OBJECTIVE: Determine the efficacy of a novel low-cost, reusable simulator for training fundamental skills associated with safe and effective intraoperative cholangiography (IOC). DESIGN: The simulator uses a balloon and retention suture tubing (representing the gallbladder, cystic duct, common bile duct, and common hepatic duct) attached to a piece of wood and placed in a laparoscopic trainer (representing the abdominal cavity) covered by a piece of simulated skin to obscure it. Following a tutorial on performing a simulated IOC using this, simulation participants independently completed a video-recorded simulated IOC and a post-training survey about the appearance and perceived usefulness of the IOC simulator as a training tool. Two experienced surgeons assessed participants' IOC performance using an IOC procedural checklist developed for this purpose. Procedural time (in seconds) was recorded and used as an additional measure of performance. SETTING: The OhioHealth Learning Center simulation facility in the Department of Surgery at Riverside Methodist Hospital, a large tertiary care independent medical center that is part of the OhioHealth care system. PARTICIPANTS: Eleven attending surgeons and 16 general surgery residents of different levels participated in the simulation. Two experienced surgeons assessed participants' IOC performance. One participated in the simulation along with the other 10 surgeons; the other did not. RESULTS: High-experience participants completed more steps and spent less time than low-experience individuals; however, differences were not statistically significant. There was substantial agreement between the 2 observers regarding participants' performance. Participants scored the simulator as realistic and useful in teaching relevant steps associated with IOC. CONCLUSIONS: Despite differences between high- and low-experience participants in steps completed and time spent, these results did not prove statistically significant. Additional studies to increase sample size are warranted to determine if significant differences exist. However, participants did generally find the simulator to be an effective training tool. (C) 2019 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

BACKGROUND: There is a critical relationship between team communication and patient safety in the operating room (OR), but limited opportunities are available to help OR trainees develop the communication skills needed to be good team players. The purpose of this study was to evaluate the effectiveness of a simulation-based communication-training program developed for general surgery and obstetrics and gynecology residents. METHODS: Following a group lecture on diagnostic laparoscopy, 34 residents independently completed a laparoscopy case on a patient simulator followed by a structured debrief that targeted team-based communication skills Integrated into the case were 2 events (bradycardia and OR fire) that provided additional opportunities for the resident to communicate with his/her team. The mean Likert scale score for 11 post-training survey questions were calculated to determine residents' reaction to the training. Additionally, mean scores of observer ratings of communication performance after the simulation were calculated and analyzed using separate Wilcoxon Sign-Rank tests and kappa statistics. RESULTS: Of the 41 GS and ObGyn residents, 34 (83%) participated in the training. 18 (53%) residents completed the simulation once and 16 (47%) completed it twice. Overall, residents had a positive reaction to the training program (average survey score = 4.56 of 5) and participation in the program improved their ability to use effective communication techniques during the bradycardia and OR fire events (p < 0.05, kappa = 0.61). CONCLUSIONS: Residents had a positive reaction to the training program and participation in the program improved their ability to use effective communication techniques throughout the procedure. (C) 2018 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

OBJECTIVE: Simulation is a technique recommended for teaching and measuring teamwork, but few published methodologies are available on how best to design simulation for teamwork training in surgery and health care in general. The purpose of this article is to describe a general methodology, called event-based approach to training (EBAT), to guide the design of simulation for teamwork training and discuss its application to surgery.DESIGN: The EBAT methodology draws on the science of training by systematically introducing training exercise events that are linked to training requirements (i.e., competencies being trained and learning objectives) and performance assessment. The EBAT process involves:1. selecting a teamwork competency for training and assessment;2. defining a list of measureable learning objectives that are rooted in the teamwork competency;3. selecting a clinical context to frame the scenario development;4. defining a set of targeted knowledge, skills, and attitudes (KSAs) or behaviors that capture the pre-defined learning objectives;5. choosing clinical events to allow learners the opportunity to demonstrate the targeted KSAs or behaviors;6. identifying targeted responses to the events; and7. developing an evaluation tool to assess learners' performance.RESULTS: Of the 4 teamwork competencies endorsed by the Agency for Healthcare Research Quality and Department of Defense, "communication" was chosen to be the focus of our training efforts. A total of 5 learning objectives were defined based on 5 validated teamwork and communication techniques. Diagnostic laparoscopy was chosen as the clinical context to frame the training scenario, and 29 KSAs were defined based on review of published literature on patient safety and input from subject matter experts. Critical events included those that correspond to a specific phase in, the normal flow of a surgical procedure as well as clinical events that may occur when performing the operation. Similar to the targeted KSAs, targeted responses to the critical events were developed based on existing literature and gathering input from content experts. Finally, a 29-item EBAT-derived checklist was created to assess communication performance.CONCLUSION: Like any instructional tool, simulation is only effective if it is designed and implemented appropriately. It is recognized that the effectiveness of simulation depends on whether (1) it is built upon a theoretical framework, (2) it uses preplanned structured exercises or events to allow learners the opportunity to exhibit the targeted KSAs, (3) it assesses performance, and (4) it provides formative and constructive feedback to bridge the gap between the learners' KSAs and the targeted KSAs. The EBAT methodology guides the design of simulation that incorporates these 4 features and, thus, enhances training effectiveness with simulation. (C) 2015 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Simulation of anatomically complex procedures, such as angiography, is becoming more practical, however, computer-based modules require extensive research to assess their effectiveness. We organized two training schemas - alternating cases and consistent cases - and hypothesized that the alternating practice cases would be beneficial to test performance. Eight residents (4 radiology/4 neurosurgery) and 8 anatomy graduate students were trained on the Simbionix™ simulator in order to assess skill acquisition in diagnostic cerebral angiography over 8 sessions. We found that participants improve on total procedure time and total fluoroscopy time (p<0.05), but not on contrast injected or roadmaps created. There were no significant differences between alternating and consistent training types. Additional work needs to be done with higher sample numbers and visuospatial scores as criteria.

Medical specialties are starting to turn to new technologies, such as computer simulation, in order to complement traditional teaching methods. Simulation of anatomically complex procedures, such as angiography, is becoming more practical, however, computer‐based modules require extensive research to assess their effectiveness. There is increasing support in the literature for simulation‐based training in medicine; we are exploring a novel method for alternating simulation scenarios for cerebral angiography. Eight residents (4 radiology/4 neurosurgery) and 8 anatomy graduate students were trained on the Simbionix™ angiography simulator in order to assess skill acquisition. Participants had 8 test sessions to diagnose a cerebral aneurysm with either consistent or alternating practice cases. Subjects then would have 6 sessions to treat the aneurysms by filling them with coils. We hypothesize that the participants will benefit from both training types, but when encountering a new scenario would benefit of alternating training more, and would ultimately decrease procedure time, x‐ray time, contrast used and spatial errors. Preliminary results show a trend towards speedup, consistent with our hypothesis. These findings would have a strong impact on the implementation of novel training protocols in medicine, specifically in angiography, leading to safer, individualized learning modules.

BackgroundFailures in non‐technical skills (NTS) rather than technical expertise are frequently at the root of medical errors in the operating room (OR). NTS are the cognitive (decision making and situation awareness) and interpersonal (communication and teamwork) skills that are recognized, but not formally addressed in surgical training.PurposeTo examine the effect of simulation‐based training (SBT) on NTS performance of surgical residents during laparoscopic cholecystectomy (LC).SettingThe study was carried out in a simulated OR that was arranged with standard equipment for LC, a high‐fidelity patient simulator and a real OR team.Design11 surgery residents completed 2 identical SBT Sessions. For each Session, the resident was briefed on the LC case, completed the case in the simulated OR and debriefed his/her videotaped performance with a content expert.Assessment4 raters, blinded to the residents' PGY level and the order of the videotaped Sessions, reviewed the recordings and scored the residents' NTS using a perioperative Time Out checklist and Intraoperative LC checklist.ResultsScores on both checklists improved from Session 1 to Session 2, p<0.05, suggesting that SBT is effective for improving the NTS that underpin surgical proficiency.ConclusionIt could be reasonably argued that improved NTS of surgeons would reduce medical errors and improve patient safety in the OR.

OBJECTIVE: Failures in nontechnical skills (NTS) rather than technical expertise are frequently at the root of medical errors in the operating room (OR). NTS are the cognitive (decision making and situation awareness) and interpersonal (communication and teamwork) skills that are recognized but are not formally addressed in surgical training. The purpose of the study was to examine the effect of simulation-based training (SBT) on NTS performance of surgical residents during simulated laparoscopic cholecystectomy (LC).SETTING: The study was performed in a simulated OR at the Center for Medical Education and Innovation at Riverside Methodist Hospital, Columbus, OH. The simulated OR was arranged with standard equipment for LC, a high-fidelity patient simulator, and a real OR team.DESIGN: General surgical residents completed 2 identical SBT sessions. For each session, residents were briefed on the LC case, completed the case in the simulated OR, and debriefed their videotaped simulation performance with a content expert. The video recordings were reviewed and the residents' NTS were scored using a perioperative time-out checklist and an intraoperative checklist for LC by 4 raters who were blinded to both the residents' postgraduate year level and the order of the videotaped simulation sessions.RESULTS: Residents showed a significant improvement in completeness of the perioperative time-out checklist from session 1 (mean score = 1.27 +/- 1.00) to session 2 (mean score = 5.00 +/- 1.28), p < 0.001. Residents' scores on the intraoperative checklist also improved from session 1 to session 2, p < 0.05. Overall, residents felt that the simulation was a valuable teaching and training tool and recommend that it be incorporated into residency training.CONCLUSION: SBT appears to be an effective technique for improving NTS of surgical residents during the perioperative and intraoperative phases of surgery. As surgical proficiency is 75% nontechnical and 25% technical, it could be reasonably argued that improved NTS of surgeons could improve surgical outcomes. (C) 2015 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Students with high spatial visualization ability (Vz) outperform students with low Vz in anatomy; yet, the influence of Vz on different Bloom's Taxonomy levels of multiple‐choice questions (MCQs) has not been established. This study aimed to assess the influence of Vz on different Bloom's Taxonomy levels of MCQs & whether studying anatomy improves Vz. It is hypothesized that students with high Vz will outperform students with low Vz on higher order MCQs. Allied health students (n=47) completed the Mental Rotations Test (MRT) to establish Vz. The mean Vz was 9.1±3.6, which divided students into high Vz (n=23; avg MRT=11.8±2.9) & low Vz (n=24; avg MRT=6.5±1.6) groups. The MCQs were classified into four Bloom's levels: knowledge, comprehension, application & analysis. Data indicate that students with high Vz (avg=87.6±6.1) outperform students with low Vz on MCQs (avg=82.1±7.6; p<0.05). Students with high Vz performed better on knowledge, comprehension, & analysis MCQs (p<0.05), while there was no difference on application MCQs. Upon completion of the course, students repeated the MRT; the overall mean Vz increased from 9.1±3.6 to 12.5±4.6 (p<0.05). Both the high & low Vz groups demonstrated improvement (high Vz: 11.9±3.0 ‐ 15.3±4.4; low Vz: 6.7±1.6 ‐ 9.9±3.1, p<0.05). Results suggest that Vz plays a role in MCQ performance in both high & low order Bloom's levels & that participation in anatomy can assist in training Vz.

The practical aspect of human anatomy instruction is becoming less dissection based and increasingly more reliant on computerized, three‐dimensional (3D) teaching tools. Some students find it difficult to learn from these tools and it is important not to alienate this group of learners. Previous studies have demonstrated that the spatial relations subcomponent of spatial ability is predictive of success in 3D anatomy comprehension, but the effect of other spatial ability subcomponents has not been examined. This study explored the role of three subcomponents of spatial ability and the effect of prior domain knowledge in comprehending a 3D teaching tool. By adding more spatial ability subcomponents and a knowledge component the results may provide a broader picture of the relevant learner characteristics involved in comprehending these tools. 60 students from Western University were recruited. Participants performed an anatomy knowledge test (AKT), three standardized spatial tests, and a pre and post spatial anatomy task (SAT) with a 3D teaching tool as an intervention. Preliminary data analysis (N=24) suggests that participants’ scores on the AKT and the three spatial ability tests are predictive of learning from the 3D teaching tool (p<0.01). These results may have implications for the appropriate design and implementation of computerized 3D instructional animations.Grant Funding Source: Lippincott Williams Wilkins/AAA Education Research Scholarship

Cerebral angiography (CA) is considered the gold standard for diagnosing primary neurovascular diseases. Although guidelines have been established to ensure adequate CA experience before independent practice, current tools used to assess CA performance during training have questionable validity and reliability. The initial phases of validation often involve determining whether the tool appears to measure the construct of interest (face validity; FV) and whether the items in the tool cover a representative sample of the construct (content validity; CV). This study proposes to establish the FV and CV of 3 assessment tools (task‐specific checklist, error‐based scale, and global rating scale) developed to evaluate CA performance. FV and CV were established by asking expert catheter‐based physicians to judge whether each tool appears to be a practical and pertinent measure of CA performance and to evaluate the appropriateness of each tool item. Based on experts’ recommendations, each tool was modified to improve its ease‐of‐use, organization, and clarity. Confirmation of the FV and CV of the 3 tools will contribute to ensuring that future assessment of CA performance is both accurate and consistent.Grant Funding Source: Supported by MITACS

Students with high spatial visualization ability (Vz) achieve higher grades in anatomy than students with low Vz; however, the influence of Vz on different Bloom’s Taxonomy levels of exam questions has not been established. This study examines the effect of Vz on different Bloom’s Taxonomy levels of anatomy questions. It is hypothesized that students with high Vz will outperform students with low Vz on higher order questions. Participants completed the Mental Rotations Test (MRT) to establish Vz. The mean Vz was 11.5±4.7, which divided participants into high Vz (n=30; mean MRT=15.4±2.7) & low Vz (n=29; mean MRT=7.5±2.5) groups. Exam questions were categorized into 4 Bloom’s levels: knowledge, comprehension, application & analysis. Preliminary data indicate students with high Vz (Vz=90.67±6.91) outperform students with low Vz (Vz=84.55±12.86; p<0.05). Students with high Vz performed better on comprehension level questions (p<0.05) whereas, there was no difference when assessing other exam question levels. This suggests that while high Vz students perform better overall & on comprehension questions, there may not be significant differences on knowledge, application & analysis questions. However, this sample only included 5 knowledge, 8 application & 2 analysis questions indicating that the inclusion of future exam questions may be required to establish significance within the other question levels.

Computer-based simulation is increasingly used in medical education for training, assessment, credentialing, and practice. Compared to medical specialties such as anesthesiology and general surgery, the adoption of simulation for neurointerventional training has been slow. This may be due to the limited number of neurointerventional simulators available and the lack of research assessing their validity and training capability. The objective of this study was to assess the realism, validity, and training capability of computer-based simulation for diagnostic cerebral angiography using a commercially available simulator called the ANGIO Mentor Express.

Spatial ability, particularly spatial visualization (Vz), is a significant predictor of success in human anatomy. There is evidence that Vz can be improved through training with videogames, such as Tetris. The present study investigates the relationship between videogame training, Vz, and visuospatial anatomy comprehension. Participants (n=27) completed the Mental Rotations Test (MRT) and the Spatial Anatomy Task (SAT) in order to assess baseline levels of Vz and visuospatial anatomy comprehension, respectively. According to MRT scores, the participants were semi‐randomized into a Control (n=12) or Training (n=15) group, with both low‐ and high‐Vz individuals in each group. Participants in the Training group played five, one‐hour sessions of Tetris over five consecutive days. At least one week after baseline testing, all participants again performed the MRT and SAT. Participants in both the Control and Training groups showed significant improvements on their post‐MRT and SAT; however, contrary to our hypothesis, videogame training did not improve Vz and visuospatial anatomy comprehension beyond that observed in the Control group. Moreover, this improvement was independent of participant sex differences. Additional subjects are being recruited to help us further explore the potential utility of videogame training for anatomically‐demanding fields.

Mental rotations ability (MRA), a subset of spatial ability, is linked to success in anatomy and the STEMM disciplines. Like any ability, MRA differs in the general population. Some people can mentally rotate 2D and 3D objects with ease, while others have difficulty with these mental tasks. Previous research suggests that the cognitive processes underlying MRA are manifest in eye‐movements. However, research has focused primarily on describing how individuals of high and low‐MRA differ in eye‐movement patterns rather than demonstrating how knowledge of these differences can be used to improve observational approaches and learning. This study aims to determine whether the eye‐movement patterns (frequency of fixation, duration of fixation, salient features, and average visual scan path) of high‐MRA individuals can be used to improve spatial task performance for low‐MRA individuals. Undergraduate students at Western University will complete a standardized test of MRA (Shepard and Metzler Mental Rotations Test) while eye‐movement metrics are collected. The eye‐movement patterns of high‐MRA individuals will then be used to train low‐MRA individuals to improve performance on subsequent spatial tests. Results from these studies may be employed to guide the design and delivery of innovative eye‐movement based approaches to improve instruction in anatomy and other STEMM disciplines.

High scores in measures of mental rotation have been associated with improved spatial anatomy performance. Mental rotation training, such as video games as well as paper‐and‐pencil mental rotation tasks, has been shown to improve mental rotation scores. The purpose of the study is to determine whether video game or paper‐and‐pencil mental rotation training can improve spatial anatomy ability.Participants in the study (n=13), either medical or dental students, were asked to complete the Mental Rotations Test (MRT) and the Spatial Anatomy Task (SAT) to provide a baseline measure of their spatial ability and spatial anatomy knowledge, respectively. Based on MRT scores, participants were assigned to one of three groups: one that played 5 cumulative hours of the video game Tetris (n=3), another that completed the MRT daily over the span of a 5 days (n=4), and a control group that received no training (n=5). All participants were again asked to complete the MRT and SAT after training. Paired t‐tests were used to compare baseline and final test scores in each group.Preliminary results show that both the MRT group (p = 0.046) and the Tetris group (p = 0.014) significantly improved their total SAT scores, while the control group (p = 0.129) did not. Although more research is necessary to make definitive conclusions, the current study indicates that mental rotation training may be of benefit for students learning spatial anatomy.

Computer‐based three‐dimensional (3D) teaching tools are increasingly used in human anatomy instruction; however, these tools may compromise learning since some learners have problems comprehending them. Previous studies indicate that a person’s spatial ability is predictive of their ability to learn from 3D teaching tools. Most studies investigating this relationship have been performed on a North American population, so this effect is relatively unknown in other parts of the world. Spatial ability can be shaped by daily activities such as travel, sport, and entertainment. Rwandese people may have developed their spatial ability differently than North Americans and, therefore, learn differently from 3D teaching tools. This study investigates the role of spatial ability in comprehending a 3D computer‐based teaching tool in a Rwandese student population. 73 students at the National University of Rwanda have been recruited. Participants performed an anatomy knowledge test, 3 standardized spatial tests, and a pre and post spatial anatomy task with a 3D teaching tool as an intervention. The results of this study may help to design computerized, 3D teaching tools that are tailored to educational facilities in Rwanda. When developing 3D teaching tools it is important to take learner characteristics into account to create tools that are sensitive to the population that is learning from them.

Computer‐based simulation (CBS) is increasingly used in medical education, but evidence for its efficacy has been limited and inconsistent. Deficiencies and heterogeneity in validity and reliability study methodologies have been cited as major limitations to drawing conclusions regarding the effectiveness of CBS training. Since untested assessment methodologies can lead to reporting inaccurate performance data, it is crucial to validate CBS systems and their assessment instruments before examining the effectiveness of CBS training. This study establishes the validity (face, content and construct) and reliability (test‐retest) of a CBS system (ANGIO Mentor Express) for left and right cerebral angiography (CA). Face and content validities were established by asking experienced catheter‐based physicians to judge the overall realism of the simulated CA procedures and evaluate the appropriateness of the assessment instruments. Construct validity was assessed by comparing the performance of an expert cohort (experienced physicians) to a novice cohort (medical students and residents) of subjects. Test‐retest reliability was established by correlating performances on the simulated left CA with the right CA. Confirmation of the validity and reliability of the CBS system and its assessment instruments assures the integrity of future studies evaluating the efficacy of CBS training for CA.Grant Funding Source: None

The present study explored the problem‐solving strategies of high‐ and low‐spatial visualization ability learners on a novel spatial anatomy task to determine whether differences in strategies contribute to differences in task performance. The results of this study provide further insights into the processing commonalities and differences among learners beyond the classification of spatial visualization ability alone, and help elucidate what, if anything, high‐ and low‐spatial visualization ability learners do differently while solving spatial anatomy task problems. Forty‐two students completed a standardized measure of spatial visualization ability, a novel spatial anatomy task, and a questionnaire involving personal self‐analysis of the processes and strategies used while performing the spatial anatomy task. Strategy reports revealed that there were different ways students approached answering the spatial anatomy task problems. However, chi‐square test analyses established that differences in problem‐solving strategies did not contribute to differences in task performance. Therefore, underlying spatial visualization ability is the main source of variation in spatial anatomy task performance, irrespective of strategy. In addition to scoring higher and spending less time on the anatomy task, participants with high spatial visualization ability were also more accurate when solving the task problems. Anat Sci Educ 7: 280–288. © 2013 American Association of Anatomists.

The purpose of this study is to examine how learners’ spatial ability and prior domain knowledge contribute to the comprehension of visuospatial anatomical information from instructional animation. Spatial ability refers to one's capacity to construct, maintain, and manipulate mental representations. Prior domain knowledge refers to one's previously acquired knowledge of human anatomy. Visuospatial anatomy refers to the spatial properties of anatomical structures such as their 3D shape, form, position in the body, and relative location to surrounding structures. In cognitive science there is growing evidence suggesting that the educational value of instructional materials depends on how well their design reflects human cognitive architecture. Educational value depends on whether learners have enough cognitive resources to store and process the information presented. This study will provide objective evidence as to how learner's spatial ability and prior anatomy knowledge influence visuospatial anatomy comprehension. It will also help to determine who will benefit the most from instruction with animation. The results can be used to improve the design and implementation of instructional resources that will augment learning of visuospatial anatomical information for all learners, regardless of their innate spatial ability or prior knowledge of anatomy. Grant Funding Source : University of Western Ontario