Marleen Groenier

The role of cognitive abilities in laparoscopic simulator training

Learning minimally invasive surgery (MIS) differs substantially from learning open surgery and trainees differ in their ability to learn MIS. Previous studies mainly focused on the role of visuo-spatial ability (VSA) on the learning curve for MIS. In the current study, the relationship between spatial memory, perceptual speed, and general reasoning ability, in addition to VSA, and performance on a MIS simulator is examined. Fifty-three laparoscopic novices were tested for cognitive aptitude. Laparoscopic performance was assessed with the LapSim simulator (Surgical Science Ltd., Gothenburg, Sweden). Participants trained multiple sessions on the simulator until proficiency was reached. Participants showed significant improvement on the time to complete the task and efficiency of movement. Performance was related to different cognitive abilities, depending on the performance measure and type of cognitive ability. No relationship between cognitive aptitude and duration of training or steepness of the learning curve was found. Cognitive aptitude mediates certain aspects of performance during training on a laparoscopic simulator. Based on the current study, we conclude that cognitive aptitude tests cannot be used for resident selection but are potentially useful for developing individualized training programs. More research will be performed to examine how cognitive aptitude testing can be used to design training programs.

Psychologists' judgements of diagnostic activities: Deviations from a theoretical model

In this article, we describe an investigation into the diagnostic activities of practicing clinical psychologists. Two questionnaires were filled in by 313 psychologists. One group of psychologists (N = 175) judged the necessity of diagnostic activities; the other group (N = 138) selected the activities they would actually perform. Results showed that more participants thought that diagnostic activities were necessary than there were participants who intended to actually perform those activities. Causal analysis, by generating and testing diagnostic hypotheses to form an integrated client model with an explanation for the problem, was judged least necessary and would not be performed. We conclude that a discrepancy exists between the number and types of activities psychologists judged to be necessary and they intend to actually perform. The lack of attention for causal analysis is remarkable as causal explanations are crucial to effective treatment planning.

The decisive moment : making diagnostics decisions and designing treatments

In this thesis psychologists’ diagnostic decision making processes and their relationship with treatment decisions were investigated. Theoretical diagnostic models prescribe that the diagnostic process consists of two decision processes: classification and case formulation (Witteman, Harries, Bekker, & Van Aarle, 2007). These diagnostic decisions are used to form an integrated client model on which psychologists base their treatment decisions (Haynes, 1993). However, in clinical practice, the complex and dynamic nature of the diagnostic tasks hampers an optimal performance (Gambrill, 2005). Thus far, it has remained unclear whether the prescribed diagnostic decisions are performed in clinical practice and determine treatment decisions. Two research questions were investigated in this thesis: 1) What characterizes the diagnostic decision making process in clinical practice? and 2) What is the role of the diagnostic decision making processes in designing treatments? In chapters 2 and 3 the type of diagnostic decisions considered in the diagnostic process (chapter 2) and the sequence of decisions (chapter 3) was explored using a questionnaire with a written case description. In chapter 4 the third study is described in which an authentic diagnostic task was used. The type and sequence of psychologists’ diagnostic decisions as well as their considerations were examined in a diagnostic interview with a simulated client. In addition, it was examined to what extent these considerations are connected to psychologists’ assessment reports based on their diagnostic interviews. In chapter 5 the influence of client case complexity on the quality of case formulations was investigated. In addition, we explored the relationship between psychologists’ diagnostic decisions (classification and case formulation), their theoretical orientations and the treatment decisions. In the final chapter, the main findings of all four studies are summarized and discussed, the concept of a decision support tool is described, and suggestions for further research are made. The studies in this thesis show that psychologists’ diagnostic processes are adaptive and characterized by a focus on the client’s complaints and symptoms and on treatment selection while they continuously shift between all diagnostic decisions and reconsider previous decisions. The decisions made in the diagnostic process contribute only slightly to treatment design.

Perceptual Speed and Psychomotor Ability Predict Laparoscopic Skill Acquisition on a Simulator.

OBJECTIVE Performing minimally invasive surgery puts high demands on a surgeons cognitive and psychomotor abilities. Assessment of these abilities can be used to predict a surgeons learning curve, to create individualized training programs, and ultimately in selection programs for surgical training. The aim of this study was to examine the influence of cognitive and psychomotor ability on the training duration and learning rate. DESIGN A prospective quasiexperimental field study regarding the influence of cognitive and psychomotor ability, baseline measures of time to complete task, damage to tissue, and efficiency of movement, age, and gender on the number of sessions needed to reach a predefined performance level on a laparoscopy simulator. The same variables were investigated as predictors of the learning rate. SETTING The study was performed at the Experimental Center for Technical Medicine at the University of Twente, The Netherlands. PARTICIPANTS In all, 98 novices from the Master program of Technical Medicine followed a proficiency-based basic laparoscopic skills training. RESULTS Perceptual speed (PS) predicted training duration (hazard ratio = 1.578; 95% CI = 1.084, 2.300; p = 0.017). Cognitive (b = -0.721, p = 0.014) and psychomotor ability (b = 0.182, p = 0.009) predicted the learning rate of time to complete the task. Also, the learning rate for participants with higher levels of PS was lower (b = 0.167, p = 0.036). Psychomotor ability also predicted the learning rate for damage to tissue (b = 0.194, p = 0.015) and efficiency of movement (b = 0.229, p = 0.004). Participants with better psychomotor ability outperformed other participants across all sessions on all outcome measures. CONCLUSIONS PS predicted training duration in a basic laparoscopic skills training and the learning rate for the time to complete the task. Psychomotor ability predicted the learning rate for laparoscopic skill acquisition in terms of time to complete task, damage to tissue, and efficiency of movements. These results indicate early automation of basic laparoscopic skill. Careful selection of the cognitive abilities tests is advised for use in training programs and to identify individuals who need more training.

Performance Variables and Professional Experience in Simulated Laparoscopy: A Two-Group Learning Curve Study

OBJECTIVE Virtual reality simulators are increasingly used in laparoscopy training. Such simulators allow objective assessment of performance. However, both low-level variables and overall scores generated by the simulator can be hard to interpret. We present a method to generate intermediate performance variables and show how the resulting variables can be used to investigate the development of laparoscopic skills. DESIGN A beginner group (n = 16) and a group with intermediate laparoscopic experience (n = 9) participated in a 5-session, basic skills training course hosted by the Department of Technical Medicine at the University of Twente. Multiple simulator-generated variables were aggregated into 4 performance variables: duration, left-hand motion, right-hand motion, and damage. Differences in performance were analyzed in relation to proficiency values. RESULTS Damage performance differentiated the most between groups and proficiency values; motion performance variables differentiated the least. The more experienced group outperformed the beginner group at damage by the end of the course. CONCLUSIONS Differentiating between duration, left-hand motion, right-hand motion, and damage is a useful way to investigate laparoscopic performance development. Different performance variables follow different trajectories toward expertise. Valid and reliable clinical damage parameters are needed to investigate the relation of real-world damage to simulator damage.