test to test for significance of the means; P < 0.05 was considered significant. Pearson's correlation coefficient was used to obtain the relationship between variables.

Results:

An overwhelming 91% rated their laparoscopy skill as just “satisfactory” or worse, and 60% did not have any training facilities in their department. 66% continue to be “assistants only” in conventional laparoscopy surgeries. Assessment of basic laparoscopy skills in the dry lab revealed 92% of residents having poor laparoscopy skills; similar to the subjective opinion in the survey. Only 6% (n = 5) of the residents showed a good or better skill score in the dry lab; similar to the survey.

Conclusions:

Based on the survey, a large number of residents have a poor opinion of their own laparoscopy skills, and the training facilities available to them. The data objectively prove the self-assessment of the residents on their laparoscopy skill level.

Identifying technical skills and clinical procedures in surgery for a simulation-based curriculum: a national general needs assessment

BACKGROUND

The efficacy of simulation-based training in surgical education is well known. However, the development of training programs should start with problem identification and a general needs assessment to ensure that the content is aligned with current surgical trainee needs. The objective of the present study is to identify the technical skills and clinical procedures that should be included in a simulation-based curriculum in general surgery.

METHODS

A national, three-round Delphi process was conducted to achieve consensus on which technical skills and clinical procedures should be included in a simulation-based curriculum in general surgery. In total, 87 key opinion leaders were identified and invited to the study.

RESULTS

Round 1 of the Delphi process had a response rate of 64% (56/87) and a total of 245 suggestions. Based on these suggestions, a consolidated list of 51 technical skills or clinical procedures was made. The response rate in Delphi round 2 was 62% (54/87) resulting in a pre-prioritized order of procedures for round 3. The response rate in Delphi round 3 was 65% (35/54). The final list included 13 technical skills and clinical procedures. Training was predominantly requested within general open surgical skills, laparoscopic skills, and endoscopic skills, and a few specific procedures such as appendectomy and cholecystectomy were included in the final prioritized list.

CONCLUSION

Based on the Delphi process 13 technical skills and clinical procedures were included in the final prioritized list, which can serve as a point of departure when developing simulation-based training in surgery.

Decay of Competence with Extended Research Absences During Residency Training: A Scoping Review

A significant number of residents in postgraduate training programs pursue dedicated research training. Currently, no formal curricula exist to transition residents back into clinical roles following dedicated research leave. This scoping review aims to determine what literature exists on the challenges faced by trainees who interrupt their clinical training for extended periods of time for research leave. The Pubmed and Medline databases were searched for all study designs related to postgraduate trainees taking academic or research leave. A three-step selection process including title, abstract and full-article review was employed to identify articles that mentioned decay of knowledge, skill or competence. A narrative review of the literature was generated to present key themes identified within the studies. The search yielded 174 articles of which five investigated resident skill decay during research leave. The five studies included for analysis were cohort studies that used general surgery residents' self-perception and faculty members' perception of residents' skill decay as a measure. Residents and faculty perceived decay of residents' technical skills, leadership skills and knowledge following dedicated research leave. The greatest decay perceived was in technical skills, specifically with more complex tasks and longer periods of non-use. This review identified that residents and faculty perceive a decay of resident skills following dedicated research training. To provide the necessary support to limit this potential decay, as well as to assist in the transition back into clinical training, the needs of and challenges faced by research residents and postgraduate programs must be better understood.

Long-term retention assessment after simulation-based-training of pediatric procedural skills among adult emergency physicians: a multicenter observational study

BACKGROUND

One of the primary goals of simulation-based education is to enable long-term retention of training gains. However, medical literature has poorly contributed to understanding the best timing for repetition of simulation sessions. There is heterogeneity in re-training recommendations.

OBJECTIVES

This study assessed, through simulation-based training in different groups, the long-term retention of rare pediatric technical procedures.

METHODS

This multicenter observational study included 107 emergency physicians and residents. Eighty-eight were divided into four groups that were specifically trained for pediatric emergency procedures at different points in time between 2010 and 2015 (< 0.5 year prior for G1, between 0.5 and 2 years prior for G2, between 2 and 4 years prior for G3, and ≥ 4 years prior for G4). An untrained control group (C) included 19 emergency physicians. Participants were asked to manage an unconscious infant using a low-fidelity mannequin. Assessment was based on the performance at 6 specific tasks corresponding to airway (A) and ventilation (B) skills. The performance (scored on 100) was evaluated by the TAPAS scale (Team Average Performance Assessment Scale). Correlation between performance and clinical level of experience was studied.

RESULTS

There was a significant difference in performance between groups (p < 0.0001). For G1, 89% of the expected tasks were completed but resulted in longer delays before initiating actions than for the other groups. There was no difference between G4 and C with less than half of the tasks performed (47 and 43% respectively, p = 0.57). There was no correlation between clinical level of experience and performance (p = 0.39).

CONCLUSION

Performance decreased at 6 months after specific training for pediatric emergency skills, with total loss at 4 years after training, irrespective of experience. Repetition of simulation sessions should be implemented frequently after training to improve long-term retention and the optimal rate of refresher courses requires further research.

Development of a structured virtual reality curriculum for laparoscopic appendicectomy

BACKGROUND

Laparoscopic appendicectomy (LA) is a common surgical emergency procedure mainly performed by trainees. The aim was to develop a step-wise structured virtual reality (VR) curriculum for LA to allow junior surgeons to hone their skills in a safe and controlled environment.

METHODS

A prospective randomized study was designed using a high-fidelity VR simulator. Thirty-five novices and 25 experts participated in the assessment and their performances were compared to assess construct validity. Learning curve analysis was performed.

RESULTS

Five of the psychomotor tasks and all appendicectomy tasks showed construct validity. Learning was demonstrated in the majority of construct-valid tasks. A novel goal-directed VR curriculum for LA was constructed.

CONCLUSIONS

A step-wise structured VR curriculum for LA is proposed with a framework which includes computer generated metrics and supports deliberate practice, spacing intervals, human instruction/feedback and assessment. Future study should test the feasibility of its implementation and transferability of acquired skill.

Efficacy of Trauma Surgery Technical Skills Training Courses

OBJECTIVE

Because open surgical skills training for trauma is limited in clinical practice, trauma skills training courses were developed to fill this gap, The aim of this report is to find supporting evidence for efficacy of these courses. The questions addressed are: What courses are available and is there robust evidence of benefit?

DESIGN

We performed a systematic review of the training course literature on open trauma surgery procedural skills courses for surgeons using Kirkpatrick's framework for evaluating complex educational interventions. Courses were identified using Pubmed, Google Scholar and other databases.

SETTING AND PARTICIPANTS

The review was carried out at the University of Maryland, Baltimore with input from civilian and military trauma surgeons, all of whom have taught and/or developed trauma skills courses.

RESULTS

We found 32 course reports that met search criteria, including 21 trauma-skills training courses. Courses were of variable duration, content, cost and scope. There were no prospective randomized clinical trials of course impact. Efficacy for most courses was with Kirkpatrick level 1 and 2 evidence of benefit by self-evaluations, and reporting small numbers of respondents. Few courses assessed skill retention with longitudinal data before and after training. Three courses, namely: Advanced Trauma Life Support (ATLS), Advanced Surgical Skills for Exposure in Trauma (ASSET) and Advanced Trauma Operative Management (ATOM) have Kirkpatrick's level 2-3 evidence for efficacy. Components of these 3 courses are included in several other courses, but many skills courses have little published evidence of training efficacy or skills retention durability.

CONCLUSIONS

Large variations in course content, duration, didactics, operative models, resource requirements and cost suggest that standardization of content, duration, and development of metrics for open surgery skills would be beneficial, as would translation into improved trauma patient outcomes. Surgeons at all levels of training and experience should participate in these trauma skills courses, because these procedures are rarely performed in routine clinical practice. Faculty running courses without evidence of training benefit should be encouraged to study outcomes to show their course improves technical skills and subsequently patient outcomes. Obtaining Kirkpatrick's level 3 and 4 evidence for benefits of ASSET, ATOM, ATLS and for other existing courses should be a high priority.

Self-debriefing Model Based on an Integrated Video-Capture System: An Efficient Solution to Skill Degradation

OBJECTIVE

Video-based teaching is considered highly effective in debriefing, especially in minimally invasive surgeries. In this study, the benefits of using a new integrated video recording system, were investigated and compared to those of the standard basic skills robotic training procedure.

DESIGN

Fifty residents from the 2nd and 3rd year medical faculty without any experience of robot usage or laparoscopy were randomized into 2 groups: group A--a natural self-training group without a trainer, and group B--a self-training group assisted by an integrated video recording system during training. The training was divided into four 2-hour sessions, with a 72-hour delay between each session. Two tasks were selected for testing on the dV-Trainer, a virtual reality based robotic simulator: Match board 2 and Thread the Rings 1. After each session, the practice video recorded by the system of group B was transferred to the residents' smartphones for self-debriefing. At the end of each session, the performance score was evaluated automatically by using the simulator to plot learning curves A and B.

RESULTS

Group A showed a significant drop in performance score due to skill decay caused by the 72-hour delay. Group B exhibited a regular stepwise rising learning curve. At the end of the training, group B showed a significantly higher performance score both in Match board 2 and Thread the Rings 1. The autoanalysis and capture function, which selects only the critical errors and most valuable parts, could facilitate time saving.

CONCLUSIONS

The use of an integrated video recording system makes the self-manipulated protocol with own smartphone feasible to improve training efficiency and overcome the skill decay during robotic surgical training.

Effect of Short- Versus Long-Term Video Game Playing on Basic Laparoscopic Skills Acquisition of Veterinary Medicine Students

The objective of this study was to investigate the effect of playing video games on the performance of basic laparoscopic skills. The study was an experimental pre-test-post-test comparison group design. Fifty-two students (31 from the Western University of Health Sciences College of Veterinary Medicine and 21 from the Colorado State University College of Veterinary Medicine) completing their first or second year of the veterinary curriculum were randomized into two intervention groups. The intervention consisted of playing the video game Marble Mania on a Nintendo Wii. group L (long) played 18 hours over 6 weeks and group S (short) played 3 hours during the last week of the 6-week intervention period. Before and after the intervention, basic laparoscopic skills for both groups were assessed using a modified McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS) instrument. Participants performed two laparoscopic tasks. Results showed that the performance of students improved in both group S and L (p < .05) on both laparoscopic tasks. Both groups showed statistically significant improvement in their post-intervention scores (group L, N = 25, z = -3.711, p < .001, r = 0.742; group S, N = 27, z = -3.016, p < .003, r = 0.580). There was no significant difference in the degree of improvement between group S and group L. The results suggest that playing Marble Mania on a Wii for any time duration could be an effective method for veterinary medicine students to improve basic laparoscopic skills, and indicate the needs for additional studies.

More Learners, Finite Resources, and the Changing Landscape of Procedural Training at the Bedside

There is growing competition for nonoperative, procedural training in teaching hospitals, due to an increased number of individuals seeking to learn procedures from a finite number of appropriate teaching cases. Procedural training is required by students, postgraduate learners, and practicing providers who must maintain their skills. These learner groups are growing in size as the number of medical schools increases and advance practice providers expand their skills to include complex procedures. These various learner needs occur against a background of advancing therapeutic techniques that improve patient care but also act to reduce the overall numbers of procedures available to learners. This article is a brief review of these and other challenges that are arising for program directors, medical school leaders, and hospital administrators who must act to ensure that all of their providers acquire and maintain competency in a wide array of procedural skills. The authors conclude their review with several recommendations to better address procedural training in this new era of learner competition. These include a call for innovative clinical rotations deliberately designed to improve procedural training, access to training opportunities at new clinical sites acquired in health system expansions, targeted faculty development for those who teach procedures, reporting of competition for bedside procedures by trainees, more frequent review of resident procedure and case logs, and the creation of an institutional oversight committee for procedural training.

Avoiding Surgical Skill Decay: A Systematic Review on the Spacing of Training Sessions

OBJECTIVE

Spreading training sessions over time instead of training in just 1 session leads to an improvement of long-term retention for factual knowledge. However, it is not clear whether this would also apply to surgical skills. Thus, we performed a systematic review to find out whether spacing training sessions would also improve long-term retention of surgical skills.

DESIGN

We searched the Medline, PsycINFO, Embase, Eric, and Web of Science online databases. We only included articles that were randomized trials with a sample of medical trainees acquiring surgical motor skills in which the spacing effect was reported. The quality and bias of the articles were assessed using the Cochrane Collaboration's risk of bias assessment tool.

RESULTS

With respect to the spacing effect, 1955 articles were retrieved. After removing duplicates and articles that did not meet the inclusion criteria, 11 articles remained. The overall quality of the experiments was "moderate." Trainees in the spaced condition scored higher in a retention test than students in the massed condition.

CONCLUSIONS

Our systematic review showed evidence that spacing training sessions improves long-term surgical skills retention when compared to massed practice. However, the optimal gap between the re-study sessions is unclear.

Dominant hand, non-dominant hand, or both? The effect of pre-training in hand-eye coordination upon the learning curve of laparoscopic intra-corporeal knot tying

Background

Training of basic laparoscopic psychomotor skills improves both acquisition and retention of more advanced laparoscopic tasks, such as laparoscopic intra-corporeal knot tying (LICK). This randomized controlled trial (RCT) was performed to evaluate the effect of different pre-training programs in hand-eye coordination (HEC) upon the learning curve of LICK.

Results

The study was performed in a private center in Asunción, Paraguay, by 60 residents/specialists in gynaecology with no experience in laparoscopic surgery. Participants were allocated in three groups. In phase ₁, a baseline test was performed (T₁, three repetitions). In phase 2, participants underwent different training programs for HEC (60 repetitions): G1 with both the dominant hand (DH) and the non-dominant hand (NDH), G2 with the DH only, G3 none. In phase 3, a post HEC/pre LICK training test was performed (T₂, three repetitions). In phase 4, participants underwent a standardized training program for LICK (60 repetitions). In phase 5, a final test was performed (T₃, three repetitions). The score was based on the time taken for task completion system. The scores were plotted and non-linear regression models were used to fit the learning curves to one- and two-phase exponential decay models for each participant (individual curves) and for each group (group curves). For both HEC and LICK, the group learning curves fitted better to the two-phase exponential decay model. For HEC with the DH, G1 and G2 started from a similar point, but G1 reached a lower plateau at a higher speed. In G1, the DH curve started from a lower point than the NDH curve, but both curves reached a similar plateau at comparable speeds. For LICK, all groups started from a similar point, but immediately after HEC training and before LICK training, G1 scored better than the others. All groups reached a similar plateau but with a different decay, G1 reaching this plateau faster than the others groups.

Conclusions

This study demonstrates that pre-training in HEC with both the DH and the NDH shortens the LICK learning curve.

Spacing Repetitions Over Long Timescales: A Review and a Reconsolidation Explanation

Recent accounts of the spacing effect have proposed molecular explanations that explain spacing over short, but not long timescales. In the first half of this paper, we review research on the spacing effect that has employed spaces of 24 h or more across skill-related tasks, language-related tasks and generalization for adults and children. Throughout this review, we distinguish between learning and retention by defining learning (or acquisition) as performance at the end of training and retention as performance after a delay period. Using this distinction, we find age- and task-related differences in the manifestation of the spacing effect over long timescales. In the second half of this paper, we discuss a reconsolidation account of the spacing effect. In particular, we review the evidence that suggests the spacing of repetitions influences the subsequent consolidation and reconsolidation processes; we explain how a reconsolidation account may explain the findings for learning; the inverted-U curve for retention; and compare the reconsolidation account with previous consolidation accounts of the spacing effect.

Absolute clinical skill decay in the medical, nursing and allied health professions: a scoping review protocol

REVIEW QUESTIONS/OBJECTIVES

The objective of this scoping review is to examine and map absolute clinical skill decay in the medical, nursing and allied health professions and to map the range of approaches used to address decay of clinical skills in these professions.Specifically, the review questions are: which clinical skills, performed by which professional groups, are reported to be most susceptible to absolute clinical skill decay, and what approaches have been reported for addressing absolute clinical skill decay in the medical, nursing and allied health professions?In addressing the review questions, the following sub-questions will also be addressed:It is anticipated that this scoping review will inform further systematic review/s on the topic of addressing clinical skill decay in the medical, nursing and allied health professions, as well as identify gaps in the research knowledge base that will inform further primary research.

Retention of laparoscopic and robotic skills among medical students: a randomized controlled trial

BACKGROUND

Although simulation training beneficially contributes to traditional surgical training, there are less objective data on simulation skills retention.

OBJECTIVE

To investigate the retention of laparoscopic and robotic skills after simulation training.

METHODS

We present the second stage of a randomized single-blinded controlled trial in which 40 simulation-naïve medical students were randomly assigned to practice peg transfer tasks on either laparoscopic (N = 20, Fundamentals of Laparoscopic Surgery, Venture Technologies Inc., Waltham, MA) or robotic (N = 20, dV-Trainer, Mimic, Seattle, WA) platforms. In the first stage, two expert surgeons evaluated participants on both tasks before (Stage 1: Baseline) and immediately after training (Stage 1: Post-training) using a modified validated global rating scale of laparoscopic and robotic operative performance. In Stage 2, participants were evaluated on both tasks 11-20 weeks after training.

RESULTS

Of the 40 students who participated in Stage 1, 23 (11 laparoscopic and 12 robotic) underwent repeat evaluation. During Stage 2, there were no significant differences between groups in objective or subjective measures for the laparoscopic task. Laparoscopic-trained participants' performances on the laparoscopic task were improved during Stage 2 compared to baseline measured by time to task completion, but not by the modified global rating scale. During the robotic task, the robotic-trained group demonstrated superior economy of motion (p = .017), Tissue Handling (p = .020), and fewer errors (p = .018) compared to the laparoscopic-trained group. Robotic skills acquisition from baseline with no significant deterioration as measured by modified global rating scale scores was observed among robotic-trained participants during Stage 2.

CONCLUSION

Robotic skills acquired through simulation appear to be better maintained than laparoscopic simulation skills.

CLINICAL TRIAL

This study is registered on ClinicalTrials.gov (NCT02370407).

Off-site training of laparoscopic skills, a scoping review using a thematic analysis

BACKGROUND

The focus of research in simulation-based laparoscopic training has changed from examining whether simulation training works to examining how best to implement it. In laparoscopic skills training, portable and affordable box trainers allow for off-site training. Training outside simulation centers and hospitals can increase access to training, but also poses new challenges to implementation. This review aims to guide implementation of off-site training of laparoscopic skills by critically reviewing the existing literature.

METHODS

An iterative systematic search was carried out in MEDLINE, EMBASE, ERIC, Scopus, and PsychINFO, following a scoping review methodology. The included literature was analyzed iteratively using a thematic analysis approach. The study was reported in accordance with the STructured apprOach to the Reporting In healthcare education of Evidence Synthesis statement.

RESULTS

From the search, 22 records were identified and included for analysis. A thematic analysis revealed the themes: access to training, protected training time, distribution of training, goal setting and testing, task design, and unsupervised training. The identified themes were based on learning theories including proficiency-based learning, deliberate practice, and self-regulated learning.

CONCLUSIONS

Methods of instructional design vary widely in off-site training of laparoscopic skills. Implementation can be facilitated by organizing courses and training curricula following sound education theories such as proficiency-based learning and deliberate practice. Directed self-regulated learning has the potential to improve off-site laparoscopic skills training; however, further studies are needed to demonstrate the effect of this type of instructional design.

All for knots: evaluating the effectiveness of a proficiency-driven, simulation-based knot tying and suturing curriculum for medical students during their third-year surgery clerkship

BACKGROUND

We evaluated the effectiveness of implementing a proficiency-driven, simulation-based knot tying and suturing curriculum for medical students during their 3rd-year surgery clerkship.

METHODS

Medical students on the 3rd-year surgical clerkship completed a proficiency-driven, simulation-based knot tying and suturing curriculum consisting of 6 tasks. The effectiveness was evaluated by comparing the initial presession scores to the final postsession scores on an 8-item self-efficacy scale and evaluating pass rates on end of clerkship skills testing. A paired t test was used to analyze data.

RESULTS

Sixty-five students had matched preintervention and postintervention questionnaires for analysis. Pass rates approached 100% by the 3rd attempt on all tasks. Significant gains on all 8 items of the self-efficacy questionnaire from pretraining to post-training were noted. Timing of the general surgery rotation did not impact results.

CONCLUSIONS

Implementation of a simulation-based training, proficiency-driven knot tying and suturing curriculum for 3rd-year medical students during the surgery clerkship is feasible and effective in improving student self-efficacy and objective proficiency toward performance of the tasks taught.

Retention of laparoscopic psychomotor skills after a structured training program depends on the quality of the training and on the complexity of the task

This follow-up RCT was conducted to evaluate laparoscopic psychomotor skills retention after finishing a structured training program. In a first study, 80 gynecologists were randomly allocated to four groups to follow different training programs for hand-eye coordination (task 1) with the dominant hand (task 1-a) and the non-dominant hand (task 1-b) and laparoscopic intra-corporeal knot tying (task 2) in the Laparoscopic Skills Testing and Training (LASTT) model. First, baseline skills were tested (T1). Then, participants trained task 1 (G1: 1-a and 1-b, G2: 1-a only, G3 and G4: none) and then task 2 (all groups but G4). After training all groups were tested again to evaluate skills acquisition (T2). For this study, 2 years after a resting period, 73 participants were recruited and tested again to evaluate skills retention (T3). All groups had comparable skills at T1 for all tasks. At T2, G1, G2, and G3 improved their skills, but the level of improvement was different (G1 = G2 > G3 > G4 for task 1; G1 = G2 = G3 > G4 for task 2). At T3, all groups retained their task 1 skills at the same level than at T2. For task 2, however, a skill decay was already noticed for G2 and G3, being G1 the only group that retained their skills at the post-training level. Training improves laparoscopic skills, which can be retained over time depending on the comprehensiveness of the training program and on the complexity of the task. For high complexity tasks, full training is advisable for both skills acquisition and retention.

Comparison between Training Models to Teach Veterinary Medical Students Basic Laparoscopic Surgery Skills

The objective of this study was to compare the effectiveness of two different laparoscopic training models in preparing veterinary students to perform basic laparoscopic skills. Sixteen first- and second-year veterinary students were randomly assigned to a box trainer (Group B) or tablet trainer (Group T). Training and assessment for both groups included two tasks, "peg transfer" and "pattern cutting," derived from the well-validated McGill University Inanimate System for Training and Evaluation of Laparoscopic Skills. Confidence levels were compared by evaluating pre- and post-training questionnaires. Performance of laparoscopic tasks was scored pre- and post-training using a rubric for precision and speed. Results revealed a significant improvement in student confidence for basic laparoscopic skills (p<.05) and significantly higher scores for both groups in both laparoscopic tasks (p<.05). No significant differences were found between the groups regarding their assessment of the video quality, lighting, and simplicity of setup (p=.34, p=.15, and p=.43, respectively). In conclusion, the low-cost tablet trainer and the more expensive box trainer were similarly effective in preparing pre-clinical veterinary students to perform basic laparoscopic skills on a model.

Objective Evaluation of Otoscopy Skills Among Family and Community Medicine, Pediatric, and Otolaryngology Residents

INTRODUCTION

The objective of this study is to evaluate and compare the perceived need for otolaryngology training and otoscopy diagnostic skills in primary care (Family and Community Medicine, Pediatric Medicine), and Otolaryngology Head and Neck Surgery (OTO-HNS) postgraduate trainees. Participant otoscopy skills were evaluated using the OtoSim simulator.

METHODS

Family and Community Medicine, Pediatric, and OTO-HNS residents were recruited. Each resident participated in 3 separate otoscopy training and assessment sessions. The ability to correctly identify middle ear pathology was objectively evaluated using OtoSim™. Pretest, posttest, and 3-month retention test results were compared among residents in a paired comparison paradigm. Survey data assessing exposure to OTO-HNS during undergraduate and postgraduate training were also collected.

RESULTS

A total of 57 residents participated in the study. All residents reported limited exposure to OTO-HNS during undergraduate medical training. Primary care trainees performed poorly on pretest assessments (30% ± 7.8%; 95% CI). Significant improvement in diagnostic accuracy was demonstrated following a single 1-hour teaching session (30%-62%; p < 0.001). Primary care residents demonstrated a significant decrease in diagnostic accuracy at a 3-month follow-up assessment (62%-52%, p < 0.001). Self-perceived comfort with otology was poorly correlated to pretest performance among primary care trainees (r = 0.26) and showed a stronger positive correlation among OTO-HNS trainees (r = 0.56).

CONCLUSIONS

A single teaching session with an otoscopy simulator significantly improved diagnostic accuracy in primary care and OTO-HNS trainees. Improved performance is susceptible to deterioration at 3 months if acquired skills are not frequently used. Self-perceived comfort with otology may not be an accurate predictor of otoscopic diagnostic skill.

Porcine cadaver organ or virtual-reality simulation training for laparoscopic cholecystectomy: a randomized, controlled trial

OBJECTIVES

As conventional laparoscopic procedural training requires live animals or cadaver organs, virtual simulation seems an attractive alternative. Therefore, we compared the transfer of training for the laparoscopic cholecystectomy from porcine cadaver organs vs virtual simulation to surgery in a live animal model in a prospective randomized trial.

DESIGN

After completing an intensive training in basic laparoscopic skills, 3 groups of 10 participants proceeded with no additional training (control group), 5 hours of cholecystectomy training on cadaver organs (= organ training) or proficiency-based cholecystectomy training on the LapMentor (= virtual-reality training). Participants were evaluated on time and quality during a laparoscopic cholecystectomy on a live anaesthetized pig at baseline, 1 week (= post) and 4 months (= retention) after training.

SETTING

All research was performed in the Center for Surgical Technologies, Leuven, Belgium.

PARTICIPANTS

In total, 30 volunteering medical students without prior experience in laparoscopy or minimally invasive surgery from the University of Leuven (Belgium).

RESULTS

The organ training group performed the procedure significantly faster than the virtual trainer and borderline significantly faster than control group at posttesting. Only 1 of 3 expert raters suggested significantly better quality of performance of the organ training group compared with both the other groups at posttesting (p < 0.01). There were no significant differences between groups at retention testing. The virtual trainer group did not outperform the control group at any time.

CONCLUSIONS

For trainees who are proficient in basic laparoscopic skills, the long-term advantage of additional procedural training, especially on a virtual but also on the conventional organ training model, remains to be proven.

Influence of visual force feedback on tissue handling in minimally invasive surgery

Background

Force feedback might improve surgical performance during minimally invasive surgery. This study sought to determine whether training with force feedback shortened the tissue-handling learning curve, and examined the influence of real-time visual feedback compared with postprocessing feedback.

Methods

Medical students without experience of minimally invasive surgery were randomized into three groups: real-time force feedback, postprocessing force feedback and no force feedback (control). All performed eight suturing tasks consecutively, of which the first and eighth were the premeasurement and postmeasurement tasks respectively (no feedback). Depending on randomization, either form of feedback was given during the second to seventh task. Time, mean force non-zero and maximum force were measured with a force sensor. Results of the groups were compared with one-way ANOVA, and intragroup improvement using a paired-samples t test.

Results

A total of 72 students took part. Both intervention groups used significantly lower interaction forces than the control group during the knot-tying phase of the postmeasurement task and improved their interaction forces significantly during the knot-tying phase. The form of feedback did not influence its effectiveness.

Conclusion

The tissue-handling skills of medical students improved significantly when they were given force feedback of their performance. This effect was seen mainly during the knot-tying phase of the suturing task.

Laparoscopy training in surgical education: the utility of incorporating a structured preclinical laparoscopy course into the traditional apprenticeship method

OBJECTIVE

To investigate whether preclinical laparoscopy training offers a benefit over standard apprenticeship training and apprenticeship training in combination with simulation training.

DESIGN

This randomized controlled trial consisted of 3 groups of first-year surgical registrars receiving a different teaching method in laparoscopic surgery.

SETTING

The KU LEUVEN Faculty of Medicine is the largest medical faculty in Belgium.

PARTICIPANTS

Thirty final-year medical students starting a general surgical career in the next academic year.

METHODS

Thirty final-year medical students were randomized into 3 groups, which differed in the way they were exposed to laparoscopic simulation training but were comparable in regard to ambidexterity, sex, age, and laparoscopic psychomotoric skills. The control group received only clinical training during surgical residentship, whereas the interval group received clinical training in combination with simulation training. The registrars were allowed to do deliberate practice. The Centre for Surgical Technologies Preclinical Training Programme (CST PTP) group received a preclinical simulation course during the final year as medical students, but was not exposed to any extra simulation training during surgical residentship. At the beginning of surgical residentship and 6 months later, all subjects performed a standardized suturing task and a laparoscopic cholecystectomy in a POP Trainer. All procedures were recorded together with time and motion tracking parameters. All videos were scored by a blinded observer using global rating scales.

RESULTS

At baseline the 3 groups were comparable. At 6 months, for suturing, the CST PTP group was better than both the other groups with respect to time, checklist, and amount of movements. The interval group was better than the control group on only the time and checklist score. For the cholecystectomy evaluation, there was a statistical difference between the CST PTP study group and both other groups on all evaluation scales in favor of the CST PTP group.

CONCLUSIONS

Structured, preclinical proficiency-based training is better than clinical training combined with laboratory training or clinical training alone.