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Bellows et al. Laparoscopic training for surgical residents

directed laparoscopic training experience using low- period of the pre-test scoring. Indeed, video-based
cost portable training devices to improve laparoscopic instruction has been shown to be efficacious in the
procedural skills with the home environment has not development of laparoscopic skills. [26,27] It has been
been investigated. We used a proficiency-based, recently demonstrated that under prescribed practice
self-directed training approach both within the home conditions, video based instruction is equally effective
and workplace environment. Both groups were as faculty instruction in teaching basic surgical skills to
instructed to practice at their discretion to achieve novice trainees. [23,24,28]
expert proficiency on each task with no ramifications
if they did not succeed. We believed this would be Supervised practice-feedback is believed to be
successful based on the observation that surgical another foundation of effective learning. Feedback
trainees and those interested in surgery are highly and formative assessment refer to information about
motivated to learn the required skills and invest performance that is intended to guide learning. The
the necessary time. In addition, there seems to be purpose of giving feedback is to encourage learners

natural selection within the surgical population itself. to think about their performance and how they might

Trainee motivation is essential for learning because improve. However, feedback in practice is often
it promotes deliberate practice and persistent vague and evaluative (e.g. “good suturing”). [29] While
efforts to improve objective performance. [20] Without direct intensive practice feedback was not given in
motivated learners, any educational efforts will have our study, the use of pre-set task-specific proficiency
limited achievements and the skills laboratories criteria to guide practice was utilized. This has
will be attended infrequently. At the end of the day, been shown to give the informative feedback and
our method was met with mixed results. First of all, opportunity for error correction vital for deliberative
the self-directed training approach did enhance the practice and can improve laparoscopic training.
[6]
novices’ laparoscopic skills in both groups. But, we This may be another reason for the observed skill
also observed that few subjects attended the on- improvements in both groups.
site skill laboratory during their independent training
period. More surprising, was the observation that Our study has several limitations and must be viewed
when subjects were given the training device to use at cautiously as they may not apply for other simulators
home, they still did not find the time to frequently train or other subjects with different motivation, interests,
independently. Interestingly, on average, the home and backgrounds. If all of our subjects were surgical
trainees found only about 1-2 h to practice within a residents that were required to achieve proficiency
three-month period of time and 44% never practiced prior to being allowed into the operating room,
once during this period. These results demonstrated we believe that nearly 100% would attain the pre-
that one of the most important factors in getting defined proficiency levels as opposed to the 6%
trainees to practice and hone their laparoscopic skills noted in the current study. [30] Another limitation of
was providing them with enough free time during their our study was that we assumed that the participants
work week not changing their learning environment. knew how to self-direct their learning. Perhaps
This ultimately disproved our original hypothesis that with more oversight, including feedback and good
moving practice opportunities out of the busy and practice reinforcement, the path to greater task
stressful clinical environment to “free time” would improvements would have been identified. Another
be beneficial. Thus the hard, but unavoidable truth limitation was that the number of participants in our
appears to be that there are barriers to practice in study was small. Interestingly, for both tasks the
both settings that need to be better understood. greater improvements were with the on-site training
- although statistical significance between the two
The fact that the groups demonstrated improvement groups could not be demonstrated this may be a
despite low recorded practice rates during the training function of small numbers. A larger cohort might
period may indicate that this is due to random effects, result in statistically significant differences between
rather than due to the amount of deliberate practice. the two groups. A further limitation of this study is
However, there are many different components for it did not attempt to correlate improvement in task
procedural skills learning besides the time spent performance with improved performance in live
practicing on physical simulator with specific tasks human operations. Despite these limitations, this
such as utilizing didactic, and video-based instruction, study has provided the foundation for additional
reflection and supervised practice with feedback assessment of the home trainer as a means of
and formative assessment. [21-25] In our study, all improving operative performance.
subjects most likely received learning from the video-
based instruction and during the practice for the Essentially, our investigation is a feasibility study
130 Mini-invasive Surgery ¦ Volume 1 ¦ September 30