Ross E. Willis

Comparing three pedagogical approaches to psychomotor skills acquisition

BACKGROUND We compared traditional pedagogical approaches such as time- and repetition-based methods with proficiency-based training. METHODS Laparoscopic novices were assigned randomly to 1 of 3 training conditions. In experiment 1, participants in the time condition practiced for 60 minutes, participants in the repetition condition performed 5 practice trials, and participants in the proficiency condition trained until reaching a predetermined proficiency goal. In experiment 2, practice time and number of trials were equated across conditions. RESULTS In experiment 1, participants in the proficiency-based training conditions outperformed participants in the other 2 conditions (P < .014); however, these participants trained longer (P < .001) and performed more repetitions (P < .001). In experiment 2, despite training for similar amounts of time and number of repetitions, participants in the proficiency condition outperformed their counterparts (P < .038). In both experiments, the standard deviations for the proficiency condition were smaller than the other conditions. CONCLUSIONS Proficiency-based training results in trainees who perform uniformly and at a higher level than traditional training methodologies.

Views of surgery program directors on the current ACGME and proposed IOM duty-hour standards.

PURPOSE The purpose of this study was to survey the experiences of surgery program directors with the current Accreditation Council for Graduate Medical Education (ACGME) duty-hour standards and views of the Institute of Medicine (IOM) proposed duty-hour recommendations. METHODS A total of 118 program directors (47.6% of all surgery programs in the US) responded to the survey. RESULTS Results showed that the current duty-hour standards have hindered clinical education opportunities by reducing or eliminating rotations on many services, didactic teaching conferences, and clinical bedside teaching opportunities. Additionally, patient safety has been compromised by frequent hand offs of care. Most IOM recommendations were perceived as extremely difficult or impossible to implement, with the exception of the moonlighting recommendation. The results indicated that adopting the IOM recommendations is not feasible given current workforce limitations, and most program directors supported maintaining the current duty-hour standards until such time as there is evidence-based outcomes research to direct change. CONCLUSIONS The conclusion was that the current ACGME duty-hour standards have reduced teaching opportunities and narrowed the scope of training.

Current Status of Simulation-Based Training in Graduate Medical Education

The use of simulation in Graduate Medical Education has evolved significantly over time, particularly during the past decade. The applications of simulation include introductory and basic technical skills, more advanced technical skills, and nontechnical skills, and simulation is gaining acceptance in high-stakes assessments. Simulation-based training has also brought about paradigm shifts in the medical and surgical education arenas and has borne new and exciting national and local consortia that will ensure that the scope and impact of simulation will continue to broaden.

DNA - Uncorking the Bottleneck in Knowledge Elicitation and Organization

There are two main purposes of this paper. First, we describe a novel cognitive tool that was designed to aid in knowledge elicitation and organization for instructional purposes - specifically to be used for intelligent tutoring system development. This automated approach to knowledge elicitation is embodied in a program called DNA (Decompose, Network, Assess). Our aim for this tool is to increase the efficiency of developing the expert model - often referred to as the bottleneck in developing intelligent instructional systems. The second purpose is to present a first-order summative evaluation of the tools efficacy. Specifically, we used DNA with three statistical experts to explicate their knowledge structures related to measures of central tendency. In short, we found that DNA can be used as a standalone program to effectively elicit relevant information on which to build instruction. This was achieved in hours compared to months for conventional elicitation procedures.

A Comparison of Teaching Modalities and Fidelity of Simulation Levels in Teaching Resuscitation Scenarios

INTRODUCTION The purpose of our study was to examine the ability of novices to learn selected aspects of Advanced Cardiac Life Support (ACLS) in training conditions that did not incorporate simulation compared to those that contained low- and high-fidelity simulation activities. We sought to determine at what level additional educational opportunities and simulation fidelity become superfluous with respect to learning outcomes. METHODS Totally 39 medical students and physician assistant students were randomly assigned to 4 training conditions: control (lecture only), video-based didactic instruction, low-, and high-fidelity simulation activities. Participants were assessed using a baseline written pretest of ACLS knowledge. Following this, all participants received a lecture outlining ACLS science and algorithm interpretation. Participants were then trained in specific aspects of ACLS according to their assigned instructional condition. After training, each participant was assessed via a Megacode performance examination and a written posttest. RESULTS All groups performed significantly better on the written posttest compared with the pretest (p < 0.001); however, no groups outperformed any other groups. On the Megacode performance test, the video-based, low-, and high-fidelity groups performed significantly better than the control group (p = 0.028, p < 0.001, p = 0.019). Equivalence testing revealed that the high-fidelity simulation condition was statistically equivalent to the video-based and low-fidelity simulation conditions. CONCLUSION Video-based and simulation-based training is associated with better learning outcomes when compared with traditional didactic lectures only. Video-based, low-fidelity, and high-fidelity simulation training yield equivalent outcomes, which may indicate that high-fidelity simulation is superfluous for the novice trainee.

Virtual Reality Simulators: Valuable Surgical Skills Trainers or Video Games?

BACKGROUND Virtual reality (VR) and physical model (PM) simulators differ in terms of whether the trainee is manipulating actual 3-dimensional objects (PM) or computer-generated 3-dimensional objects (VR). Much like video games (VG), VR simulators utilize computer-generated graphics. These differences may have profound effects on the utility of VR and PM training platforms. In this study, we aimed to determine whether a relationship exists between VR, PM, and VG platforms. METHODS VR and PM simulators for laparoscopic camera navigation ([LCN], experiment 1) and flexible endoscopy ([FE] experiment 2) were used in this study. In experiment 1, 20 laparoscopic novices played VG and performed 0° and 30° LCN exercises on VR and PM simulators. In experiment 2, 20 FE novices played VG and performed colonoscopy exercises on VR and PM simulators. RESULTS In both experiments, VG performance was correlated with VR performance but not with PM performance. Performance on VR simulators did not correlate with performance on respective PM models. CONCLUSIONS VR environments may be more like VG than previously thought.

Who Will Be Able to Perform Open Biliary Surgery in 2025

BACKGROUND Although laparoscopic cholecystectomy (LC) is the gold standard, some patients still require an open cholecystectomy (OC). This study evaluates the mean number of OCs performed by each graduating general surgery resident during each of 3 decades. STUDY DESIGN Data were obtained from all patients undergoing a cholecystectomy during 3 decades: prelaparoscopic era (1981 to 1990), first decade of LC (1991 to 2001), and recent decade of LC (2004 to 2013). Data were prospectively collected and retrospectively reviewed and analyzed by chi-square or Fishers exact test. RESULTS Compared with the prelaparoscopic decade, the number of patients undergoing an OC decreased considerably, by 67%, during the first decade of LC, and by 92% during the most recent decade at the 2 core teaching hospitals. Mean number of OCs performed per graduating chief general surgery resident decreased significantly for both laparoscopic decades compared with the prelaparoscopic decade (70.4, 22.4, and 3.6, respectively). In the last decade at the core institutions, 683 (8.8%) patients also underwent an intraoperative cholangiogram (IOC) and 36 (0.5%) underwent common bile duct exploration (CBDE). When biliary cases done at affiliated institutions during the last decade were included, the mean number of OCs (from 3.6 to 10.2), IOCs (from 683 to 2,098), and CBDEs (from 36 to 116) all increased (p < 0.001) per graduating chief general surgery resident. CONCLUSIONS There has been a considerable decline in the number of OCs, IOCs, and CBDEs available to our trainees during the past 30 years. New training paradigms should include renewed focus on performing an IOC and/or CBDE as clinically indicated during LC; high-quality simulation programs for OC, IOC, and CBDE; and the availability of an advanced video library depicting complicated open biliary procedures.

Performance on Brief Practice Examination Identifies Residents at Risk for Poor ABSITE and ABS Qualifying Examination Performance

OBJECTIVE Performance on the American Board of Surgery (ABS) Qualifying Exam (QE) correlates well with chief resident American Board of Surgery In-Training Exam (ABSITE) scores. Yearly ABSITE performance is a useful gauge of resident fund of knowledge and can identify residents at risk of QE failure. We hypothesize that a brief practice exam administered 1-3 times each academic year can identify residents at risk of poor ABSITE performance and also identify early in the chief resident year those at risk for poor QE performance. METHODS In 2005 we began administering 2-3 times/year an approximately 50 question exam consisting of questions authored by residents and edited by faculty based on the ABSITE exam keywords. The exam was considered mandatory and educational time was allotted. Data were analyzed by determining an individuals score deviation from the mean within PGY class. The standard deviation was then compared to the corresponding years ABSITE percentile and in the final year, QE performance using the Spearman rank correlation test. RESULTS A total of 710 individual practice exams were offered and 462 (65.1%) were completed in 9 sessions. Two hundred sixty-three residents completed both a practice examination and ABSITE in the year preceding the administration of the ABSITE. Twenty-six chief residents completed a practice examination in the year immediately preceding the ABS QE. Correlations between practice exam scores and ABSITE score percentile were statistically significant (p= 0.01-0.05) for each year the test was administered. The correlation between the practice exam score for chief residents preceding the QE and first attempt QE score was also significant (r =0.416, p<0.05). CONCLUSIONS A residents performance on a brief practice exam administered throughout the year is significantly correlated with both ABSITE performance and ABS QE performance. Such a test can be a useful adjunct for identifying residents at risk for poor ABSITE performance as well as identify prior to return of ABSITE scores those residents at risk for poor ABS QE performance.

The Effect of Patient Education on the Perceptions of Resident Participation in Surgical Care

OBJECTIVE To decipher if patient attitudes toward resident participation in their surgical care can be improved with patient education regarding resident roles, education, and responsibilities. DESIGN An anonymous questionnaire was created and distributed in outpatient surgery clinics that had residents involved with patient care. In total, 3 groups of patients were surveyed, a control group and 2 intervention groups. Each intervention group was given an informational pamphlet explaining the role, education, and responsibilities of residents. The first pamphlet used an analogy-based explanation. The second pamphlet used literature citations and statistics. SETTING Keesler Medical Center, Keesler AFB, MS. University of Texas Health Science Center at San Antonio, San Antonio, TX. PARTICIPANTS A total of 454 responses were collected and analyzed-211 in the control group, 118 in the analogy pamphlet group, and 125 in the statistics pamphlet group. RESULTS Patients had favorable views of residents assisting with their surgical procedures, and the majority felt that outcomes were the same or better regardless of whether they read an informational pamphlet. Of all the patients surveyed, 80% agreed or strongly agreed that they expect to be asked permission for residents to be involved in their care. Further, 52% of patients in the control group agreed or strongly agreed to a fifth-year surgery resident operating on them independently for routine procedures compared to 62% and 65% of the patients who read the analogy pamphlet and statistics pamphlet, respectively (p = 0.05). When we combined the 2 intervention groups compared to the control group, this significant difference persisted (p = 0.02). CONCLUSION Most patients welcome resident participation in their surgical care, but they expect to be asked permission for resident involvement. Patient education using an information pamphlet describing resident roles, education, and responsibilities improved patient willingness to allow a chief resident to operate independently.

Rapid decay of transthoracic echocardiography skills at 1 month: A prospective observational study

OBJECTIVE Focused transthoracic echocardiography (FTTE) is an emerging tool in the management of critically ill patients, but the lack of adequate training models has limited the expansion of this technology. Although basic FTTE training courses have been shown to be sufficient in developing echocardiography skills, limited data exist regarding skill retention. In an effort to develop an adequate FTTE training model, we sought to determine the degree of skill retention after FTTE training. DESIGN A prospective, observational study. SETTING An academic center. PARTICIPANTS Surgical residents and medical students: 31 subjects were enrolled from February to June 2016. RESULTS Participants underwent a 2-hour FTTE course including didactics and a hands-on session measuring ejection fraction of left ventricle (LV) and inferior vena cava (IVC) diameter. Written knowledge and performance examinations applying FTTE were conducted before the course, immediately after, and at 1- and 3-month intervals, which were evaluated on a 0 to 9 scale and analyzed with paired t-tests. Performance examination scores obtaining the LV and IVC views preinitial and postinitial training increased from 1.7 to 6.5 (LV) and from 2.0 to 6.8 (IVC) (p < 0.01), decreased to 5.0 and 4.8, respectively, at 1 month (posttraining vs 1 month, p < 0.01), and did not significantly change at 3 months (5.4 and 5.0, respectively). Written examination scores increased from 42% to 62% (pretraining vs posttraining, p < 0.01), decreased to 48% in 1 month (posttraining vs 1 month, p < 0.01), and further decreased to 34% at 3 months (1 month vs 3 month, p < 0.01). CONCLUSIONS Although a short training course appears sufficient to impart basic FTTE skills and knowledge, skills are significantly decayed at 1 month and knowledge continually decreases at 1 and 3 months. Future FTTE training models should consider the rapid degradation of knowledge and skills in determining frequency of refresher training and ongoing evaluation.