Surgical Education Research Laboratory — Research
Traditionally, surgical educators have approached skills acquisition via time-based (e.g., a suture clinic may last 1 hour) or repetition-based (e.g., a learner practices a specific skill for 5 trials) teaching methods. In many cases, the time or repetition allotment may not be sufficient to ensure that slower learners have mastered the skill, while at the same time, may be too much practice for faster learners. Neither of these pedagogies ensures that a trainee has truly mastered the skill to establish consistency and short- and long-term retention, which may result in wide variation of skill performance among learners. More recently, there has been a push to implement a proficiency-based training method. At its core, proficiency-based training makes use of the construct of deliberate practice, in which learners engage in repetitive performance, receive rigorous assessment, and receive informative feedback. Trainees practice a skill until achieving a proficiency metric developed by evaluating expert performance. Deliberate practice provides a motivational component for training in ways that simply passing time or performing some arbitrary number of practice repetitions cannot.
Our lab has demonstrated that Proficiency-based training results in trainees who perform uniformly and at a higher level than traditional training methodologies, despite equating total training time for each condition. We continue to develop curricula that incorporate deliberate practice for skills such as suturing and knot-tying, vascular anastomosis, and bowel anastomosis.
Transfer of Flexible Endoscopy Simulation Training to the Clinical Environment
Surgical residents have learned flexible endoscopy techniques by practicing on patients in hospital settings under the strict guidance of experienced surgeons. Simulation is often used to "pre-train" novices on endoscopic skills before practicing on actual patients; nonetheless the optimal method of training remains unknown. Two types of flexible endoscopy simulators currently exist on the market: Virtual reality (VR) and physical model (PM; e.g., manikin-based simulator). VR and PM simulators differ in terms of whether the trainee is manipulating actual 3D objects (PM) or computer-generated 3D objects (VR). Much like video games, VR simulators utilize computer-generated graphics. These differences may have profound effects on the utility of VR and PM training platforms. While PM simulators may more accurately represent the visual stimuli present in the real-world, VR simulators have the advantage of being more convenient and consistent. The purpose of this study was to compare endoscopic VR and PM simulators and their respective roles in transferring skills to the clinical environment. We have found that training on either simulator results in improved performance in the clinical environment, thus providing support for the practice of pre-training novices on simulation equipment and the utility of currently available simulators.
Writing Questions as a Study Method for the ABSITE
The study method employed by most students is the standard 'read-complete practice questions-take a test' approach. A less commonly used learning strategy is one in which students generate questions as study materials. Generating questions contributes to a deeper level of understanding, which has been termed the 'generative effect.' This strategy is rooted in the levels of processing theory of cognition, which posits that the more deeply information is processed the more likely it will be remembered.
At our institution, we have demonstrated that residents who generate practice test questions outperform those who do not generate practice test questions on the annual American Board of Surgery In-Training Exam (ABSITE). Additionally, we have found that performance on these practice tests correlated with actual ABSITE scores and American Board of Surgery Qualifying Exam first-time pass rates. We are currently conducting a randomized, multi-institutional study to further examine the effects of question generation on ABSITE performance.
Optimal Practice Schedules
While break periods during training sessions are desirable, it is unclear what learners should do during these breaks. Some educators recommend that learners abstain from all task-related practice; however, it is possible that switching to an alternate exercise during break periods can also be effective. The construct of proactive interference posits that new learning is disrupted by prior learning. Proactive interference can be 'released' when the nature of the task is changed after several practice trials. While this phenomenon has been studied extensively with cognitive verbal learning, it is unclear whether proactive interference plays a role in learning psychomotor skills. We conducted a study to examine whether the construct of proactive interference could be used to create to create a practice schedule that would optimize a trainee's time. We found that when trainees alternated training on two vastly different exercises (e.g., a laparoscopic exercise and a suturing exercise), their performance was increased. Conversely, when trainees alternated training on two similar laparoscopic exercises, their performance was decreased. Using these data, we can recommend that a trainee's practice time would be best utilized by varying their practice activities.