Laparoscopic skills training of surgical residents: a comparison of two proficiency-based independent approaches

Introduction

To maximize the benefit of time in the operating room, laparoscopic skills training outside the operating room has become the gold standard for educating surgical residents. It is well documented that residents benefit from this form of training and can lead to improved operative performance. In fact, training is an integral and essential component of a trainee’s job. However, there is no consensus regarding the optimal method or learning environment for teaching laparoscopic skills in order to maximize trainees’ education while maintaining an equitable and sustainable work-life balance. Recently, several studies have suggested that mandatory, proctored, proficiency-based goal-directed training is the best method for training.^[1-3] However, this approach is not without disadvantages. For example, this type of training requires a significant amount of practice time per trainee in a workplace environment where shortened work hours are being mandated.^[4-6] This laborious process of proctored, on-site training programs is time consuming and significantly impinges on the residents’ pre-existing didactic requirements, patient care responsibilities, and overall operative experience.^[7-9] In fact, duty-hour limitations have led to a significant re-evaluation of the traditional surgical education paradigm, with emphasis on increased efficiency of educational efforts. Accordingly, a disadvantage of these on-site training facilities is that they are often not readily accessible to the resident. Unless dedicated training time is made mandatory for residents, few residents independently take advantage of these costly facilities during their already busy week.^[10] If educators seek to facilitate laparoscopic learning, they should provide the trainees with the opportunities for extracurricular practice. Finally, there is also an economical aspect to consider as the use of surgical educators can be costly, time consuming, and difficult to achieve for smaller institutions.

An independent learning approach where trainees are given self-study resources (i.e. video/didactic tutorials) as well as unlimited access to the on-site training facility and encouraged to practice at their own pace is one alternative strategy.^[6] The advantages of such self-directed training method are reduced instructor time and simplified scheduling. Moreover, several studies have shown that learning can be facilitated if learners are able to self-direct their own training experience.^[11-13] However, in the United States, the training time on-site within the workplace environment is counted toward the already restricted resident duty hours. A hybrid approach that employs an independent learning approach using at-home, portable laparoscopic trainer outside the time constraints of the hospital environment, has not been fully investigated. As medical educators and mentors, the best methods of teaching laparoscopic skills and the most efficacious learning environment where trainees feel motivated and allocate a high priority to practice needs to be the standard for resident education. Clearly, laparoscopic training should not be considered after exhaustion from work-related activities. In fact, there is evidence to suggest that motor training during periods of exhaustion can deteriorate and may create an environment that promotes poor technique.^[14] This is precisely why home training may be beneficial. It would be portable, accessible, convenient, flexible and inexpensive once initiated. Indeed, trainees could practice the laparoscopic skills at their preferred time, for example when are well-rested and away from work stressors, and not at a time that fits others’ schedules. Therefore, we hypothesized that an at-home independent, proficiency-based laparoscopy training method using a low-cost device will improve the laparoscopic skills of novice trainees and that this training method-environment combination would be equivalent to traditional, independent hospital-based, laparoscopic training. The primary endpoint of the study was to compare trainee performance before and after at home practice training.

Methods

Results

Discussion

Laparoscopic training is an integral and essential component of a surgical trainee’s job. However, within a changing surgical environment alternative methods for laparoscopic training must be sought for training which incorporate opportunities to practice. In this un-blinded, randomized study, two proficiency-based independent approaches were employed to teach laparoscopic skills to beginners, with one tactic employing standard on-site physical box trainers at the workplace and the other relying on a similar device used in the trainee’s home, outside the stress of the work environment. Both methods allowed trainees to practice their laparoscopic skills at their own pace. In the beginning, pre-training skills were homogenous with minimal baseline experience in the two groups. In the end, novice trainees showed improvement in their laparoscopic skills using our self-directed, proficiency-based home training program. However, at most, it was comparable to our on-site program in terms of feasibility and rates of participation. Several studies have shown that learning can be facilitated if learners are able to self-direct their own training experience^[11-13] while other studies have shown that low cost, portable training device can improve laparoscopic skills.^[18,19] However, the ability of a self-directed laparoscopic training experience using low-cost portable training devices to improve laparoscopic procedural skills with the home environment has not been investigated. We used a proficiency-based, self-directed training approach both within the home and workplace environment. Both groups were instructed to practice at their discretion to achieve expert proficiency on each task with no ramifications if they did not succeed. We believed this would be successful based on the observation that surgical trainees and those interested in surgery are highly motivated to learn the required skills and invest the necessary time. In addition, there seems to be natural selection within the surgical population itself. Trainee motivation is essential for learning because it promotes deliberate practice and persistent efforts to improve objective performance.^[20] Without motivated learners, any educational efforts will have limited achievements and the skills laboratories will be attended infrequently. At the end of the day, our method was met with mixed results. First of all, the self-directed training approach did enhance the novices’ laparoscopic skills in both groups. But, we also observed that few subjects attended the on-site skill laboratory during their independent training period. More surprising, was the observation that when subjects were given the training device to use at home, they still did not find the time to frequently train independently. Interestingly, on average, the home trainees found only about 1-2 h to practice within a three-month period of time and 44% never practiced once during this period. These results demonstrated that one of the most important factors in getting trainees to practice and hone their laparoscopic skills was providing them with enough free time during their work week not changing their learning environment. This ultimately disproved our original hypothesis that moving practice opportunities out of the busy and stressful clinical environment to “free time” would be beneficial. Thus the hard, but unavoidable truth appears to be that there are barriers to practice in both settings that need to be better understood.

The fact that the groups demonstrated improvement despite low recorded practice rates during the training period may indicate that this is due to random effects, rather than due to the amount of deliberate practice. However, there are many different components for procedural skills learning besides the time spent practicing on physical simulator with specific tasks such as utilizing didactic, and video-based instruction, reflection and supervised practice with feedback and formative assessment.^[21-25] In our study, all subjects most likely received learning from the video-based instruction and during the practice for the period of the pre-test scoring. Indeed, video-based instruction has been shown to be efficacious in the development of laparoscopic skills.^[26,27] It has been recently demonstrated that under prescribed practice conditions, video based instruction is equally effective as faculty instruction in teaching basic surgical skills to novice trainees.^[23,24,28]

Supervised practice-feedback is believed to be another foundation of effective learning. Feedback and formative assessment refer to information about performance that is intended to guide learning. The purpose of giving feedback is to encourage learners to think about their performance and how they might improve. However, feedback in practice is often vague and evaluative (e.g. “good suturing”).^[29] While direct intensive practice feedback was not given in our study, the use of pre-set task-specific proficiency criteria to guide practice was utilized. This has been shown to give the informative feedback and opportunity for error correction vital for deliberative practice and can improve laparoscopic training.^[6] This may be another reason for the observed skill improvements in both groups.

Our study has several limitations and must be viewed cautiously as they may not apply for other simulators or other subjects with different motivation, interests, and backgrounds. If all of our subjects were surgical residents that were required to achieve proficiency prior to being allowed into the operating room, we believe that nearly 100% would attain the pre-defined proficiency levels as opposed to the 6% noted in the current study.^[30] Another limitation of our study was that we assumed that the participants knew how to self-direct their learning. Perhaps with more oversight, including feedback and good practice reinforcement, the path to greater task improvements would have been identified. Another limitation was that the number of participants in our study was small. Interestingly, for both tasks the greater improvements were with the on-site training - although statistical significance between the two groups could not be demonstrated this may be a function of small numbers. A larger cohort might result in statistically significant differences between the two groups. A further limitation of this study is it did not attempt to correlate improvement in task performance with improved performance in live human operations. Despite these limitations, this study has provided the foundation for additional assessment of the home trainer as a means of improving operative performance.

Essentially, our investigation is a feasibility study evaluating if home training is viable, however it was not performed to determine if programs can “avoid obligations” and “negate” work hours regulations. Our study found that novice individuals trained on either the home or the on-site training device were able to improve their laparoscopic skills objectively and subjectively using an independent proficiency-based training method. However, none of the participants practiced for more than 1 or 2 h in the 3-month training period. Therefore, we feel that the only valid conclusion that can be drawn is that when overworked and exhausted trainees who are expected to train on their own time, do not regularly engage in training exercises, regardless of whether these are provided at home or in the workplace. The solution to conducting training in a stressful work environment may not be to simply “suggest” that trainees practice at home, but rather to understand the work-related stressors and reconfigure jobs, and perhaps even to increase staffing, to minimize stress exposure.