Effect of instructor feedback on skills retention after laparoscopic simulator training: follow-up of a randomized trial.

BACKGROUND: Instructor feedback reduces the number of repetitions and time to reach proficiency during laparoscopic simulator training. The objective of this study was to examine the effect of instructor feedback on long-term skill retention. METHODS: A 6-month follow-up of a randomized trial. Participants were surgical novices (medical students). All participants (n = 99) initially practiced a laparoscopic salpingectomy on the LapSim virtual reality simulator to proficiency. The intervention group could request instructor feedback, whereas the control group could not. After 6 months, the participants (n = 65) practiced on the simulator until they reached proficiency again. The primary outcomes were the total time and the number of repetitions. RESULTS: Initially, the intervention group used significantly fewer repetitions (29 vs 65, p < 0.0005) and less total training time (162 vs 342 min, p < 0.0005) than the control group to reach the proficiency level. At follow-up, both the groups used an equal number of repetitions (21 vs 20, p = 0.72) and time (83 vs 73 min, p = 0.37) to reach the same proficiency level. CONCLUSIONS: Instructor feedback during proficiency-based laparoscopic simulator training does not affect the long-term retention of skills.

A structured four-step curriculum in basic laparoscopy: development and validation.

OBJECTIVE: The objective of this study was to develop a four-step curriculum in basic laparoscopy consisting of validated modules integrating a cognitive component, a practical component and a procedural component. DESIGN: A four-step curriculum was developed. The methodology was different for each step. Step 1: A 1-day course in basic laparoscopy developed on the background of a regional needs analysis. Step 2: A multiple-choice test, developed and validated through interviews with experts in laparoscopy and subsequently through a Delphi audit involving regional chief physicians. Step 3: A procedural training task (a salpingectomy) on a validated virtual reality simulator. Step 4: An operation on a patient (a salpingectomy) with following formative assessment based on a validated assessment scale. SETTING: University hospital, Copenhagen, Denmark. POPULATION: Fifty-two first-year residents in obstetrics and gynecology from 2009 to 2011. METHOD: Observational cohort study. MAIN OUTCOME MEASURE: Completion rate. RESULTS: All participants completed step 1 and improved post-course test scores compared with pre-course test scores, p = 0.001. Step 2 was completed by 75% (37/52); all improved test scores after 6 months, p = 0.001. Step 3 was completed by 75%. Participants used 238 min (range 75-599) and 38 repetitions (range 8-99) to reach proficiency level on a virtual reality simulator. Step 4 was completed by 55%. There was no correlation between test scores and simulator training time. Protected training time was correlated with increasing completion rate. CONCLUSION: A four-step curriculum in basic laparoscopy is applicable in residency training. Protected training time correlated with increasing completion rate.

Instructor feedback versus no instructor feedback on performance in a laparoscopic virtual reality simulator: a randomized trial.

OBJECTIVE: To investigate the impact of instructor feedback versus no instructor feedback when training a complex operational task on a laparoscopic virtual reality simulator. BACKGROUND: : Simulators are now widely accepted as a training tool, but there is insufficient knowledge about how much feedback is necessary, which is useful for sustainable implementation. METHODS: A randomized trial complying with CONSORT Statement. All participants had to reach a predefined proficiency level for a complex operational task on a virtual reality simulator. The intervention group received standardized instructor feedback a maximum of 3 times. The control group did not receive instructor feedback. Participants were senior medical students without prior laparoscopic experience (n = 99). Outcome measures were time, repetitions, and performance score to reach a predefined proficiency level. Furthermore, influence of sex and perception of own surgical skills were examined. RESULTS: Time (in minutes) and repetitions were reduced in the intervention group (162 vs 342 minutes; P < 0.005) and (29 vs 65 repetitions; P < 0.005). The control group achieved a higher performance score than the intervention group (57% vs 49%; P = 0.004). Men used less time (in minutes) than women (P = 0.037), but no sex difference was observed for repetitions (P = 0.20). Participants in the intervention group had higher self-perception regarding surgical skills after the trial (P = 0.011). CONCLUSIONS: Instructor feedback increases the efficiency when training a complex operational task on a virtual reality simulator; time and repetitions used to achieve a predefined proficiency level were significantly reduced in the group that received instructor feedback compared with the control group. TRIAL REGISTRATION NUMBER: NCT01497782.

Development and validation of a theoretical test in basic laparoscopy.

BACKGROUND: Testing of knowledge is an important component in a successful skills curriculum. Nonetheless, structured testing of basic procedure-relevant knowledge in the surgical domains is not ordinary practice. A regional need assessment showed insufficient knowledge regarding basic laparoscopy for first-year residents in obstetrics and gynecology. This study therefore aimed to develop and validate a framework for a theoretical knowledge test, a multiple-choice test, in basic theory related to laparoscopy. METHODS: The content of the multiple-choice test was determined by conducting informal conversational interviews with experts in laparoscopy. The subsequent relevance of the test questions was evaluated using the Delphi method involving regional chief physicians. Construct validity was tested by comparing test results from three groups with expected different clinical competence and knowledge levels: senior medical students, first-year residents, and chief physicians. RESULTS: The four conversational interviews resulted in the development of 47 test questions, which were narrowed down to 37 test questions after two Delphi rounds involving 12 chief physicians. Significant differences were found between the test scores from the senior medical students (n = 14) and the first-year residents (n = 52) (median test scores, 18 vs. 24, respectively; p = 0.001), and between the first-year residents and the chief physicians (n = 12) (median test scores, 24 vs. 33, respectively; p = 0.001). Internal consistency (Cronbach's alpha) was 0.82. There was no evidence of differential item functioning between the three groups tested. CONCLUSIONS: A newly developed knowledge test in basic laparoscopy proved to have content and construct validity. The formula for the development and validation of a theoretical test could potentially be used for any topics that require structured testing of knowledge.

Vacuum extraction: development and test of a procedure-specific rating scale.

OBJECTIVES: To develop and validate an Objective Structured Assessment of Technical Skills (OSATS) scale for vacuum extraction. DESIGN: Two-part study design: Primarily, development of a procedure-specific checklist for vacuum extraction. Hereafter, validation of the developed OSATS scale for vacuum extraction in a prospective observational study. SETTING: Rigshospitalet, University Hospital of Copenhagen. POPULATION: For development, an obstetric expert from each labor ward in Denmark (28 departments) was invited to participate. For validation, nine first-year residents and 10 chief physicians with daily work in the obstetric field were tested. METHODS: The Delphi method was used for development of the scale. In a simulated vacuum extraction scenario, first-year residents and obstetric chief physicians were rated using the developed OSATS scale for vacuum extraction to test construct validity of the scale. MAIN OUTCOME MEASURES: Consensus for the content of the scale. To test the scale of Cronbach's alpha, interclass correlation and differential item function was calculated in the prospective study. RESULTS: 89% completed the first and 61% completed the second Delphi round. Hereafter, consensus was obtained. There was a significant difference between residents' and experts' performance for total score and for the score of the separate parts of the scale. Cronbach's alpha for total score and for the separate parts of the scale was 0.91-0.95 and interclass correlation 0.84-0.9. CONCLUSIONS: The OSATS scale for vacuum extraction is a reliable test for differentiating between competence levels in a simulated setting.

Instructor feedback versus no instructor feedback on performance in a laparoscopic virtual reality simulator: a randomized educational trial.

BACKGROUND: Several studies have found a positive effect on the learning curve as well as the improvement of basic psychomotor skills in the operating room after virtual reality training. Despite this, the majority of surgical and gynecological departments encounter hurdles when implementing this form of training. This is mainly due to lack of knowledge concerning the time and human resources needed to train novice surgeons to an adequate level. The purpose of this trial is to investigate the impact of instructor feedback regarding time, repetitions and self-perception when training complex operational tasks on a virtual reality simulator. METHODS/DESIGN: The study population consists of medical students on their 4th to 6th year without prior laparoscopic experience. The study is conducted in a skills laboratory at a centralized university hospital. Based on a sample size estimation 98 participants will be randomized to an intervention group or a control group. Both groups have to achieve a predefined proficiency level when conducting a laparoscopic salpingectomy using a surgical virtual reality simulator. The intervention group receives standardized instructor feedback of 10 to 12 min a maximum of three times. The control group receives no instructor feedback. Both groups receive the automated feedback generated by the virtual reality simulator. The study follows the CONSORT Statement for randomized trials. Main outcome measures are time and repetitions to reach the predefined proficiency level on the simulator. We include focus on potential sex differences, computer gaming experience and self-perception. DISCUSSION: The findings will contribute to a better understanding of optimal training methods in surgical education. TRIAL REGISTRATION: NCT01497782.

Can both residents and chief physicians assess surgical skills?

BACKGROUND: It is known that structured assessment of an operation can provide trainees with useful knowledge and potentially shorten their learning curve. However, methods for objective assessment have not been widely adopted into the clinical setting. This might be because of a lack of expertise using an assessment tool. The aim of this present study was to investigate if a validated laparoscopic procedure-specific assessment tool could be used by doctors with different levels of experience. METHODS: The study was conducted as an observer-blinded, prospective cohort study. Three video recordings of a right-side laparoscopic salpingectomy were distributed to ten chief physicians, eight residents (fourth year trainees), and two expert assessors (all in gynecology) in order to be assessed using a validated procedure-specific assessment tool. The three salpingectomies were selected because they easily showed the different operational levels: novice, intermediate, and expert. The two expert assessors, i.e., our gold standard, were familiar with the OSA-LS assessment scale, but the chief physicians and the residents were not. All participants were blinded to the fact that surgeons with different experience had performed the salpingectomies. RESULTS: No significant differences between the residents and chief physicians were observed in any of the three assessed operations: novice, p = 0.63; intermediate, p = 0.93; and expert, p = 0.93. The chief physicians and residents matched our gold standard in assessing the intermediate operation (p = 0.177), but not the novice operation (p = 0.005) or the expert operation (p = 0.001). CONCLUSIONS: Residents and chief physicians generated similar performance scores when assessing operations using a laparoscopic procedure-specific assessment scale, and they could distinguish performance levels between the surgeons. They matched the assessment score of our expert on the intermediate operation. We conclude that a procedure-specific assessment scale can be used by both residents and chief physicians when giving formative feedback.

Clinical skills training in obstetrics - a descriptive survey of current practice in Denmark.

The Danish National Board of Health has recommended that labor wards establish regular obstetric emergency skills training programs. The aim of this study was to describe current practice in Denmark. A questionnaire was sent to all obstetric departments in Denmark in 2008. All responded. Simulation-based training was conducted in 26/28 obstetrical departments. Settings for the training programs were mainly local. Training was provided for shoulder dystocia, postpartum bleeding and basic neonatal resuscitation in almost all the departments, but was not organized in a uniform way. Neither the program itself nor the participants' performance was evaluated in a structured or validated way. Obstetric emergency skills training is being actively conducted in the majority of the Danish labor wards. However, it still remains a challenge to ensure the uniform organization and evaluation of the current training programs. Development of validated national or international standards for an obstetric training program should be a future aim.

Retention of laparoscopic procedural skills acquired on a virtual-reality surgical trainer.

BACKGROUND: Virtual-reality (VR) simulator training has been shown to improve surgical performance in laparoscopic procedures in the operating room. We have, in a randomised controlled trial, demonstrated transferability to real operations. The validity of the LapSim virtual-reality simulator as an assessment tool has been demonstrated in several reports. However, an unanswered question regarding simulator training is the durability, or retention, of skills acquired during simulator training. The aim of the present study is to assess the retention of skills acquired using the LapSim VR simulator, 6 and 18 months after an initial training course. METHODS AND MATERIALS: The investigation was designed as a 6- and 18-month follow-up on a cohort of participants who earlier participated in a skills training programme on the LapSim VR. The follow-up cohort consisted of trainees and senior consultants allocated to two groups: (1) novices (experience < 5 procedures, n = 9) and (2) experts (experience > 200 procedures during the past 3 years, n = 10). Each participant performed ten sessions. Assessment of skills was based on time, economy of movement and the error parameter "bleeding". The novice group were re-tested after 6 and 18 months, whereas the expert group were only retested once, after 6 months. None of the novices performed laparoscopic surgery in the follow-up period. The experts continued their daily work with laparoscopic surgery. RESULTS AND CONCLUSIONS: Novices showed retention of skills after 6 months. After 18 months, novices' laparoscopic skills had returned to the pre-training level. This indicates that laparoscopic skills seemed to deteriorate in the period between 6 and 18 months without training. Experts showed consistent performance over time. This information can be included when planning training curricula in minimal invasive surgery.

[Neonatal consequences of vacuum-assisted delivery]. / Neonatale konsekvenser efter vakuumekstraktion.

About 5000 babies annually, or 1/12 of all births, are the result of vacuum-assisted delivery in Denmark. Towards the end of the 1990'ies, the US FDA published a national warning concerning increasing complications and mortality after vacuum-assisted delivery, and other countries followed. One explanation is that training is no longer given the needed focus. Recent introduction of new requirements on Danish specialist training and the fact that vacuum-assisted delivery is an important procedure in obstetrics provides the basis for this article which systematically reviews the neonate consequences for the termed baby following vacuum-assisted delivery.

[Bacterial pyomyositis in a 12-year-old girl without fever]. / Pyomyositis uden feber hos 12-årig pige.

Bacterial pyomyositis is generally found in tropical countries. This case report presents pyomyositis in a 12-year-old girl who was admitted without fever to the paediatric department. The only symptom was pain in the left hip. Staphylococcus aureus was cultured from the blood on day 4. Magnetic resonance imaging (MRI) revealed infection in the left m. ileopsoas. Previous ultrasound, computerised tomography, x-ray and bone-scintigraphy were normal. After 11 days of intravenous antibiotic therapy and clinical remission, secondary bone affection was detected by a new MRI. Long-term antibiotic treatment is required in such cases because of the risk of secondary bone affection. This patient was treated for 11 days with intravenous antibiotic therapy and for the subsequent three months with tablets.

[Twin gestation in a single horn of a bicornuate uterus]. / Gemelligraviditet i et horn af bicorn uterus.

Bicornuate uterus is associated with early foetal loss and extremely preterm delivery. A patient with dichorionic twins in a single horn of a bicornuate uterus was admitted in week 24 + 6 with preterm labour. Long-term treatment with a combination of tocolytics, atosiban and diclofenac inhibited labour until week 26 + 3 where both babies were born. Both babies are still alive. Longterm tocolytic treatment may be successful in specific cases, but there is no evidence for a general use of long-term tocolysis in preterm labour.