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Redefining surgical training a new model and tool

A new model for surgical training incorporating motor imagery mental practice with deliberate practise based on Design and Development research.

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Redefining surgical training a new model and tool

  1. 1. Redefining Surgical Training A Proposed Model and Tool Vaikunthan Rajaratnam Senior Consultant Hand & Reconstructive Microsurgery Service Department of Orthopaedic Surgery
  2. 2. A Design & Development Research A thesis submitted in fulfilment of the requirements for the degree of Doctor of Philosophy (Education) Cluster of Education and Social Sciences Open University Malaysia 2020 GRANT : HOMER FY18/A02
  3. 3. Practice Implications • Mental skill training for simulation (motor imagery and mental practice )- incorporated into surgical residency • Faculty trained in IDT/DDR/instructional videos /mental scripts development Every index procedure need: 1. Expert instructional video 2. A mental script incorporating kinaesthetic cues 3. Narration of the mental script incorporated into the video 4. Innovate, design, and develop simple practice models for deliberate practice. Deliberate practice in surgical training is a highly structured activity explicitly directed at improvement of performance in a surgical procedure. Specific motor tasks are invented to overcome weaknesses and performance is carefully monitored to provide cues for ways to achieve further improvement. Repeated practice in motivated individuals receiving regular reinforcement and feedback IDT – Instructional Design and Technology - science of instruction, and provides a systematic and an evidence-based methodology for the creation of instructional materials for effective teaching DDR – Design and Development Research
  4. 4. Background and Setting • Traditional apprentice model - mentorship and one-to-one supervision • Restriction of working hours and protected time - reduce training hours • Challenge - competent surgeons with shorter training time • Reduced operating room surgical skill acquisition • Emphasis on • quality-of-care, • non-technical skills in surgery (NOTS) • workplace efficiency and • safety perspective Trainees do not feel competent or ready to operate independently at the end of their training. Competency not equal to excellence Lack of time and opportunities to practice - focuses on competence rather than excellence. Annabelle L. Fonseca, Vikram Reddy, Walter E. Longo, Richard J. Gusberg, Graduating general surgery resident operative confidence: perspective from a national survey, Journal of Surgical Research, Volume 190, Issue 2,2014,Pages 419-428,ISSN 0022-4804, https://doi.org/10.1016/j.jss.2014.05.014. Daniels AH, DiGiovanni CW. Is Subspecialty Fellowship Training Emerging as a Necessary Component of Contemporary Orthopaedic Surgery Education? J Grad Med Educ. 2014;6(2):218-221. doi:10.4300/JGME-D-14-00120.1
  5. 5. Challenges to Surgical Training • competency @ 15,000 and 20,000 hours = 12.5 years ( @ 40 weeks/year and 5-day week at 8 hours a day) (Purcell Jackson & Tarpley, 2009). • reduced worked based training/patient exposure (Reznick & MacRae 2006). • Fits and Posner, Bandura, Ericsson and Jeannerod • Competency vs Expert - Norm vs criterion referenced • A novel and proven model in training that produces • expert surgeons effectively and efficiently. “ten years’ duration of effortful activity which can only be sustained for a limited period daily to allow for recovery from a daily or weekly routine” Kavic, M. S. (2012). Teaching and Learning of Surgery. JSLS : Journal of the Society of Laparoendoscopic Surgeons, 16(3), 341–344) Kneebone, R., & Aggarwal, R. (2009). Surgical training using simulation. BMJ, 338, b1001 Dreyfus, S. E. (2004). The Five-Stage Model of Adult Skill Acquisition. Bulletin of Science, Technology & Society, 24(3), 177–181. .
  6. 6. THEORETICAL FRAMEWORK NEW MODEL
  7. 7. Mental Practice In Surgical Training: A Narrative Synthesis Review Prisma Flow Diagram Outlining Search Strategy • Effective skill acquisition/retention. • Lack of methodological rigour • Development of the mental script • Mental Script important in MP
  8. 8. Conceptual Framework
  9. 9. New model for the acquisition of expert motor skills
  10. 10. Execution of the model to create a training programme for a surgical skill
  11. 11. Results of HTA analysis Element Work object Methods Tools Materials Ergonomics Conditions Align edges Incision on the rubber glove model Manipulate method: Support edge Forceps: jewellers Stabilise with ulnar border support Adequate Tension Drive needle Needle Support method: counter pressure Forceps: jewellers, needle, needle driver Suture size: 8/0 needle and suture Rotation of needle holder Precision point of entry and exit High magnification Follow arc of needle Withdraw Suture Suture/Needle Withdraw method: continuous Forceps: jewellers, needle driver Suture size: 8/0 Low magnification Visualise needle/suture Needle remains in field of view Tie suture Suture Tie: three throws Square knot Forceps: jewellers, needle driver, Suture size: 8/0 Visualise tension in suture Square knots & Position know Cut suture Suture Forceps jewellers, Micro scissors, Cut with tip scissors Stitch length Ericsson, K. A. (2006). Protocol analysis and expert thought: Concurrent verbalizations of thinking during experts’ performance on representative tasks. The Cambridge Handbook of Expertise and Expert Performance, 223–242.
  12. 12. Goals and start and end criteria for subtasks, and elements Subtask Join cut edge of glove To connect the rubber glove together using sutures Start: needle driver is used End: suture from the last stitch is cut Inspect repair To ensure repair of rubber glove with equidistant and secured knot and free ends at right angles to incision Start: suture from last stitch is cut End: instrument is put down Elements Align To move edges of rubber glove in alignment Start: tool moves towards glove edge to grasp and move End: rubber edge is released from tool after move Drive needle To puncture rubber edge with needle Start: needle moves towards rubber edge to pierce End: needle fully passes the rubber edge walls or is removed before passing the rubber edge wall (failed attempt) Withdraw suture To pull suture through rubber edge Start: suture is pulled through the rubber edge End: suture thread is no longer being pulled Tie suture To fasten suture thread with knots Start suture wrapped around needle driver End knots are tightened Cut suture To severe excess suture thread from knot Start: scissors enter field of view to cut End: suture ends of the knots are cut End: instrument is put down
  13. 13. Expert Video modelling & The training Module https://tinyurl.com/MICROSUTURE
  14. 14. Content and Face Validity of mental script by the expert review panel Question Response How well could you instruct another surgeon to perform the procedure exactly how you do it? (Likert Score 1-7 1 – poor, 7 very well) Average 6 (6.6) What is missing in the detailed script if any? Nil. What is unnecessary? All was needed. How would you organise the steps and scheme arranged in the script? The sequencing satisfactory. How else can the script be improved? Nil.
  15. 15. Script validation • 20 participants (10 novice and 10 experienced) • A pre- and posttest repeated measures design used, with each participant serving as his own control. • Mental Imagery Questionnaire (MIQ) used as key outcome measure • Capture the quality and richness of mental imagery experiences before and after MIMP training. • Each item scored on a Likert scale of 1–7 with clearly defined anchors. • Each participant completed MIQ before and after MP training • MIQ was a manipulation check on participants’ imagery experiences.
  16. 16. Evaluation of the mental script Question Average Score Range The activities involved in the study that I was involved in have been undertaken methodically. 6.0 4-7 The rationale for the undertaken/engaged activities involved in the study was logical. 6.2 6-7 The intended benefits of mental practice as adjunct to skill training as conducted in the study were achieved. 6.4 6-7 Mental practice as adjunct to skill training can have an impact in resident training in Singapore generally. 5.7 5-7 Mental practice as adjunct to skill training is an appropriate and sustainable strategy for resident training in Singapore generally. 5.7 5-7 Mental practice training should be part of basic skill training for all residents in Singapore generally. 5.9 5-7 Cronbach's Alpha 0.81 Split-Half with Spearman-Brown Adjustment 0.83 Mean for Test 35.6 7 Standard Deviation for Test 2.62
  17. 17. Mental Imagery assessed using Mental Imagery Questionnaire (MIQ). Questions Average Max-Min How ready or 'energised’ do you feel to carry out microsurgical suturing? 5.4 7, 3 How confident do you feel to carry out microsurgical suturing? 5.5 7, 4 How well do you think you can perform microsurgical suturing compared to others at your stage? 5.7 7, 4 How helpful is the activity you have just been performing in preparing you to perform microsurgical suturing? 5.8 7, 4 How easily can you ‘see’ yourself performing microsurgical suturing? 5.1 7, 2 How vivid/clear are the images of microsurgical suturing in your mind? 5.0 7, 2 How vivid/clear are the images of microsurgical suturing in your mind? 5.1 7, 2 How easily can you ‘feel’ yourself performing microsurgical suturing? 5.0 7, 2 How easily would you be able to talk someone through the steps of microsurgical suturing? 4.8 7, 2  Cronbach's Alpha  0.93  Split-Half with Spearman-Brown Adjustment  0.97  Mean for Test  47.35  Standard Deviation for Test  8.60 Male: 18 Female: 10 Average age: 38 (27-58).
  18. 18. Slide 1 Title: Introduction Time: 8 seconds Media Notes Screen Text: Media Script: Slide begins with intro background music. Sample mp3 from YouTube royalty free stock music. Static image of amputated thumb and index finger (jpeg). Audio narration begins describing what microsurgery is. Micro suturing the basis MICROSURGERY Microsurgery is the basic competency needed for complex reconstruction in the human body. Media: Image Thumb amputation.jpeg Audio narration.mp3 Music Silence for a film an nannie mp3 from youtube royalty free stock music Video None Interaction: Quiz: Nil None Branching: Advance: Next: Slide 2 Automatic, but video pause possible via pause button on video player. Prev: N/A Expert Instructional Video Storyboard
  19. 19. Control Experiment Average Age 23.9 (22-26) 23.1(21-30) Male 5 7 Female 5 3 Total 10 10 There were 11 participants in the control and 11 in the experimental group. Both groups had 1 drop out, leaving 10 participants in each group.
  20. 20. Control Experiment Average time in minutes 13.0 11.0 Sample Size 10 10 Standard Deviation 6.5 3.2 Median 10.7 9.6 Skewness 1.9 1.4 Outliers 29.1 30 Outlier count 1 0 Mann Whitney U 44 56 Time taken to complete task in minutes Time taken (control vs experimental group) was not statistically significant (p-value equals 0.68)
  21. 21. Control Experiment Average 3.9 4.5 Sample Size 11 10 Standard Deviation 0.4 0.4 Median 3.8 4.6 Skewness 1.1 0.4 Outliers 4.9 0 Outlier count 1 0 Mann Whitney U 96 14 Analysis of the quality of micro suturing (SMART Scores) p-value equals 0.003 Quality of suturing in the experimental group is far superior to that of the control group Stanford Microsurgery and Resident Training (SMaRT) Scale Instrument)
  22. 22. Thank you • Acknowledgements to my supervisor Associate Professor Dr Zahari Hamidon of Open University Malaysia • Appreciation of Dr Hannah Ng and Dr Tong Pei-Yein for their assistance • Views and all ignorance expressed are solely my personal expressions • This research was funded by HOMER Grant of National Healthcare Group of Singapore • Contact me for further information - vaikunthan@gmail.com

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A new model for surgical training incorporating motor imagery mental practice with deliberate practise based on Design and Development research.

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