Systematic review of predictors of surgical performance

Novel multimodal sensing and machine learning strategies to classify cognitive workload in laparoscopic surgery

BACKGROUND

Surgeons can experience elevated cognitive workload (CWL) during surgery due to various factors including operative technicalities and the environmental demands of the operating theatre. This can result in poorer outcomes and have a detrimental effect on surgeon well-being. The objective measurement of CWL provides a potential solution to facilitate classification of workload levels, however results are variable when physiological measures are used in isolation. The aim of this study is to develop and propose a multimodal machine learning (ML) approach to classify CWL levels using a bespoke sensor platform and to develop a ML approach to impute missing pupil diameter measures due to the effect of blinking or noise.

MATERIALS AND METHODS

Ten surgical trainees performed a simulated laparoscopic cholecystectomy under cognitive conditions of increasing difficulty, namely a modified auditory N-back task with increasing difficulty and a verbal clinical scenario. Physiological measures were recorded using a novel platform (MAESTRO). Electroencephalography (EEG) and functional near-infrared spectroscopy (fNIRS) were used as direct measures of CWL. Indirect measures included electromyography (EMG), electrocardiography (ECG) and pupil diameter (PD). A reference point for validation was provided by subjective assessment of perceived CWL using the SURG-TLX. A multimodal machine learning approach that systematically implements a CNN-BiLSTM, a binary version of the metaheuristic Manta Ray Foraging Optimisation (BMRFO) and a version of Fuzzy C-Means (FCM) called Optimal Completion Strategy (OCS) was used to classify the associated perceived CWL state.

RESULTS

Compared to other state of the art classification techniques, cross-validation results for the classification of CWL levels suggest that the CNN-BLSTM and BMRFO approach provides an average accuracy of 97 % based on the confusion matrix. Additionally, OCS demonstrated a superior average performance of 9.15 % in terms of Root-Mean-Square-Error (RMSE) when compared to other PD imputation methods.

CONCLUSION

Perceived CWL levels were correctly classified using a multimodal ML approach. This approach provides a potential route to accurately classify CWL levels, which may have application in future surgical training and assessment programs as well as the development of cognitive support systems in the operating room.

SEEG4D: a tool for 4D visualization of stereoelectroencephalography data

Epilepsy is a prevalent and serious neurological condition which impacts millions of people worldwide. Stereoelectroencephalography (sEEG) is used in cases of drug resistant epilepsy to aid in surgical resection planning due to its high spatial resolution and ability to visualize seizure onset zones. For accurate localization of the seizure focus, sEEG studies combine pre-implantation magnetic resonance imaging, post-implant computed tomography to visualize electrodes, and temporally recorded sEEG electrophysiological data. Many tools exist to assist in merging multimodal spatial information; however, few allow for an integrated spatiotemporal view of the electrical activity. In the current work, we present SEEG4D, an automated tool to merge spatial and temporal data into a complete, four-dimensional virtual reality (VR) object with temporal electrophysiology that enables the simultaneous viewing of anatomy and seizure activity for seizure localization and presurgical planning. We developed an automated, containerized pipeline to segment tissues and electrode contacts. Contacts are aligned with electrical activity and then animated based on relative power. SEEG4D generates models which can be loaded into VR platforms for viewing and planning with the surgical team. Automated contact segmentation locations are within 1 mm of trained raters and models generated show signal propagation along electrodes. Critically, spatial-temporal information communicated through our models in a VR space have potential to enhance sEEG pre-surgical planning.

Investigating the impact of gaming and spatial cognition on laparoscopic surgical skills

BACKGROUND

The purpose of this study was to examine the association between video gaming experience, spatial cognition, and laparoscopic surgical skills in a cohort of 50 medical students.

METHOD

Participants were assessed for video gaming experience, spatial cognition, and laparoscopic skills. The number of hours played per week was also recorded. Structural equation modeling was used to determine the relationship between these variables.

RESULTS

Our findings revealed that video gaming experience and spatial cognition exerted a positive influence on laparoscopic skills. Interestingly, students who excessively indulged in video games without concomitant improvements in spatial cognition experienced a negative impact on their laparoscopic skills.

CONCLUSIONS

These findings underscore the potential of video gaming as a tool for improving surgical skills, but also highlight the potential downsides of excessive gaming. The positive correlation between gaming and surgical skills suggests that video games could be integrated into surgical education. Future research should focus on identifying specific video games that effectively promote visuospatial skills as well as determining the optimal balance between gaming and traditional surgical training.

Development and validation of metrics for a new RAPN training model

Robot-assisted partial nephrectomy (RAPN) is a complex and index procedure that urologists need to learn how to perform safely. No validated performance metrics specifically developed for a RAPN training model (TM) exist. A Core Metrics Group specifically adapted human RAPN metrics to be used in a newly developed RAPN TM, explicitly defining phases, steps, errors, and critical errors. A modified Delphi meeting concurred on the face and content validation of the new metrics. One hundred percent consensus was achieved by the Delphi panel on 8 Phases, 32 Steps, 136 Errors and 64 Critical Errors. Two trained assessors evaluated recorded video performances of novice and expert RAPN surgeons executing an emulated RAPN in the newly developed TM. There were no differences in procedure Steps completed by the two groups. Experienced RAPN surgeons made 34% fewer Total Errors than the Novice group. Performance score for both groups was divided at the median score using Total Error scores, into HiError and LoError subgroups. The LowErrs Expert RAPN surgeons group made 118% fewer Total Errors than the Novice HiErrs group. Furthermore, the LowErrs Expert RAPN surgeons made 77% fewer Total Errors than the HiErrs Expert RAPN surgeons. These results established construct and discriminative validity of the metrics. The authors described a novel RAPN TM and its associated performance metrics with evidence supporting their face, content, construct, and discriminative validation. This report and evidence support the implementation of a simulation-based proficiency-based progression (PBP) training program for RAPN.

Optical angle and visuospatial ability affect basic laparoscopic simulator task performance

Surgical trainees show decreased performance during laparoscopic surgery when the laparoscope (camera) is not aligned with their line of sight towards the operating area. In this study we investigate the influence of visuospatial ability on laparoscopic simulator performance under such non-zero optical angles. Novices were invited to participate in a laparoscopic training session. After completing a visuospatial ability assessment, they performed a simplified laparoscopic task on an in-house developed laparoscopic simulator under eight different optical angles ranging between 0° and 315° in steps of 45°. Data-analysis showed decreased performance under all non-zero optical angles for task duration (mean difference between 1506 and 5049 ms, standard error between 499 and 507, p < .05) and for accuracy under optical angles greater than ±45° (mean difference between 1.48 and 2.11, standard error 0.32, p < .01). Performance-zones were identified for various optical angle ranges and differed for task duration and accuracy. Participants of high visuospatial ability performed significantly better under non-zero angles for accuracy compared to participants of low visuospatial ability (mean difference 0.95, standard error 0.34, p < .01), except for the 180° optical angle (no difference).

Development and validation of an objective virtual reality tool for assessing technical aptitude among potential candidates for surgical training

BACKGROUND

Good technical skills are crucial for surgeons. Yet although surgical training programs strive to assess technical aptitude when selecting surgical residents, valid assessments of such aptitude are still lacking. Surgical simulators have been proposed as a potentially effective tool for this purpose. The current study aims to develop a technical aptitude test using a virtual reality surgical simulator, and to validate its use for the selection of surgical residents.

METHODS

The study had three phases. In Phase 1, we developed an initial version of the technical aptitude test using the Lap-X-VR laparoscopic simulator. In Phases 2 and 3 we refined the test and collected empirical data to evaluate four main sources of validity evidence (content, response process, internal structure, and relationships with other variables), and to evaluate the feasibility and acceptability of the test. Specifically, Phase 2 comprised a review of the test by 30 senior surgeons, and in Phase 3 a revised version of the test was administered to 152 interns to determine its psychometric properties.

RESULTS

Both the surgeons and interns rated the test as highly relevant for selecting surgical residents. Analyses of the data obtained from the trial administration of the test supported the appropriateness of the score calculation process and showed good psychometric properties, including reliability (α = 0.83) and task discrimination (mean discrimination = 0.5, SD = 0.1). The correlations between test scores and background variables revealed significant correlations with gender, surgical simulator experience, and video game experience (ps < 0.001). These variables, however, explained together only 10% of the variance in test scores.

CONCLUSIONS

We describe the systematic development of an innovative virtual reality test for assessing technical aptitude in candidates for surgical training, and present evidence for its validity, feasibility and acceptability. Further validation is required to support the application of the test for selection, as well as to discern the impact of gender, surgical simulator experience, and video game experience on the fairness of test results. However, the test appears to be a promising tool that may help training programs assess the suitability of candidates for surgical training.

Cognitive models for mentally visualizing a sharp instrument in a blind procedure

Purpose

Our objective was to understand the cognitive strategies used by surgeons to mentally visualize navigation of a surgical instrument through blind space.

Methods

We conducted semi-structured interviews with 15 expert and novice surgeons following simulated retropubic trocar passage on 3D-printed models of pelvises segmented from preop MRIs. Midurethral sling surgery involves blind passage of a trocar among the urethra, bladder, iliac vessels, and bowel while relying primarily on haptic feedback from the suprapubic bone (SPB) for guidance. Our conceptual foundation was based on Lahav's study on blind people's mental mapping of spaces using haptic cues. Participants detailed how they mentally pictured the trocar's location relative to vital anatomy. We coded all responses and used constant comparative analysis to generate themes, confirmed with member checking.

Results

Expert and novice participants utilized multiple cognitive strategies combined with haptic feedback to accomplish safe trocar passage. Some used a step-by-step route strategy, visualizing sequential 2D axial images of anatomy adjacent to the SPB. Others used a map strategy, forming global 3D pictures. Although these mental pictures vanished when they were "lost," a safe zone could be reestablished by touching the SPB. Experts were more likely to relate their body position to the trocar path and rely on minor variations in resistance. Novices were more inclined toward backtracking of the trocar.

Conclusions

Our findings may be extended to any blind surgical procedure. Teaching visualization strategies and incorporating tactile feedback can be used intraoperatively to help learners navigate their instrument safely around vital organs.

Neuropsychological Differences Between Surgery Interns and Age-Matched Adults

OBJECTIVE

The purpose of this study was to assess how neuropsychological factors differ between general surgery interns and normative data from age-matched adults in the general population.

DESIGN

Participants completed a comprehensive neuropsychological assessment battery. Neuropsychological factors assessed included: executive function (Behavioral Rating Inventory of Executive Function, BRIEF), working memory (Wechsler Adult Intelligence Scale, or WAIS, digit span), psychomotor speed (WAIS coding, Trails A and B), selective attention (D2 Test of Attention), and problem solving (Tower of London, TOL). Data for all measures was compared to previously published normative data for age-matched, healthy adults in the general population using one-sample t-tests.

SETTING

This study was completed at Indiana University School of Medicine in Indianapolis, IN, which is a large academic healthcare training institution.

PARTICIPANTS

Postgraduate year 1 general surgery residents (PGY1s) voluntarily participated in this study.

RESULTS

Twenty-six general surgery PGY1s completed all measures. We found that PGY1s had significantly better behavioral inhibition, working memory, selective attention, problem solving, and psychomotor speed than their counterparts in the general population (Table 1). Conversely, we found that PGY1s had significantly lower cognitive flexibility (p = 0.02) and ability to monitor task progress (p = 0.006) than the general population.

CONCLUSIONS

The results from this study indicate that there are several neuropsychological factors that may help explain the high achievement of general surgery PGY1s. Assessment of these factors could aid general surgery programs in the selection and training of high-caliber residents. However, there are indicators that PGY1s struggle from cognitive inflexibility and task monitoring compared to the general population. These skills are needed to manage the complex and dynamic nature of surgical performance, so educators should consider methods to enhance junior residents' development of these characteristics.

Laparoscopic simulator performance and learning curves under different optical angles

BACKGROUND

Deviated optical angles create visuospatial and psychomotor challenges during laparoscopic procedures, resulting in delayed operative time and possibly adverse events. If it is possible to train the skills needed to work under these deviated optical angles, this could benefit procedure time and patient safety. This study investigates the influence of the optical angle on development of basic laparoscopic surgical skills.

METHODS

A total of 58 medical students performed a four-session laparoscopic training course on a Virtual Reality Simulator. During each session, they performed an identical task under optical angles of 0°, 45° and - 45°. Performance parameters of task duration and damage were compared between the optical angles to investigate the effect of optical angle on performance development. The 4th session performance was compared to the 2nd session performance for each angle to determine improvement.

RESULTS

Participants performed the task significantly faster under the 0° optical angle compared to the plus and minus 45° optical angles during the last three sessions (z between - 2.95 and - 2.09, p < .05). Participants improved significantly and similarly for task duration during the training course under all optical angles. At the end of the training course however significant performance differences between the zero and plus/minus 45 optical angles remained. Performance for damage did not improve and was not affected by optical angle throughout the course.

CONCLUSION

Dedicated virtual reality training improves laparoscopic basic skills performance under deviated optical angles as it leads to shorter task duration, however a lasting performance impairment compared to the 0° optical angle remained. Training for performing under deviating optical angles can potentially shorter the learning curve in the operating room.

Human visual explanations mitigate bias in AI-based assessment of surgeon skills

Artificial intelligence (AI) systems can now reliably assess surgeon skills through videos of intraoperative surgical activity. With such systems informing future high-stakes decisions such as whether to credential surgeons and grant them the privilege to operate on patients, it is critical that they treat all surgeons fairly. However, it remains an open question whether surgical AI systems exhibit bias against surgeon sub-cohorts, and, if so, whether such bias can be mitigated. Here, we examine and mitigate the bias exhibited by a family of surgical AI systems-SAIS-deployed on videos of robotic surgeries from three geographically-diverse hospitals (USA and EU). We show that SAIS exhibits an underskilling bias, erroneously downgrading surgical performance, and an overskilling bias, erroneously upgrading surgical performance, at different rates across surgeon sub-cohorts. To mitigate such bias, we leverage a strategy -TWIX-which teaches an AI system to provide a visual explanation for its skill assessment that otherwise would have been provided by human experts. We show that whereas baseline strategies inconsistently mitigate algorithmic bias, TWIX can effectively mitigate the underskilling and overskilling bias while simultaneously improving the performance of these AI systems across hospitals. We discovered that these findings carry over to the training environment where we assess medical students' skills today. Our study is a critical prerequisite to the eventual implementation of AI-augmented global surgeon credentialing programs, ensuring that all surgeons are treated fairly.

Predictive factors of academic success in neuromusculoskeletal anatomy among doctor of physical therapy students

Predictors of academic success in anatomy have been studied, but not in Doctor of Physical Therapy (DPT) students. The objectives of this study were to (1) explore predictors of academic success in a DPT anatomy course, (2) evaluate sex-based differences in the predictors of academic success and their influence on anatomy course grade, and (3) investigate the influence of the DPT anatomy course on visual-spatial ability. Forty-nine DPT students completed a demographic questionnaire, Learning and Study Strategies Inventory (LASSI), and Mental Rotations Test (MRT) before the ten-week anatomy course (MRT-1) and repeated the MRT at the end of the course (MRT-2). Anatomy course grade was determined based on quizzes and written and practical examinations. Multiple regression analysis showed significant associations between the predictor variables age (p = 0.010) and the LASSI anxiety subscale (p = 0.017), which measures anxiety coping, with the anatomy course grade. On the MRT-1, male DPT students attempted and correctly answered more questions than females (both, p < 0.0001). Female students had higher LASSI self-regulation and use of academic resources subscale scores (both, p < 0.05). In the 44 DPT students that completed the MRT-2, the number of correct and attempted responses increased following the anatomy course (p < 0.0001). Age and anxiety coping, but not sex, are predictors of anatomy course grades in DPT students. Mental rotations test scores improved following the anatomy course. The LASSI should be used in other cohorts to identify students with low anxiety subscale scores in order to provide targeted support.

4,300 steps per day prior to surgery are associated with improved outcomes after pancreatectomy

BACKGROUND

Decreased preoperative physical fitness and low physical activity have been associated with preoperative functional reserve and surgical complications. We sought to evaluate daily step count as a measure of physical activity and its relationship with post-pancreatectomy outcomes.

METHODS

Patients undergoing pancreatectomy were given a remote telemonitoring device to measure their preoperative levels of physical activity. Patient activity, demographics, and perioperative outcomes were collected and compared in univariate and multivariate logistic regression analysis.

RESULTS

73 patients were included. 45 (61.6%) patients developed complications, with 17 (23.3%) of those patients developing severe complications. These patients walked 3437.8 (SD 1976.7) average daily steps, compared to 5918.8 (SD 2851.1) in patients without severe complications (p < 0.001). In logistic regression analysis, patients who walked less than 4274.5 steps had significantly higher odds of severe complications (OR = 7.5 (CI 2.1, 26.8), p = 0.002).

CONCLUSION

Average daily steps below 4274.5 before surgery are associated with severe complications after pancreatectomy. Preoperative physical activity levels may represent a modifiable target for prehabilitation protocols.

Using Job Analysis for Identifying the Desired Competencies of 21st-Century Surgeons for Improving Trainees Selection

OBJECTIVE

The current selection for surgical training is based on ineffective methods. In order to identify or to develop more valid selection tools to improve the selection, it is necessary to first define what are the competencies that are most important for success in contemporary surgery. Therefore, the current study aims to identify what competencies are required for success as a surgeon in the 21st-century and to evaluate their relative importance for selection for surgical training.

METHODS

Job analysis was conducted using a mixed-methods design. First, 104 senior surgeons from all surgical fields from various hospitals in Israel were interviewed in order to query their perceptions of competencies associated with success as a surgeon. Their answers were coded and analyzed to create a list of important competencies. Next, a larger sample of 1,102 surgeons and residents from all surgical fields completed a questionnaire in which they rated the importance of each competency in the list for success as a surgeon and for selection for surgical training in the 21st-century.

RESULTS

Twenty-four competencies (five technical skills, six cognitive abilities, 13 personality characteristics) were identified in the interview analysis. Analysis of the questionnaire's data revealed that all 24 competencies were perceived as important for success as a surgeon in the 21st-century as well as for selection for surgical training. The perceived importance of personality characteristics was higher than both cognitive abilities (p < 0.001) and technical skills (p < 0.001). The results did not differ between different surgical fields.

CONCLUSIONS

Twenty-four competencies were identified as important for 21st-century surgeons and for selection for surgical training. Although all competencies were perceived as important, personality characteristics were perceived as more important than technical skills and cognitive abilities. This updated definition of required competencies may aid in developing more valid selection methods of candidates for surgical training.

Do our hands see what our eyes see? Investigating spatial and haptic abilities

Spatial abilities (SAs) are cognitive resources used to mentally manipulate representations of objects to solve problems. Haptic abilities (HAs) represent tactile interactions with real-world objects transforming somatic information into mental representations. Both are proposed to be factors in anatomy education, yet relationships between SAs and HAs remain unknown. The objective of the current study was to explore SA-HA interactions. A haptic ability test (HAT) was developed based on the mental rotations test (MRT) with three-dimensional (3D) objects. The HAT was undertaken in three sensory conditions: (1) sighted, (2) sighted with haptics, and (3) haptics. Participants (n = 22; 13 females, 9 males) completed the MRT and were categorized into high spatial abilities (HSAs) (n = 12, mean± standard deviation: 13.7 ± 3.0) and low spatial abilities (LSAs) (n = 10, 5.6 ± 2.0) based on score distributions about the overall mean. Each SA group's HAT scores were compared across the three sensory conditions. Spearman's correlation coefficients between MRT and HAT scores indicated a statistically significant correlation in sighted condition (r = 0.553, p = 0.015) but were not significant in the sighted with haptics (r = 0.0.078, p = 0.212) and haptics (r = 0.043, p = 0.279) conditions. These data suggest HAs appear unrelated to SAs. With haptic exploration, LSA HAT scores were compensated; comparing HSA with LSA: sighted with haptics [median (lower and upper quartiles): 12 (12,13) vs. 12 (11,13), p = 0.254], and haptics [12 (11,13) vs. 12 (10,12), p = 0.381] conditions. Migrations to online anatomy teaching may unwittingly remove important sensory modalities from the learner. Understanding learner behaviors and performance when haptic inputs are removed from the learning environment represents valuable insight informing future anatomy curriculum and resource development.

Real-Time Dual Video Conferencing of Simulated Tracheostoma Maturation During Residency Interviews

BACKGROUND

There are few reports of dexterity tests being done in a distance telecommunication setting for residency applicant evaluation.

OBJECTIVE

To report the feasibility and suitability of a virtual suturing skills assessment during residency interviews when added to the standard assessment process.

METHODS

A suturing simulation was developed and implemented during otolaryngology-head and neck surgery (OHNS) residency interviews for the 2020-2021 cycle at one program. On the day of the interview, the activity was completed in real time using 2-camera video conferencing with the 2 resident assessors providing a numerical assessment based on an adapted scoring rubric from prior suturing activities at the institution. The exercise involved suturing a 3/4-inch Penrose drain circumferentially with half-vertical mattress stitches to simulate the maturation of a tracheostoma. The residency selection committee then completed a 7-item Likert-type survey, developed by the authors, to evaluate the simulation exercise.

RESULTS

Fifty-one applicants representing all interviewees in the cycle successfully completed this assessment without technologic disruptions. The total cost associated with obtaining and providing the necessary supplies to applicants was $34.78 per interviewee. Time required to complete the suturing task was estimated to range from 10 to 20 minutes. The residency selection committee viewed this exercise as a success (14 of 16, 87.5%) and viewed the results as a valuable adjunct in the overall assessment of candidates (15 of 16, 93.8%).

CONCLUSIONS

A simple motor exercise completed over real-time telecommunication was feasible and perceived as helpful to the residency selection committee when assessing OHNS residency candidates.

Impact of compulsory participation of medical students in a multiuser online game to learn radiological anatomy and radiological signs within the virtual world Second Life

Competitive game-based learning within Second Life enables effective teaching of basic radiological anatomy and radiological signs to medical students, with good acceptance and results when students participate voluntarily, but unknown in a compulsory context. The objectives of this study were to reproduce a competitive online game based on self-guided presentations and multiple-choice tests in a mandatory format, to evaluate its development and student perceptions compared to a voluntary edition in 2015 (N = 90). In 2016 and 2017, respectively, 191 and 182 third-year medical students participated in the game as a mandatory course activity. The mean (±SD) score of the game was 74.7% (±19.5%) in 2015, 71.2% (±21.5%) in 2016, and 67.5% (±21.5%) in 2017 (P < 0.01). Participants valued positively the organization and educational contents but found the virtual world less attractive and the game less interesting than in the voluntary edition. The experience globally was rated with 8.2 (±1.5), 7.8 (±1.5), and 7.1 (±1.7) mean points (±SD) in a ten-point scale, in the 2015, 2016, and 2017 editions, respectively (P < 0.05). Competitive learning games within virtual worlds like Second Life have great learning potential in radiology, but the mean score in the game decreased, acceptance of virtual world technology was lower, and opinion about the game was worse with a compulsory participation, and even worse when dropouts were not allowed. Under the conditions in which this study was conducted, learning games in three-dimensional virtual environments should be voluntary to maintain adequate motivation and engagement of medical students.

The role of virtual reality simulation in surgical training in the light of COVID-19 pandemic: Visual spatial ability as a predictor for improved surgical performance: a randomized trial

INTRODUCTION

Due to the current COVID-19 pandemic, surgical training has become increasingly challenging due to required social distancing. Therefore, the use of virtual reality (VR)-simulation could be a helpful tool for imparting surgical skills, especially in minimally invasive environments. Visual spatial ability (VSA) might influence the learning curve for laparoscopic surgical skills. However, little is known about the influence of VSA for surgical novices on VR-simulator training regarding the complexity of different tasks over a long-term training period. Our study evaluated prior VSA and VSA development in surgical trainees during VR-simulator training, and its influence on surgical performance in simulator training.

METHODS

In our single-center prospective two-arm randomized trial, VSA was measured with a tube figure test before curriculum training. After 1:1 randomization, the training group (TG) participated in the entire curriculum training consisting of 48 different VR-simulator tasks with varying difficulty over a continuous nine-day training session. The control group (CG) performed two of these tasks on day 1 and 9. Correlation and regression analyses were used to assess the influence of VSA on VR-related surgical skills and to measure procedural abilities.

RESULTS

Sixty students (33 women) were included. Significant improvements in the TG in surgical performance and faster completion times were observed from days 1 to 9 for the scope orientation 30° right-handed (SOR), and cholecystectomy dissection tasks after the structured 9-day training program. After training, the TG with pre-existing low VSA scores achieved performance levels similar to those with pre-existing high VSA scores for the two VR simulator tasks. Significant correlations between VSA and surgical performance on complex laparoscopic camera navigation SOR tasks were found before training.

CONCLUSIONS

Our study revealed that that all trainees improved their surgical skills irrespective of previous VSA during structured VR simulator training. An increase in VSA resulted in improvements in surgical performance and training progress, which was more distinct in complex simulator tasks. Further, we demonstrated a positive relationship between VSA and surgical performance of the TG, especially at the beginning of training. Our results identified pre-existing levels of VSA as a predictor of surgical performance.

Design and Validity Evidence for a Unique Endoscopy Simulator Using a Commercial Video Game

Background Procedural simulation enhances early endoscopy training. Multiple commercial simulators are available; however, their application is limited by cost and poor user compliance. First-person "shooter" (FPS) video games are popular. In this study, we aimed to show that a novel in-house designed colonoscope controller used to play an FPS video game shares similar constructs with real-life endoscopy. Methodology Participants completed the first three levels on an FPS video game, Portal (Valve Corporation, Bellevue, WA), first using a conventional controller and then the modified endoscope controller. A total of 12 expert endoscopists and 12 surgical residents with minimal endoscopy experience were evaluated based on completion time, button presses, and hand motion analyses. Results Experts outperformed novices for completion time (expert: 944 seconds; novice: 1,515 seconds; p = 0.006) and hand movements (expert: 1,263.1; novice: 2,052.6; p = 0.004) in using the novel colonoscope controller. There was no difference in button presses or total path length traveled. Furthermore, performance did not differ using conventional game controls. Conclusions Experts outperformed novices using the endoscope but not the conventional controller with respect to the economy of movement and completion time. This result confirms that our endoscope-controlled video game shares similar paradigms with real-life endoscopy and serves as a first step toward creating a more enjoyable and cheaper alternative to commercially available endoscopy simulators.

The innate aptitude's effect on the surgical task performance: a systematic review

Surgery is known to be a craft profession requiring individuals with specific innate aptitude for manipulative skills, and visuospatial and psychomotor abilities. The present-day selection process of surgical trainees does not include aptitude testing for the psychomotor and manual manipulative skills of candidates for required abilities. We aimed to scrutinize the significance of innate aptitudes in surgical practice and impact of training on skills by systematically reviewing their significance on the surgical task performance. A systematic review was performed in compliance with PRISMA guidelines. An initial search was carried out on PubMed/Medline for English language articles published over 20 years from January 2001 to January 2021. Search strategy and terms to be used included ‘aptitude for surgery’, ‘innate aptitude and surgical skills, ‘manipulative abilities and surgery’, and ‘psychomotor skills and surgery’. MERSQI score was applied to assess the quality of quantitatively researched citations. The results of the present searches provided a total of 1142 studies. Twenty-one studies met the inclusion criteria out of which six citations reached high quality and rejected our three null hypothesis. Consequently, the result specified that all medical students cannot reach proficiency in skills necessary for pursuing a career in surgery; moreover, playing video games and/or musical instruments does not promote skills for surgery, and finally, there may be a valid test with predictive value for novices aspiring for a surgical career. MERSQI mean score was 11.07 (SD = 0.98; range 9.25–12.75). The significant findings indicated that medical students with low innate aptitude cannot reach skills necessary for a competent career in surgery. Training does not compensate for pictorial-skill deficiency, and a skill is needed in laparoscopy. Video-gaming and musical instrument playing did not significantly promote aptitude for microsurgery. The space-relation test has predictive value for a good laparoscopic surgical virtual-reality performance. The selection process for candidates suitable for a career in surgery requests performance in a simulated surgical environment.

Aptitude and attitude: predictors of performance during and after basic laparoscopic skills training

Background

Manual dexterity and visual-spatial ability are considered key to the development of superior laparoscopic skills. Nevertheless, these abilities do not reliably explain all the variance found in the technical performance of surgical trainees. Consequently, we must look beyond these abilities to improve our understanding of laparoscopic skills and to better identify/develop surgical potential earlier on.

Purpose

To assess the individual and collective impact of physical, cognitive, visual, and psychological variables on performance during and after basic simulation-based laparoscopic skills training.

Method

Thirty-four medical students (laparoscopic novices) completed a proficiency-based laparoscopic skills training program (using either a 2D or 3D viewing mode). This was followed by one testing session, a follow-up testing session with new (yet similar) tasks, and a series of physical, cognitive, visual, and psychological measures.

Results

The statistical models that best predicted variance in training performance metrics included four variables: viewingmode (2D vs 3D), psychologicalflexibility, perceivedtaskdemands, and manualdexterity (bimanual). In subsequent testing, a model that included viewingmode and manualdexterity (assembly) best predicted performance on the pre-practiced tasks. However, for a highly novel, spatially complex laparoscopic task, performance was best predicted by a model that comprised viewingmode, visual-spatialability, and perceivedtaskdemands. At follow-up, manualdexterity (assembly) alone was the best predictor of performance on new (yet similar) tasks.

Conclusion

By focussing exclusively on physical/cognitive abilities, we may overlook other important predictors of surgical performance (e.g. psychological variables). The present findings suggest that laparoscopic performance may be more accurately explained through the combined effects of physical, cognitive, visual, and psychological variables. Further, the results suggest that the predictors may change with both task demands and the development of the trainee. This study highlights the key role of psychological skills in overcoming initial training challenges, with far-reaching implications for practice.

Evidence-Based Selection of Surgical Residents

Residency programs should use a systematic method of recruitment that begins with defining unique desired candidate attributes. Commonly sought-after characteristics may be delineated via the residency application. Scores from standardized examinations taken in medical school predict academic success, and may correlate to overall performance. Strong letters of recommendation and a personal history of prior success outside the medical field both forecast success in residency. Interviews are crucial to determining fit within a program, and remain a valid measure of an applicant's ability to prosper in a particular program, even with many interviews being completed in the virtual realm.

Different approaches to selection of surgical trainees in the European Union

BACKGROUND

There is an increasing global interest in selection processes for candidates to surgical training. The aim of the present study is to compare selection processes to specialist surgeon training in the European Union (EU). A secondary goal is to provide guidance for evidence-based methods by a proposed minimum standard that would align countries within the EU.

METHODS

Publications and grey literature describing selection strategies were sought. Correspondence with Union Européenne des Médecins Specialists (UEMS) Section of Surgery delegates was undertaken to solicit current information on national selection processes. Content analysis of 13 semi-structured interviews with experienced Swedish surgeons on the selection process. Two field trips to Ireland, a country with a centralized selection process were conducted. Based on collated information typical cases of selection in a centralized and decentralized setting, Ireland and Sweden, are described and compared.

RESULTS

A multitude of methods for selection to surgical training programs were documented in the 27 investigated countries, ranging from locally run processes with unstructured interviews to national systems for selection of trainees with elaborate structured interviews, and non-technical and technical skills assessments. Associated with the difference between centralized and decentralized selection systems is whether surgical training is primarily governed by an employment or educational logic. Ireland had the most centralized and elaborate system, conducting a double selection process using evidence-based methods along an educational logic. On the opposite end of the scale Sweden has a decentralized, local selection process with a paucity of evidence-based methods, no national guidelines and operates along an employment logic, and Spain that rely solely on examination tests to rank candidates.

CONCLUSION

The studied European countries all have different processes for selection of surgical trainees and the use of evidence-based methods for selection is variable despite similar educational systems. Selection in decentralized systems is currently often conducted non-transparent and subjectively. A suggested improvement towards an evidence-based framework for selection applicable in centralized and decentralized systems as well as educational and employer logics is suggested.

Speed versus damage: using selective feedback to modulate laparoscopic simulator performance

BACKGROUND

Adaptive training is an approach in which training variables change with the needs and traits of individual trainees. It has potential to mitigate the effect of personality traits such as impulsiveness on surgical performance. Selective performance feedback is one way to implement adaptive training. This paper investigates whether selective feedback can direct performance of trainees of either high- or low impulsiveness.

METHODS

A total of 83 inexperienced medical students of known impulsiveness performed a four-session laparoscopic training course on a Virtual Reality Simulator. They performed two identical series of tasks every session. During one series of tasks they received performance feedback on duration and during the other series they received feedback on damage. Performance parameters (duration and damage) were compared between the two series of tasks to assess whether selective performance feedback can be used to steer emphasis in performance. To assess the effectiveness of selective feedback for people of high- or low impulsiveness, the difference in performance between the two series for both duration and damage was also assessed.

RESULTS

Participants were faster when given performance feedback for speed for all exercises in all sessions (average z-value = - 4.14, all p values < .05). Also, they performed better on damage control when given performance feedback for damage in all tasks and during all sessions except for one (average z-value = - 4.19, all but one p value < .05). Impulsiveness did not impact the effectiveness of selective feedback.

CONCLUSION

Selective feedback on either duration or damage can be used to improve performance for the variable that the trainee receives feedback on. Trainee impulsiveness did not modulate this effect. Selective feedback can be used to steer training focus in adaptive training systems and can mitigate the negative effects of impulsiveness on damage control.

The effect of a three-dimensional instructional video on performance of a spatially complex procedure in surgical residents in relation to their visual-spatial abilities

BACKGROUND

The effect of three-dimensional (3D) vs. two-dimensional (2D) video on performance of a spatially complex procedure and perceived cognitive load were examined among residents in relation to their visual-spatial abilities (VSA).

METHODS

In a randomized controlled trial, 108 surgical residents performed a 5-Flap Z-plasty on a simulation model after watching the instructional video either in a 3D or 2D mode. Outcomes included perceived cognitive load measured by NASA-TLX questionnaire, task performance assessed using Observational Clinical Human Reliability Analysis and the percentage of achieved safe lengthening of the scar.

RESULTS

No significant differences were found between groups. However, when accounted for VSA, safe lengthening was achieved significantly more often in the 3D group and only among individuals with high VSA (OR = 6.67, 95%CI: 1.23-35.9, p = .027).

CONCLUSIONS

Overall, 3D instructional videos are as effective as 2D videos. However, they can be effectively used to enhance learning in high VSA residents.

Do Video Games Predict an Early Advanced Capacity to Learn Interventional Radiology Skills?

PURPOSE

To elucidate the relationship between video game (VG) play and interventional radiology (IR) technical skills in medical students.

MATERIALS AND METHODS

Twenty medical students recruited at our institution's IR symposium completed a survey to ascertain demographics and prior VG experience, then participated in a 3-part trial of skills assessing IR and VG skill and visuospatial aptitude (VSA). IR skill was evaluated via an endovascular simulation task, VG skill by performance on three separate VGs, and VSA using the Cube Comparison test. Regression analysis was tested the strength of relationship between IR skill and VG experience, VG skill, and VSA, respectively, and participants were stratified by IR skill to top and bottom halves for survey-response comparison.

RESULTS

There was no correlation between either VG skill or visuospatial aptitude and IR skill (r = -0.22, p = 0.35; and r = 0.14, p = 0.57). Greater number of years playing VGs correlated with superior IR skill (Spearman's rho=-0.45, p<0.05). Students who selected IR as their specialty of interest had extensive VG experience, playing for > 15 years (n = 4, 80%), at least 10 hours per week at their peak (n = 3, 60%), and reported being either "skilled" or "highly skilled" at VGs (n = 3, 60%).

CONCLUSIONS

In our study, though limited by power, number of years playing VGs correlated positively with IR skills in medical students. Prior VG experience may predict an early advanced capacity to learn IR skills and an interest in the specialty.

Recent evidence on visual-spatial ability in surgical education: A scoping review

BACKGROUND

Understanding the relationships between structures is critical for surgical trainees. However, the heterogeneity of the literature on visual-spatial ability (VSA) in surgery makes it challenging for educators to make informed decisions on incorporating VSA into their programs. We conducted a scoping review of the literature on VSA in surgery to provide a map of the literature and identify where gaps still exist for future research.

METHODS

We searched databases until December 2019 using keywords related to VSA and surgery. The resulting articles were independently screened by two researchers for inclusion in our review.

RESULTS

We included 117 articles in the final review. Fifty-nine articles reported significant correlations between VSA tests and surgical performance, and this association is supported by neuroimaging studies. However, it remains unclear whether VSA should be incorporated into trainee selection and whether there is a benefit of three-dimensional (3D) over two-dimensional (2D) training.

CONCLUSIONS

It appears that VSA correlates with surgical performance in the simulated environment, particularly for novice learners. Based on our findings, we make suggestions for how surgical educators may use VSA to support novice learners. Further research should determine whether VSA remains correlated to surgical performance when trainees move into the operative environment.

Does spatial awareness training affect anatomy learning in medical students?

Spatial ability (SA) is the cognitive capacity to understand and mentally manipulate concepts of objects, remembering relationships among their parts and those of their surroundings. Spatial ability provides a learning advantage in science and may be useful in anatomy and technical skills in health care. This study aimed to assess the relationship between SA and anatomy scores in first- and second-year medical students. The training sessions focused on the analysis of the spatial component of objects' structure and their interaction as applied to medicine; SA was tested using the Visualization of Rotation (ROT) test. The intervention group (n = 29) received training and their pre- and post-training scores for the SA tests were compared to a control group (n = 75). Both groups improved their mean scores in the follow-up SA test (P < 0.010). There was no significant difference in SA scores between the groups for either SA test (P = 0.31, P = 0.90). The SA scores for female students were significantly lower than for male students, both at baseline and follow-up (P < 0.010). Anatomy training and assessment were administered by the anatomy department of the medical school, and examination scores were not significantly different between the two groups post-intervention (P = 0.33). However, participants with scores in the bottom quartile for SA performed worse in the anatomy questions (P < 0.001). Spatial awareness training did not improve SA or anatomy scores; however, SA may identify students who may benefit from additional academic support.

Scoping Evidence Review on Training and Skills Assessment for Open Emergency Surgery

OBJECTIVE

Scope evidence on technical performance metrics for open emergency surgery. Identify surgical performance metrics and procedures used in trauma training courses.

DESIGN

Structured literature searches of electronic databases were conducted from January 2010 to December 2019 to identify systematic reviews of tools to measure surgical skills employed in vascular or trauma surgery evaluation and training.

SETTING AND PARTICIPANTS

Faculty of Shock Trauma Anesthesiology Research Center, University of Maryland School of Medicine, Uniformed Services University of Health Sciences, Bethesda, Maryland and Implementation Science, King's College, London.

RESULTS

The evidence from 21 systematic reviews including over 54,000 subjects enrolled into over 840 eligible studies, identified that the Objective Structured Assessment of Technical Skill was used for elective surgery not for emergency trauma and vascular control surgery procedures. The Individual Procedure Score (IPS), used to evaluate emergency trauma procedures performed before and after training, distinguished performance of residents from experts and practicing surgeons. IPS predicted surgeons who make critical errors and need remediation interventions. No metrics showed Kirkpatrick's Level 4 evidence of technical skills training benefit to emergency surgery outcomes.

CONCLUSIONS

Expert benchmarks, errors, complication rates, task completion time, task-specific checklists, global rating scales, Objective Structured Assessment of Technical Skills, and IPS were found to identify surgeons, at all levels of seniority, who are in need of remediation of technical skills for open surgical hemorrhage control. Large-scale, multicenter studies are needed to evaluate any benefit of trauma technical skills training on patient outcomes.

Validation of Training and Acquisition of Surgical Skills in Veterinary Laparoscopic Surgery: A Review

At present, veterinary laparoscopic surgery training is lacking in experiences that provide a controlled and safe environment where surgeons can practice specific techniques while receiving experts' feedback. Surgical skills acquired using simulators must be certified and transferable to the operating room. Most models for practicing laparoscopic skills in veterinary minimally invasive surgery are general task trainers and consist of boxes (simulators) designed for training human surgery. These simulators exhibit several limitations, including anatomic species and procedural differences, as well as general psychomotor training rather than in vivo skill recreation. In this paper, we review the existing methods of training, evaluation, and validation of technical skills in veterinary laparoscopic surgery. Content includes global and specific scales, and the conditions a structured curriculum should meet for improving the performance of novice surgeons during and after training. A focus on trainee-specific assessment and tailored-technical instruction should influence training programs. We provide a comprehensive analysis of current theories and concepts related to the evaluation and validation of simulators for training laparoscopic surgery in small animal surgery. We also highlight the need to develop new training models and complementary evaluation scales for the validation of training and acquisition of basic and advanced skills in veterinary laparoscopic surgery.

Anatomy Dissection Course Improves the Initially Lower Levels of Visual-Spatial Abilities of Medical Undergraduates

Visual-spatial abilities are considered a successful predictor in anatomy learning. Previous research suggest that visual-spatial abilities can be trained, and the magnitude of improvement can be affected by initial levels of spatial skills. This case-control study aimed to evaluate (1) the impact of an extra-curricular anatomy dissection course on visual-spatial abilities of medical undergraduates and (2) the magnitude of improvement in students with initially lower levels of visual-spatial abilities, and (3) whether the choice for the course was related to visual-spatial abilities. Course participants (n = 45) and controls (n = 65) were first and second-year medical undergraduates who performed a Mental Rotations Test (MRT) before and 10 weeks after the course. At baseline, there was no significant difference in MRT scores between course participants and controls. At the end of the course, participants achieved a greater improvement than controls (first-year: ∆6.0 ± 4.1 vs. ∆4.9 ± 3.2; ANCOVA, P = 0.019, Cohen's d = 0.41; second-year: ∆6.5 ± 3.3 vs. ∆6.1 ± 4.0; P = 0.03, Cohen's d = 0.11). Individuals with initially lower scores on the MRT pretest showed the largest improvement (∆8.4 ± 2.3 vs. ∆6.8 ± 2.8; P = 0.011, Cohen's d = 0.61). In summary, (1) an anatomy dissection course improved visual-spatial abilities of medical undergraduates; (2) a substantial improvement was observed in individuals with initially lower scores on the visual-spatial abilities test indicating a different trajectory of improvement; (3) students' preferences for attending extracurricular anatomy dissection course was not driven by visual-spatial abilities.

Spatial abilities training in the field of technical skills in health care: A systematic review

OBJECTIVE

To conduct a systematic review of the effect of interventions on spatial abilities in the field of technical skills in health care.

METHODS

A literature search was conducted up to November 14, 2017 in Scopus and in several databases on EBSCOhost platform. Citations were obtained, articles related to retained citations were reviewed and a final list of included studies was identified. Methods in the field of technical skills relating an intervention to spatial abilities test scores between intervention groups or obtained before and after the intervention were identified as eligible. The quality of included studies was assessed and data were extracted in a systematic way.

RESULTS

A series of 5513 citations was obtained. Ninety-nine articles were retained and fully reviewed, yielding four included studies. No difference in the Hidden Figure Test score after one year was observed after residency training in General Surgery of at least nine months. A first-year dental curriculum was not found to elevate the Novel Object Cross-Sections Test score (P = 0.07). A two-semester learning period of abdominal sonography was found to increase the Revised Minnesota Paper Form Board Test score (P < 0.05). A hands-on radiology course using interactive three-dimensional image post-processing software consisting of seven two-hour long seminars on a weekly basis was found to amplify the Cube Perspective Test score (P < 0.001).

CONCLUSION

Spatial abilities tests scores were enhanced by courses in abdominal sonography and hands-on radiology, but were not improved by residency training in General Surgery and first-year dental curriculum.

Fast or safe? The role of impulsiveness in laparoscopic simulator performance

BACKGROUND

Little is known about the relation between impulsiveness and surgical performance even though research in similar high-risk/high-skills shows evidence of more hazardous behavior by impulsive professionals. We investigated the impact of impulsiveness on laparoscopic simulator performance.

METHODS

Eighty-three subjects participated in a four-session laparoscopic training course. Based on the Eysenck Personality test, we created equal sized high- and low impulsiveness groups and compared task duration and errors on tasks for two laparoscopic simulators.

RESULTS

The low impulsiveness group outperformed the high impulsiveness group on damage on the LapSim virtual reality trainer (U = 459, p < .049), and showed a trend towards better error performance on the FLS videotrainer. We found no differences on task duration.

CONCLUSIONS

In surgical simulation training, high impulsiveness is associated with creating more damage, but not with faster performance. Time needed to correct errors may have obscured faster performance in the high impulsiveness group.

SUMMARY FOR THE TABLE OF CONTENTS

Subjects were divided into high- and low impulsiveness groups based on the Eysenck Impulsiveness Inventory test. Performance (time and errors) were compared between groups for tasks on the LapSim virtual reality trainer and FLS videotrainer. Low impulsive subjects outperformed high impulsive subjects on errors.

Hand-eye coordination, movement reaction time and hand tactile sensitivity depending on the practiced sports discipline

BACKGROUND

Practicing competitive sports, particularly those disciplines in which the upper limbs are involved in the movement, develops physical fitness and its special feature, namely the hand-eye coordination. Some sport disciplines require manipulation of an object. Using a sport equipment every day, several times, during training and matches must affect the characteristics of the skin of the palmar side of the hand. It may be presumed to affect the tactile sensitivity of the skin. The aim of the study was to determine the relationship between hand-eye coordination and tactile sensitivity in basketball, volleyball, handball, football and combat sports players as compared to those who do not practice competitive sports.

METHODS

Overall, 121 men were subject to tests. The tactile sensitivity threshold was determined at three points of the palmar side of the hand using The Touch-Test™ Sensory Evaluators esthesiometer. The second test involved hand-eye coordination of the upper limbs and it was carried out using cross-type machine.

RESULTS

The greatest tactile sensitivity was shown in combat sports players. These players also demonstrated the shortest reaction time and the lowest number of errors in the motor coordination test. The correlation between tactile sensitivity and coordination was found to be the strongest in subjects not practicing sports.

CONCLUSIONS

The most interesting finding is that in the group of athletes using hands (team sports games and combat sports) the correlation between movement coordination and tactile sensitivity is weaker.

Emotional Intelligence Predicts Accurate Self-Assessment of Surgical Quality: A Pilot Study

BACKGROUND

Self-assessment is fundamental in surgical training. Accuracy of self-assessment is superior with greater age, experience, and the use of video playback. Presently, there is scarce evidence in the literature regarding predictors for a surgical trainee's aptitude for self-assessment. The objective of this study was to investigate whether emotional intelligence or visual-spatial aptitude can predict effective self-assessment among novice surgeons performing laparoscopic appendectomy (LA).

MATERIALS AND METHODS

Eighteen novice trainees performed a simulated LA, and two aptitude measures were evaluated: (1) emotional intelligence questionnaire and (2) visual spatial ability test. Self-assessment of their performance was conducted using the Objective Assessment of Surgical and Technical Skills global rating scale and ranking five subtasks of the procedure in order of quality of performance after watching a playback of their LA. Two blinded experts (senior consultant surgeons, performed >100 LAs) assessed surgical quality using the same scoring system. Candidates were ranked into higher and lower aptitude groups for the two aptitude measures. Spearman's rank correlation coefficient was calculated to identify if either of the two groups demonstrated greater agreement between self and expert assessment in relation to the two aptitude measures.

RESULTS

Participants with a higher degree of emotional intelligence demonstrated significant agreement with expert assessment (r = 0.73, P = 0.031).

CONCLUSIONS

Emotional intelligence can predict better self-assessment of surgical quality after performing a simulated LA. This may facilitate early identification of individuals who might require mentoring or guidance with self-assessment as well as contribute to selection criteria.

Identification and development of talent in surgery

Purpose

Education of the surgeon and development of surgical expertise have been debated for centuries. Today, research in surgical education applies terms and methods from other performance domains such as sport and music. However, there still seems to be a lack of consensus as to how talent may be brought into the discourse about surgical education. Especially, when it comes to identifying and developing trainees who in the future will perform better than the average surgeon.

Design/methodology/approach

This five-step scoping study aims to map existing literature about talent identification, talent development and development of expertise in the domains of surgery, sport and music in the period of 1985-2014.

Findings

A total of 242 studies, divided in the four domains of surgery (69 studies), sport (115 studies), music (34 studies) and cross-disciplinary studies (24 studies) published in the period 1985-2014 were included.

Originality/value

Informed by the performance domains of sports and music and their inclusion of a holistic, ecological approach to research, this study suggests that research in surgical education may benefit from broadening its view on talent by including psychosocial variables and environmental, demographic and structural influencers when considering how surgical talent may be identified and developed.

Identification of Warning Signs During Selection of Surgical Trainees

OBJECTIVE

The aim was to document empirical observations about antecedents to and practices of unsuitable behaviours amongst surgical trainees and develop an interview guide that could be used for the selection process.

DESIGN

A mixed methods design was adopted combining a survey distributed to senior surgeons and heads of departments, followed by semi-structured interviews with experienced surgeons.

SETTING

All surgical departments and hospitals in The South Swedish Health Care Region.

PARTICIPANTS

The survey was completed by 54 of 83 eligible surgeons above 50years of age, and 4 of 7 heads of surgical departments. Semi-structured interviews with 13 surgeons representing local, regional, and university hospitals from the same cohort.

RESULTS

Forty-six (85%) surgeons and four of seven heads of departments responded that they had come across surgical trainees deemed unsuitable to train and work as a surgeon. All heads of department and 31 of 54 of the surgeons believed tendencies towards unsuitability are evident early during training. From the survey, 107 statements described reasons for finding a trainee unsuitable. Qualitative analysis of the interviews and free-text answers of the survey led to identification of 11 problem domains with associated "warning signs". An interview guide to help detect unsuitability tendencies in candidates during selection procedures was constructed.

CONCLUSIONS

Experienced surgeons have quite consistent views on what makes a person unsuitable as a surgeon. Their views have been systematized into 11 problem domains, and a set of 'warning signs' for unsuitable behaviours and traits has been developed. Early detection of these signs and traits is important for the individual, the work environment, and patient safety. A recommendation for a minimum framework for selection including the constructed interview guide is presented.

How do visual-spatial and psychomotor abilities influence clinical performance in periodontal plastic surgery?

AIM

We want to evaluate the relationship of self-assessed experience and proficiency, manual dexterity and visual-spatial ability with surgical performance.

MATERIAL AND METHODS

A total of 26 professionals were included in the study which consisted of four parts: (a) self-assessment by a questionnaire regarding proficiency and experience, (b) evaluation of visual-spatial ability, (c) testing of manual dexterity assessed by validated psychomotor tests and (d) evaluation of surgical performance by Objective Structured Assessment of Technical Skills (OSATS).

RESULTS

Self-assessed proficiency and experience levels did not correlate with objectively evaluated surgical performances (OSATS). However, low-level visual-spatial ability tests strongly correlated with OSATS while intermediate- and high-level tests did not. No correlation was found between psychomotor ability and clinical performance.

CONCLUSIONS

Self-assessed proficiency is not a good predictor for surgical performance as experts tend to be overconfident. To evaluate and predict surgical performance, visual-spatial ability tests seem to be more appropriate than measuring manual dexterity which failed to correlate with the surgical outcome.

The Effect of Visual-Spatial Ability on the Learning of Robot-Assisted Surgical Skills

BACKGROUND

The aim of this study was to determine the correlation of visual-spatial ability with progression along the learning curve for robotic surgical skills training.

METHODS

A total of 21 novice participants were recruited. All participants completed a training program consisting of 5 training sessions of 30 minutes of virtual reality (VR) simulation and 30 minutes of dry laboratory training. The VR simulation part was the subject of the present study. During VR simulation training, participants performed the basic skill exercises of Camera Targeting 1, Pick and Place, and Peg Board 1 followed by advanced skill exercises of Suture Sponge 1 and Thread the Rings. The visual-spatial ability was assessed using a mental rotation test (MRT). Pearson correlation coefficients were used to assess the relationship between the MRT score and simulator score for the aforementioned 5 tasks. Student t test was used to compare the simulator score between high- and low-MRT score groups.

RESULTS

A median MRT score of 26/40 (range: 13-38) was observed. Approximately 19 participants completed the full curriculum but 2 did not complete "Thread the Rings" during the study period. A significant correlation was observed between the MRT score and simulator score only in "Suture Sponge 1" over the first 3 attempts (first: r = 0.584, p = 0.0054; second: r = 0.443, p = 0.0443; third: r = 0.4458, p = 0.0428). After the third attempt, this significant correlation was lost. Comparison of the score for "Suture Sponge 1" between the high-MRT and low-MRT scoring participants divided by a median MRT score of 26 also showed a significant difference in the score until the third trial.

CONCLUSION

Our observations suggest that the spatial cognitive ability influences the initial learning of robotic suturing skills. Further studies are necessary to verify the usefulness of an individual's spatial ability to tailor the surgical training program.

Visuospatial Aptitude Testing Differentially Predicts Simulated Surgical Skill

OBJECTIVE

To determine whether visuospatial perception (VSP) testing is correlated to simulated or intraoperative surgical performance as rated by the American College of Graduate Medical Education (ACGME) milestones.

DESIGN

(Canadian Task Force classification II-2).

SETTING

Two academic training institutions.

PARTICIPANTS

Forty-one residents, including 19 from Brigham and Women's Hospital and 22 from the Mayo Clinic, from 3 different specialties: obstetrics and gynecology, general surgery, and urology.

INTERVENTION

Participants underwent 3 different tests: visuospatial perception testing (VSP), Fundamentals of Laparoscopic Surgery (FLS) peg transfer, and da Vinci robotic simulation peg transfer. Surgical grading from the ACGME milestones tool was obtained for each participant. Demographic and background information was also collected, including specialty, year of training, previous experience with simulated skills, and surgical interest. Standard statistical analyses were performed using Student's t test, and correlations were determined using adjusted linear regression models.

MEASUREMENTS AND MAIN RESULTS

In univariate analysis, Brigham and Women's Hospital and Mayo Clinic training programs differed in times and overall scores for both the FLS peg transfer and da Vinci robotic simulation peg transfer tests (p < .05 for all). In addition, type of residency training affected time and overall score on the robotic peg transfer test. Familiarity with tasks correlated with higher score and faster task completion (p = .05 for all except VSP score). There were no differences in VSP scores by program, specialty, or year of training. In adjusted linear regression modeling, VSP testing was correlated only to robotic peg transfer skills (average time, p = .006; overall score, p = .001). Milestones did not correlate to either VSP or surgical simulation testing.

CONCLUSION

VSP score was correlated with robotic simulation skills, but not with FLS skills or ACGME milestones. This suggests that the ability of VSP score to predict competence differs between tasks. Therefore, further investigation of aptitude testing is needed, especially before its integration as an entry examination into a surgical subspecialty.

Physical activity and frailty as indicators of cardiorespiratory reserve and predictors of surgical prognosis: General and digestive surgery population characterization

INTRODUCTION

Frailty and low physical activity and cardiorespiratory reserve are related to higher perioperative morbimortality. The crucial step in improving the prognosis is to implement specific measures to optimize these aspects. It is critical to know the magnitude of the problem in order to implement preoperative optimization programmes.

OBJECTIVE

To characterize surgical population in a university hospital.

METHODS

All patients undergoing preoperative evaluation for abdominal surgery with admission were prospectively included during a 3-month period. Level of physical activity, functional capacity, frailty and emotional state were assessed using score tests. Additionally, physical condition was evaluated using 5 Times Sit-to-Stand Test. Demographic, clinical and surgical data were collected.

RESULTS

One hundred and forty patients were included (60±15yr-old, 56% male, 25% ASA III or IV). Forty-nine percent of patients were proposed for oncologic surgery and 13% of which had received neoadjuvant treatment. Seventy percent of patients presented a low functional capacity and were sedentary. Eighteen percent of patients were considered frail and more than 50% completed the 5 Times Sit-to-Stand Test at a higher time than the reference values adjusted to age and sex. Advanced age, ASA III/IV, sedentarism, frailty and a high level of anxiety and depression were related to a lower functional capacity.

CONCLUSIONS

The surgical population of our area has a low functional reserve and a high index of sedentary lifestyle and frailty, predictors of postoperative morbidity. It is mandatory to implement preoperative measures to identify population at risk and prehabilitation programmes, considered highly promising preventive interventions towards improving surgical outcome.

Graduating otolaryngology resident preparedness for fellowship as assessed by fellowship faculty

OBJECTIVES/HYPOTHESIS

The purpose of this study was to evaluate fellowship program directors' perceptions of incoming clinical fellows' preparedness for subspecialty training and to thereby identify strengths and shortcomings in otolaryngology training programs' ability to prepare residents for fellowship.

STUDY DESIGN

Validated e-mail survey.

METHODS

Two hundred eleven otolaryngology subspecialty fellowship program directors and faculty directly involved with training fellows were contacted. A validated survey by the American College of Surgeons was modified and distributed to otolaryngology fellowship faculty in six otolaryngology subspecialties. The 59-item survey employed a five-response Likert scale tailored to each subspecialty. Responses were collected between November 2016 and January 2017.

RESULTS

One hundred ten otolaryngology faculty responded to the survey (52%). Respondents had worked with fellows for a mean of 12 years (standard deviation = 8). Respondents felt fellows were competent in the areas of professionalism, clinical evaluation, and management. Pediatric faculty were more likely to disagree about fellows' independence in the operating room (P = .004) and during call (P = .002) compared to other specialties. Laryngology and facial plastic and reconstructive surgery faculty felt more neutral about anatomy recognition (P = .008), tissue manipulation (P = .002), and use of energy sources (e.g., cautery, lasers) (P < .001). Fellows in all subspecialties were felt to be least prepared in research and academic interest.

CONCLUSIONS

Faculty involved in fellowship training feel that fellows are well-prepared overall upon entering fellowship. Residency programs may benefit from providing more experience with facial plastic reconstructive surgery, laryngology, and pediatrics. Regardless of specialty, residents could benefit from increased training in research design, data analysis, and basic statistics.

LEVEL OF EVIDENCE

NA Laryngoscope, E280-E286, 2018.

Getting to the Root of Fine Motor Skill Performance in Dentistry: Brain Activity During Dental Tasks in a Virtual Reality Haptic Simulation

Background

There is little evidence considering the relationship between movement-specific reinvestment (a dimension of personality which refers to the propensity for individuals to consciously monitor and control their movements) and working memory during motor skill performance. Functional near-infrared spectroscopy (fNIRS) measuring oxyhemoglobin demands in the frontal cortex during performance of virtual reality (VR) psychomotor tasks can be used to examine this research gap.

Objective

The aim of this study was to determine the potential relationship between the propensity to reinvest and blood flow to the dorsolateral prefrontal cortices of the brain. A secondary aim was to determine the propensity to reinvest and performance during 2 dental tasks carried out using haptic VR simulators.

Methods

We used fNIRS to assess oxygen demands in 24 undergraduate dental students during 2 dental tasks (clinical, nonclinical) on a VR haptic simulator. We used the Movement-Specific Reinvestment Scale questionnaire to assess the students’ propensity to reinvest.

Results

Students with a high propensity for movement-specific reinvestment displayed significantly greater oxyhemoglobin demands in an area associated with working memory during the nonclinical task (Spearman correlation, r_s=.49, P=.03).

Conclusions

This small-scale study suggests that neurophysiological differences are evident between high and low reinvesters during a dental VR task in terms of oxyhemoglobin demands in an area associated with working memory.

Evaluation of learning curves for ovariohysterectomy of dogs and cats and castration of dogs

OBJECTIVE To define learning curves for fourth-year veterinary students performing ovariohysterectomy procedures in dogs and cats and castration in dogs. DESIGN Retrospective study. SAMPLE 3,196 ovariohysterectomies or castrations performed in dogs and cats by 88 veterinary students during a spay-neuter surgery and animal shelter rotation (n = 3,056) or by 1 experienced general practitioner (n = 140). PROCEDURES Data collected from medical records included patient signalment, type and duration of procedure, and sequence (by date and time) of the procedure within a list of procedures of the same type generated for each student. For each procedure type, geometric mean surgery time and 95% confidence intervals were determined for each number of surgeries completed by ≥ 10 students. Median surgery times for the same procedure types were determined for the experienced practitioner. The learning curve for each procedure was modeled with nonlinear (3-factor exponential equation with a nonzero asymptote) and linear regression. For each procedure, the asymptote (optimal surgery time) for students was compared with the experienced practitioner's median surgery time. RESULTS 2,945 surgeries (mean, 33/student) performed by ≥ 10 students were analyzed. Surgery time decreased in a nonlinear manner as student experience increased for castration of adult or pediatric dogs and ovariohysterectomy of pediatric dogs and adult or pediatric cats. Surgery time decreased in a linear manner as experience increased for ovariohysterectomy of adult dogs. CONCLUSIONS AND CLINICAL RELEVANCE To the authors' knowledge, this was the first study to map surgery times for common surgical procedures consecutively performed by veterinary students. Results clearly indicated the value of repetition to improve surgical skills (as measured by surgery time) during a 3-week period.

Visuospatial function predicts one-week motor skill retention in cognitively intact older adults

Motor learning declines with aging, such that older adults retain less motor skill after practice compared to younger adults. However, it remains unclear if these motor learning declines are related to normal cognitive changes associated with aging. The purpose of this study was to examine which cognitive domains would best predict the amount of retention on a motor task one week after training in cognitively intact older adults. Twenty-one adults ages 65-84 years old were assessed with Repeatable Battery for the Assessment of Neuropsychological Status, which assesses five cognitive domains (immediate and delayed memory, visuospatial/constructional, language, and attention). Participants also completed one training session of a functional upper extremity task, and were re-tested one week later. Stepwise regression indicated that the visuospatial domain was the only significant predictor of how much skill participants retained over one week, with a visual perception subtest explaining the most variance. Results from this study support previous work reporting that older adults' capacity for motor learning can be probed with visuospatial tests. These tests may capture the structural or functional health of neural networks critical for skill learning within the aging brain, and provide valuable clinical insight about an individual's unique rehabilitation potential.

Early Performance on an Eye Surgery Simulator Predicts Subsequent Resident Surgical Performance

OBJECTIVE

To examine early performance on an eye surgery simulator and its relationship to subsequent live surgical performance in a single large residency program.

DESIGN

Retrospective study.

SETTING

Massachusetts Eye and Ear, Harvard Medical School, Department of Ophthalmology.

METHODS

In a retrospective study, we compared performance of 30 first-year ophthalmology residents on an eye surgery simulator to their surgical skills as third-year residents. Variables collected from the eye surgery simulator included scores on the following modules of the simulator (Eyesi, VRmagic, Mannheim, Germany): antitremor training level 1, bimanual training level 1, capsulorhexis level 1 (configured), forceps training level 1, and navigation training level 1. Subsequent surgical performance was assessed using the total number of phacoemulsification cataract surgery cases for each resident, as well as the number performed as surgeon during residency and scores on global rating assessment of skills in intraocular surgery (GRASIS) scales during the third year of residency. Spearman correlation coefficients were calculated between each of the simulator performance and subsequent surgical performance variables. We also compared variables in a small group of residents who needed extra help in learning cataract surgery to the other residents in the study.

MAIN OUTCOME MEASURES

Relationships between Eyesi scores early in residency and surgical performance measures in the final year of residency.

RESULTS

A total of 30 residents had Eyesi data from their first year of residency and had already graduated so that all subsequent surgical performance data were available. There was a significant correlation between capsulorhexis task score on the simulator and total surgeries (r = 0.745, p = 0.008). There was a significant correlation between antitremor training level 1 (r = 0.554, p = 0.040), and forceps training level 1 (r = 0.622, p = 0.023) with primary surgery numbers. There was a significant correlation between forceps training level 1 (r = 0.811, p = 0.002), and navigation training level 1 (r = 0.692, p = 0.013) with total GRASIS score. There was a significant inverse correlation between total GRASIS score and residents in need of extra help (r = -0.358, p = 0.003).

CONCLUSION

Module scores on an eye surgery simulator early in residency may predict a resident׳s future performance in the operating room. These scores may allow early identification of residents in need of supplemental training in cataract surgery.

Assessing the effects of manual dexterity and playing computer games on catheter-wire manipulation for inexperienced operators

AIM

To investigate the effect of playing computer games and manual dexterity on catheter-wire manipulation in a mechanical aortic model.

MATERIAL AND METHODS

Medical student volunteers filled in a preprocedure questionnaire assessing their exposure to computer games. Their manual dexterity was measured using a smartphone game. They were then shown a video clip demonstrating renal artery cannulation and were asked to reproduce this. All attempts were timed. Two-tailed Student's t-test was used to compare continuous data, while Fisher's exact test was used for categorical data.

RESULTS

Fifty students aged 18-22 years took part in the study. Forty-six completed the task at an average of 168 seconds (range 103-301 seconds). There was no significant difference in the dexterity score or time to cannulate the renal artery between male and female students. Students who played computer games for >10 hours per week had better dexterity scores than those who did not play computer games: 9.1 versus 10.2 seconds (p=0.0237). Four of 19 students who did not play computer games failed to complete the task, while all of those who played computer games regularly completed the task (p=0.0168).

CONCLUSION

Playing computer games is associated with better manual dexterity and ability to complete a basic interventional radiology task for novices.