SUMMARY Review date: 1969 to 2003, 34 years. Background and context: Simulations are now in widespread use in medical education and medical personnel evaluation. Outcomes research on the use and effectiveness of simulation technology in medical education is scattered, inconsistent and varies widely in methodological rigor and substantive focus. Objectives: Review and synthesize existing evidence in educational science that addresses the question, ‘What are the features and uses of high-fidelity medical simulations that lead to most effective learning?’. Search strategy: The search covered five literature databases (ERIC, MEDLINE, PsycINFO, Web of Science and Timelit) and employed 91 single search terms and concepts and their Boolean combinations. Hand searching, Internet searches and attention to the ‘grey literature’ were also used. The aim was to perform the most thorough literature search possible of peer-reviewed publications and reports in the unpublished literature that have been judged for academic quality. Inclusion and exclusion criteria: Four screening criteria were used to reduce the initial pool of 670 journal articles to a focused set of 109 studies: (a) elimination of review articles in favor of empirical studies; (b) use of a simulator as an educational assessment or intervention with learner outcomes measured quantitatively; (c) comparative research, either experimental or quasi-experimental; and (d) research that involves simulation as an educational intervention. Data extraction: Data were extracted systematically from the 109 eligible journal articles by independent coders. Each coder used a standardized data extraction protocol. Data synthesis: Qualitative data synthesis and tabular presentation of research methods and outcomes were used. Heterogeneity of research designs, educational interventions, outcome measures and timeframe precluded data synthesis using meta-analysis. Headline results: Coding accuracy for features of the journal articles is high. The extant quality of the published research is generally weak. The weight of the best available evidence suggests that high-fidelity medical simulations facilitate learning under the right conditions. These include the following:

/pdf/features-and-uses-of-high-fidelity-medical-simulations-that-51wb8k5opy.pdf

Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review

In the past few years, considerable developments have been made in the objective assessment of technical proficiency of surgeons. Technical skills should be assessed during training, and various methods have been developed for this purpose 

Surgical competence entails a combination of knowledge, technical skills, decision making, communication skills, and leadership skills. Of these, dexterity or technical proficiency is considered to be of paramount importance among surgical trainees. The assessment of technical skills during training has been considered to be a form of quality assurance for the future.1 Typically surgical learning is based on an apprenticeship model. In this model the assessment of technical proficiency is the responsibility of the trainers. However, their assessment is largely subjective.2 Objective assessment is essential because deficiencies in training and performance are difficult to correct without objective feedback.3

The introduction of the Calman system in the United Kingdom, the implementation of the European Working Time Directive, and the financial pressures to increase productivity4 have reduced the opportunity to learn surgical skills in the operating theatre. Studies have shown that these changes have resulted in nearly halving the surgical case load that trainees are exposed to.5 Surgical proficiency must therefore be acquired in less time, with the risk that some surgeons may not be sufficiently skilled at the completion of training.6 This and increasing attention of the public and media on the performance of doctors have given rise to an interest in the development of robust methods of assessment of technical skills.7 We review the research in this field in the past decade. Our objectives are to explore all the available methods, establish their validity and reliability, and examine the possibility of using these methods on the basis of the available evidence.

We collected information for this review from …

/pdf/objective-assessment-of-technical-skills-in-surgery-2zjt7ye7k4.pdf

Objective assessment of technical skills in surgery

In the past few years, considerable developments have been made in the objective assessment of technical proficiency of surgeons. Technical skills should be assessed during training, and various methods have been developed for this purpose 

Surgical competence entails a combination of knowledge, technical skills, decision making, communication skills, and leadership skills. Of these, dexterity or technical proficiency is considered to be of paramount importance among surgical trainees. The assessment of technical skills during training has been considered to be a form of quality assurance for the future.1 Typically surgical learning is based on an apprenticeship model. In this model the assessment of technical proficiency is the responsibility of the trainers. However, their assessment is largely subjective.2 Objective assessment is essential because deficiencies in training and performance are difficult to correct without objective feedback.3

The introduction of the Calman system in the United Kingdom, the implementation of the European Working Time Directive, and the financial pressures to increase productivity4 have reduced the opportunity to learn surgical skills in the operating theatre. Studies have shown that these changes have resulted in nearly halving the surgical case load that trainees are exposed to.5 Surgical proficiency must therefore be acquired in less time, with the risk that some surgeons may not be sufficiently skilled at the completion of training.6 This and increasing attention of the public and media on the performance of doctors have given rise to an interest in the development of robust methods of assessment of technical skills.7 We review the research in this field in the past decade. Our objectives are to explore all the available methods, establish their validity and reliability, and examine the possibility of using these methods on the basis of the available evidence.

We collected information for this review from … 

Computer-enhanced "robotic" cardiac surgery: experience in 148 patients

Background: The awkward visual and physical interface of video-endoscopic surgery (VES) has been shown to increase the physical workload of the surgeon, yet there is a lack of objective information on the mental effort and stress demanded by VES techniques. This study addresses the hypothesis that VES is more stressful than open surgery using an ergonomic analysis of surgical tasks in a laboratory setting. Methods: A portable ergonomic work station was developed using a software Virtual Instrument (VI) interfaced with electronic hardware to compare the mental workload of 28 surgeons. The task was knot tying. The independent variable was work condition: rest, open technique, or VES technique. Dependent variables were tonic skin conductance level (SCL), electrooculogram (EOG), and subjective reports of concentration (CON) and stress (STR). Statistical analysis used nonparametric methods. Results: Subjects tied fewer knots using the VES technique (p <0.05). The SCL increased progressively from rest to the open task to the VES task (p <0.05), correlating with the subjects' reported increase in mental stress level (p <0.05). Eye blinks decreased from rest to the open task (p <0.05), consistent with the subjects' reported increase in level of mental concentration. From the open to the VES task, eye blinks increased (p <0.05), as would be expected given the greater demands of the VES task. Experienced subjects demonstrated less variability in SCL levels across tasks. Conclusions: VES technique requires greater concentration and places greater mental stress on surgeons than to open surgery. More experience with VES may decrease this effect. Studies are needed to improve the human-technology interface the stress.

Performing laparoscopic surgery is significantly more stressful for the surgeon than open surgery.

HYPOTHESIS Better endoscopic task performance and more ergonomic movements of a surgeon's dominant upper limb can be achieved within a certain range of intracorporeal-extracorporeal instrument length ratio. DESIGN Investigating the effect of 3 intracorporeal-extracorporeal instrument length ratios (240:120 mm, level 1; 180:180 mm, level 2; and 120:240 mm, level 3) on efficiency and quality of a standardized endoscopic task (intracorporeal surgeon's knot). Ten surgeons tied 360 knots inside a trainer in a random sequence. Task efficiency was measured by the execution time, which was recorded for each knot. Task quality was measured by the knot quality score, derived from the force-extension curves obtained by distraction of each knot in a tensiometer. Motion analysis parameters were obtained at the elbow and shoulder joints using a 3-dimensional motion analysis system (Kinemetrix Model 5.0-3D/3MBM; Medical Research Ltd, Leeds, England). The Kruskal-Wallis and Mann-Whitney tests were used for analysis. RESULTS The level 3 ratio had the lowest knot quality score (P = .07) and longest execution time (P<.05). The range of movement at the elbow was significantly greater with the level 3 ratio than with the level 1 ratio (P<.05). The level 3 ratio also resulted in the widest range of movement at the shoulder (P<.05 for level 2 vs 3; P = .06 for level 1 vs 3). The median angular velocity was 329.5 degrees/s, 360 degrees/s, and 530 degrees/s for levels 1, 2, and 3, respectively (P = .10). CONCLUSIONS Intracorporeal-extracorporeal instrument length ratio below 1.0 degrades task performance and is associated with a wider range of movement at the elbow and shoulder and a higher angular velocity at the shoulder.

Effect of intracorporeal-extracorporeal instrument length ratio on endoscopic task performance and surgeon movements.

Background: Very little research has been carried out on the ergonomics of surgeon-instrument interface. The aim of this study is to investigate the effect of experience on the moti

Differences between experts and trainees in the motion pattern of the dominant upper limb during intracorporeal endoscopic knotting.

Laparoscopic common bile duct (CBD) exploration is performed when transcystic duct extraction is not appropriate or has failed. The current indications for laparoscopic direct CBD exploration are: 

1.

Failed transcystic extraction if CBD diameter is > 8 mm.




2.

Large single or multiple stones (>1.0 cm), providing the load is not excessive (see below).




3.

Unsuccessful attempts at endoscopic stone extraction for large/occluding stones.




4.

Intrahepatic stones, which are inaccessible via a transcystic approach.

Common Bile Duct Exploration via Laparoscopic Choledochotomy

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Papers

Effect of intracorporeal-extracorporeal instrument length ratio on endoscopic task performance and surgeon movements.

Differences between experts and trainees in the motion pattern of the dominant upper limb during intracorporeal endoscopic knotting.

Common Bile Duct Exploration via Laparoscopic Choledochotomy