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

1. Redefining Surgical Training
A Proposed Model and Tool
Vaikunthan Rajaratnam
Senior Consultant
Hand & Reconstructive Microsurgery Service
Department of Orthopaedic Surgery

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. 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. 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. 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. THEORETICAL FRAMEWORK
NEW MODEL

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. Conceptual Framework

9. New model for the acquisition of expert motor skills

10. Execution of the model to create a training programme for a surgical skill

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. 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

15. Expert Video modelling & The training Module
https://tinyurl.com/MICROSUTURE

16. 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.

17. 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.

18. 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

19. 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).

20. 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

21. 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.

22. 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)

23. 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)

24. 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