0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Special Article |

The Formula for a Successful Laparoscopic Skills Curriculum FREE

Dimitrios Stefanidis, MD, PhD; B. Todd Heniford, MD
[+] Author Affiliations

Author Affiliations: Division of Gastrointestinal and Minimally Invasive Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina.


Arch Surg. 2009;144(1):77-82. doi:10.1001/archsurg.2008.528.
Text Size: A A A
Published online

Although multiple simulators have been validated as effective training tools, curriculum development is lagging, and considerable work is needed to determine the best methods for training. This article identifies the factors that influence the successful incorporation of simulator training into the resident curriculum, reviews the evidence regarding laparoscopic curriculum development in the surgical literature, and provides a formula for effective curriculum design. A successful laparoscopic skills curriculum depends on many factors including participant motivation, available resources and personnel, and trainee and faculty commitment. It should encompass goal-oriented training, sensitive and objective performance metrics, appropriate methods of instruction and feedback, deliberate, distributed, and variable practice, an amount of overtraining, maintenance training, and a cognitive component. A curriculum that follows these principles is likely to spark trainee interest, ensure their satisfaction and participation in training sessions, and lead to an effective and efficient way of acquiring new skills using simulators. A skills curriculum is a dynamic process that should be tailored to individual needs and be continuously optimized based on accumulated evidence and experience.

Figures in this Article

Evidence of the educational value of simulators for surgical training is accumulating rapidly15; however, most surgical training programs struggle to incorporate them into their residency curricula.6,7 Although multiple simulators have been validated as effective training tools,1,2 curriculum development is lagging, and considerable work is needed to determine the best methods for training. Realizing the importance of a structured curriculum for simulator training, the Association of Program Directors in Surgery, in collaboration with the American College of Surgeons and the American Board of Surgery, recently released a national curriculum for the teaching and mastery of surgical skills for use by residency programs.8

In addition to a structured skills curriculum, many other factors influence the successful incorporation of simulator training into the residency curriculum.2,9 It is not surprising that after the acquisition of surgical simulators for resident training, many surgery programs encounter difficulties incorporating them into their curriculum.

This article aims to identify the factors that influence the successful incorporation of simulator training into the resident curriculum, explore the evidence regarding laparoscopic curriculum development in the surgical literature, and provide a formula for effective curriculum design.

Many factors affect the successful incorporation of simulator training into the surgical curriculum. One of the most important is trainee motivation. Trainee motivation is essential for learning because it fuels participation in training sessions and ensures deliberate practice and persistent efforts to improve performance.10,11 Without motivated learners, any educational intervention will have limited success and skills laboratories will be attended infrequently.

Motivation can be either internal or external.10 Internal motivation is a prerequisite for learning, but is unique to each individual and may be impossible to modify. External motivation, which refers to interventions aimed at modifying behavior and characterizes all aspects of our daily lives, may effectively produce the desired outcome of a training intervention. However, external factors can also affect trainee motivation negatively, and should therefore be carefully evaluated before skills training implementation. In the case of surgical residents, fatigue, long working hours, limited free time, interference with clinical responsibilities, and operating room experience can all negatively affect a trainee's motivation to participate in a skills curriculum. Moreover, accumulating operative experience may render training for similar tasks or procedures on inanimate models less stimulating for senior residents. These factors make voluntary participation, which relies mainly on the internal motivation of trainees, unlikely to succeed.1214 In a study by Chang et al,12 resident participation in a skills curriculum in a busy residency program was only 14%, and the authors concluded that participation should be mandatory. In our institution, attendance rates jumped from 6% to 71% when time was dedicated specifically to skills training and supervising personnel were hired.14 These studies highlight the importance of external motivation. Residents can be motivated to attend training sessions by mandating participation or by introducing punitive measures when attendance is low. Scheduling mandatory training sessions at consistent, predetermined hours that are known to both trainees and faculty, much like the scheduling of morbidity and mortality conferences or grand rounds, is an effective strategy.2 Moreover, setting performance requirements on simulators before operating room participation is allowed and encouraging healthy competition among residents by introducing awards for good attendance and performance can also be helpful.

Another important factor for a successful simulator curriculum is the availability of dedicated personnel and appropriate resources. Simulation centers must have the financial resources to ensure their long-term continuation.2 It is paramount that skills curricula be built on appropriately validated simulators and that skills laboratories be well equipped and offer training variability to maintain participant interest and maximize trainee benefit.

The availability of ample space is important because it allows more residents to train concurrently and makes the scheduling of sessions more flexible. It can also facilitate the organization of large departmental skills courses and the training of outside participants.

Even more important than space and resources, however, is dedicated personnel who can schedule sessions, provide instruction and performance feedback during training, monitor progress, carry out research studies, troubleshoot equipment, order supplies, and, in essence, ensure the smooth operation of the center. Without dedicated personnel, a skills laboratory is unlikely to be successful. It is not surprising that the certification criteria for Educational Institutes set by the American College of Surgeons have specific requirements for space and dedicated personnel.15 Nevertheless, recent studies have demonstrated that equipment and training practices vary broadly in skills laboratories in US residency programs. A recent study demonstrated that only 55% of 162 US surgery training programs surveyed had skills laboratories, with widely ranging setup costs ($300-$1 000 000), and only 73% of those offered supervised training to their residents.6

Faculty commitment and support should not be overlooked. The attending surgeons must believe in the importance of the skills curriculum and support resident participation by allowing residents to leave the clinic or be absent from the operating room during scheduled training sessions. The skills curriculum director and the program director or chairman should encourage other faculty to teach with simulation equipment and to help create a comprehensive and challenging curriculum.

In addition to the factors that contribute to the success of skills centers, the most important contributor to resident learning is the simulator curriculum. A number of publications have demonstrated the importance of structured skills curricula for the acquisition of a variety of laparoscopic techniques.5,1619

A simulator skills curriculum should incorporate a cognitive component as the first critical step for surgical skill acquisition.20 Didactic sessions should accompany manual skills training on simulators to provide learners with the required knowledge and to improve their understanding of the task or procedure they are learning. Moreover, the direct application of knowledge into practice may significantly improve the retention of this information compared with didactics alone. Realizing the importance of an accompanying cognitive component to manual skills training, the Society of American Gastrointestinal and Endoscopic Surgeons– and American College of Surgeons–endorsed Fundamentals of Laparoscopic Surgery education module includes CD-ROM–based material on the physiology and fundamental knowledge of basic laparoscopy in addition to the 5 basic laparoscopic manual tasks.21 Furthermore, the 20 new modules of the American College of Surgeons/Association of Program Directors in Surgery national skills curriculum also include a cognitive component.8 Thus, a laparoscopic skills curriculum should incorporate procedural video tutorials and reading material that will put the manual skill acquisition into context, improve the knowledge of trainees, and motivate them to work harder on their skills. On a practical note, laparoscopic textbooks and well-chosen journal articles, along with the Fundamentals of Laparoscopic Surgery CD-ROM and procedural videos that may be available at a local level or can be obtained from national organizations, can be used for resident teaching.

A specific component of the cognitive elements of a simulator curriculum is the instruction and demonstration of the motor skills to be acquired. It is well documented that effective instruction facilitates skill acquisition and leads to superior learning of trainees,10,22 whereas inappropriate instruction and demonstration may have a negative effect on performance.10 Video-based education has proved effective for the acquisition and retention of simulator-acquired skill.2325 Rosser et al23 demonstrated that a CD-ROM tutorial on laparoscopic skills effectively transferred the cognitive information necessary for skill development, and that trainees who watched a CD-ROM tutorial on laparoscopic suturing performed this task significantly better than those who did not watch it.26 Recently, Xeroulis et al25 demonstrated that computer-based video instruction was as effective as expert feedback for the retention of simulator-acquired suturing and knot-tying skill. In our experience, frequent video tutorial viewings during simulator training showed a trend toward faster achievement of proficiency.27 Thus, task demonstration should be one of the first steps of simulator training and video tutorials should be used liberally to provide effective instruction to trainees, which will minimize the need and expense of expert instructor involvement.27 The new national skills curriculum incorporates a number of instructional videos that can be used by residency programs,8 but additional videos can also be easily created at a local level.

In the literature, feedback refers to the return of performance-related information to the performer and consists of intrinsic and extrinsic or augmented feedback.10 Intrinsic feedback is directly available to the sensory system of the performer, ie, the visual, auditory, or haptic perceptions during the performance of tasks. Extrinsic or augmented feedback is provided by an external source and aims to augment intrinsic feedback. Augmented feedback facilitates achievement of the action goal and motivates learners to continue to strive for the achievement of that goal.10 In medical education, feedback has been defined as an informed nonevaluative appraisal of performance by the teacher28 and aims to reinforce strengths and foster improvements in the learner by providing insight into actions and consequences by highlighting the differences between the intended and the actual results of the actions.28 Indeed, improved performance owing to augmented feedback has been demonstrated during simulator training,11,26,29,30 but inappropriate feedback may also have deleterious effects on skill acquisition.10 In a recent study, intense continuous external feedback during simulator training impaired acquisition of laparoscopic suturing skills compared with limited intermittent feedback provided after task completion.27 Furthermore, summary expert feedback after training sessions has resulted in better skill retention compared with concurrent feedback,25 and expert verbal feedback has been shown to be more effective than motion efficiency feedback.31 Performance feedback is thus essential for skill acquisition and retention during simulator training, and laboratory coordinators and faculty should devote time to observation of trainees during practice to provide them with feedback at the end of the training session on how to improve their performance.

For improved motor skill acquisition, a successful skills curriculum should set training goals that motivate learners by providing a performance target. Proficiency-based simulator curricula set training goals based on expert-derived performance, tailor the training to individual needs, and have been demonstrated to produce uniform skill and improve operating room performance.4,5,32,33 Several authors have highlighted the advantages of proficiency-based training and the limitations of traditional time-based training (Figure 1).4,5,3439 While one study failed to demonstrate significant performance differences in the animal operating room between a goal-directed simulator-trained group and a self-directed group,40 additional study of better quality is needed to establish the advantages of proficiency-based training. Nevertheless, such training is limited by our incomplete understanding of surgical expertise.11 Who is the appropriate expert from whom to derive performance goals? How many experts are needed to create reliable goals? How many times should trainees perform the task at the expert level to have truly reached proficiency? Should we even use expert performance as a training goal or are there other more suitable methods? Are the available metrics the most appropriate for performance assessment and sensitive enough to distinguish subtle performance differences? If we do not understand who is truly an expert in a task, and if our metrics cannot capture subtle but important performance differences, the goals set for novices may be flawed and thus their learning may be incomplete. The traditional metrics of speed and accuracy used by most proficiency-based curricula may not be ideal for the measurement of superior performance,41 as they provide little or no information about what effort the performer invested or how much learning has occurred.10,42 Even motion-tracking metrics, which have proved valid for performance assessment on simulators and in the operating room,4346 have similar limitations.47 While 2 individuals may perform similarly based on speed, accuracy, and motion metrics, they may experience substantial differences in workload and attentional demands, which reflect differences in experience, true skill level, and learning.10,42 Importantly, incomplete metrics may impair the ability of simulators to confer the maximal skill to trainees. In a prior study,41 a visual-spatial secondary task that measured the spare attentional capacity of the performer proved more sensitive in detecting superior performance differences than the traditional metrics of speed and accuracy. Thus, incorporating these new metrics of automaticity42,48 into simulator training may help to better define and assess performance; this may have a considerable positive effect on trainee skill acquisition and learning. Such metrics may also help us determine the appropriate simulator training duration. Currently, most proficiency-based curricula require that trainees reach the proficiency level 2 consecutive times, an arbitrary amount of overtraining. Overtraining refers to the amount of additional training after initial proficiency is achieved that can positively affect trainee skill and learning.10 Because excessive training can lead to skill degradation,10 secondary task metrics may help quantify the amount of overtraining required to maximize learning by identifying the point of training where learning is complete. In a recent study,49 the application of automaticity metrics led to longer training duration of novices compared with the traditional metrics of speed and accuracy. On a practical note, expert-derived performance goals on the chosen tasks of the available simulators should be established and provided to residents as training goals. Such goals that are usually based on speed and accuracy/errors (±motion metrics) can be found in the literature for most laparoscopic simulators, but could also be established using local experts and previously described methods.14,50,51 In addition, trainees should be required to achieve these goals on consecutive attempts (2 are used by most authors)4,32,37 and perform a number of additional repetitions (5-10) for reinforcement. As mentioned, these requirements need further study, and additional metrics may be needed for optimal performance assessment.

Place holder to copy figure label and caption
Figure 1.

The typical learning characteristics of different individuals during simulation training. Each trainee (solid line) achieves the expert-derived performance goal at different training durations. When the training duration is chosen arbitrarily (dashed line, arrow), some trainees will not have achieved the desired performance level and others will have trained for too long. Given the variability of individual skill acquisition rates, time-based curricula prevent some trainees from reaching the desired skill level, while others train longer than needed.

Graphic Jump Location

Deliberate, repetitive practice is essential for performance improvement11 and should be an integral component of a skills curriculum. Another important factor is practice distribution. Distributed practice (multiple training sessions) has been demonstrated to lead to better skill acquisition compared with massed practice (all training occurs in one training session).10 Moulton et al52 demonstrated in a randomized controlled trial that residents retain and transfer simulator-acquired skills better if taught in a distributed rather than massed manner. Little is known about the optimal duration of and the interval between training sessions. Expert opinion suggests that 1-hour training sessions may be best,11 but no high-quality evidence exists. From a practical standpoint, weekly 1-hour sessions may be best suited for resident training. Such a schedule provides ample opportunity for training and rest time between sessions, is easy to organize, and is unlikely to interfere with the busy schedule of the house officer.

An important and frequently overlooked aspect of simulator training is the retention of acquired skill. Evidence suggests that simulator-acquired skill deteriorates over time without ongoing practice.37,39 A recent study showed that novices who trained at regular intervals after achieving initial proficiency maintained more of their skill 6 months later than those who had no ongoing training.37 Maintenance training should thus be part of all simulator curricula and can be accomplished by scheduling testing/training sessions every 1 to 3 months after initial proficiency is achieved. Evidence of significant skill deterioration between retention sessions should lead to the reinstatement of weekly training.

Because proficiency-based simulator curricula have variable lengths depending on individual performance differences, the ability to predict training duration enables educators to better plan training sessions so that every trainee can achieve proficiency within the confines of the academic year. A number of baseline tests have been shown to correlate with the training duration of a proficiency-based simulator curriculum.53,54 Using this information may help identify slow learners early in the training process so they can undergo more intense training and complete the curriculum in the required time.53 Testing at baseline and at the end of the curriculum combined with performance monitoring during training can help boost trainees' motivation by enabling them to track improvements in their performance.20 It also helps instructors document participant progress, adjust the curriculum, and obtain useful information for future curriculum improvement and research. Thus, training should be tailored to individual needs based on baseline performance.

Practice variability and increasing levels of training difficulty have also been shown to improve the retention and transfer of simulator-acquired skill55,56 by challenging trainees, increasing the contextual interference of training, and promoting the development of different learning strategies.57 A recent systematic review of the effect of high-fidelity medical simulations on learning reported that learning was enhanced when trainees practiced with progressively increasing levels of difficulty.55 Similar findings were reported by Ali et al58 and Aggarwal et al19 for laparoscopic simulator training. We have previously demonstrated that training in laparoscopic suturing under more difficult simulator conditions led to improved performance on the simulator but not in the animal operating room.33 Skills curricula should thus include many tasks, variability of practice, and training of increasing difficulty. Furthermore, the curriculum should be adjusted to the level of training by fostering basic skills for the junior residents and should become more challenging for the seniors. Along these lines, junior residents should start with basic laparoscopic skill training and advance to complex laparoscopic procedural training over the ensuing years.

Mental imagery, the mental rehearsal of a skill before it is practiced, appears to be effective as a practice strategy to facilitate the learning and relearning of motor skills and can be used as a preparation strategy for well-learned skills.10,59 Its application to simulator training may prove valuable.59

In summary, a successful laparoscopic skills curriculum depends on many factors including participant motivation, available resources and personnel, and trainee and faculty commitment. It should encompass goal-oriented training, sensitive performance metrics, appropriate methods of instruction and feedback, deliberate, distributed, and variable practice, an amount of overtraining, maintenance training, and a cognitive component (Figure 2). A curriculum that follows these principles is likely to spark trainee interest, ensure participation and satisfaction, and lead to an effective and efficient way of acquiring new skills using simulators. While a best formula for a simulator curriculum may not exist, a skills curriculum is a dynamic process that should be in constant evolution based on accumulated experiences. Furthermore, a skills curriculum should have plasticity and should be tailored to the individual training needs rather than be inflexible and insensitive to individual learning differences. Our experience with the practical application of these principles to the resident curriculum has recently been published elsewhere.14

Place holder to copy figure label and caption
Figure 2.

Schematic representation of a suggested simulator curriculum for cognitive and manual skills training, adjusted to the level of the trainee. The line represents the academic year; boxes, individual training sessions.

Graphic Jump Location

Correspondence: Dimitrios Stefanidis, MD, PhD, Department of General Surgery, Carolinas Medical Center, 1000 Blythe Blvd, MEB 601, Charlotte, NC 28203 (dimitrios.stefanidis@carolinashealthcare.org).

Accepted for Publication: December 11, 2007.

Author Contributions:Study concept and design: Stefanidis and Heniford. Drafting of the manuscript: Stefanidis. Critical revision of the manuscript for important intellectual content: Heniford. Study supervision: Heniford.

Financial Disclosure: None reported.

Fried  GMFeldman  LSVassiliou  MC  et al.  Proving the value of simulation in laparoscopic surgery. Ann Surg 2004;240 (3) 518- 525
PubMed Link to Article
Haluck  RSSatava  RMFried  G  et al.  Establishing a simulation center for surgical skills: what to do and how to do it. Surg Endosc 2007;21 (7) 1223- 1232
PubMed Link to Article
Aggarwal  RMoorthy  KDarzi  A Laparoscopic skills training and assessment. Br J Surg 2004;91 (12) 1549- 1558
PubMed Link to Article
Korndorffer  JR  JrDunne  JBSierra  R  et al.  Simulator training for laparoscopic suturing using performance goals translates to the operating room. J Am Coll Surg 2005;201 (1) 23- 29
PubMed Link to Article
Ahlberg  GEnochsson  LGallagher  AG  et al.  Proficiency-based virtual reality training significantly reduces the error rate for residents during their first 10 laparoscopic cholecystectomies. Am J Surg 2007;193 (6) 797- 804
PubMed Link to Article
Korndorffer  JR  JrStefanidis  DScott  DJ Laparoscopic skills laboratories: current assessment and a call for resident training standards. Am J Surg 2006;191 (1) 17- 22
PubMed Link to Article
Gould  JC Building a laparoscopic surgical skills training laboratory: resources and support. JSLS 2006;10 (3) 293- 296
PubMed
American College of Surgeons Division of Education, ACS/APDS Surgical Skills Curriculum for Residents: Phase I. American College of Surgeons Web site. http://www.facs.org/education/surgicalskills.html. Accessed November 12, 2007
Aggarwal  RDarzi  A Organising a surgical skills centre. Minim Invasive Ther Allied Technol 2005;14 (4) 275- 279
PubMed Link to Article
Magill  RLearning and Control: Concepts and Applications. New York, NY McGraw Hill2004;
Ericsson  KA Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med 2004;79 (10) ((suppl)) S70- S81
PubMed Link to Article
Chang  LPetros  JHess  DT  et al.  Integrating simulation into a surgical residency program: is voluntary participation effective? Surg Endosc 2007;21 (3) 418- 421
PubMed Link to Article
Kolkman  WVan de Put  MAVan den Hout  WB  et al.  Implementation of the laparoscopic simulator in a gynecological residency curriculum. Surg Endosc 2007;21 (8) 1363- 1368
PubMed Link to Article
Stefanidis  DAcker  CSwiderski  DHeniford  BTGreene  FL Challenges during the implementation of a laparoscopic skills curriculum in a busy general surgery residency program [published online ahead of print February 26, 2008]. J Surg Educ 2008;65 (1) 4- 7
PubMed Link to Article
 Program requirements. American College of Surgeons Web site. http://www.facs.org/education/accreditationprogram/requirements.html. Accessed October 16, 2008
Yoo  MCVillegas  LJones  DB Basic ultrasound curriculum for medical students: validation of content and phantom. J Laparoendosc Adv Surg Tech A 2004;14 (6) 374- 379
PubMed Link to Article
Scott  DJBergen  PCRege  RV  et al.  Laparoscopic training on bench models: better and more cost effective than operating room experience? J Am Coll Surg 2000;191 (3) 272- 283
PubMed Link to Article
Hamilton  ECScott  DJKapoor  A  et al.  Improving operative performance using a laparoscopic hernia simulator. Am J Surg 2001;182 (6) 725- 728
PubMed Link to Article
Aggarwal  RGrantcharov  TMoorthy  K  et al.  A competency-based virtual reality training curriculum for the acquisition of laparoscopic psychomotor skill. Am J Surg 2006;191 (1) 128- 133
PubMed Link to Article
Fried  GM Lessons from the surgical experience with simulators: incorporation into training and utilization in determining competency. Gastrointest Endosc Clin N Am 2006;16 (3) 425- 434
PubMed Link to Article
Peters  JHFried  GMSwanstrom  LL  et al.  Development and validation of a comprehensive program of education and assessment of the basic fundamentals of laparoscopic surgery. Surgery 2004;135 (1) 21- 27
PubMed Link to Article
Hodges  NJFranks  IM Modelling coaching practice: the role of instruction and demonstration. J Sports Sci 2002;20 (10) 793- 811
PubMed Link to Article
Rosser  JCHerman  BRisucci  DA  et al.  Effectiveness of a CD-ROM multimedia tutorial in transferring cognitive knowledge essential for laparoscopic skill training. Am J Surg 2000;179 (4) 320- 324
PubMed Link to Article
Takiguchi  SSekimoto  MYasui  M  et al.  Cyber visual training as a new method for the mastery of endoscopic surgery. Surg Endosc 2005;19 (9) 1204- 1210
PubMed Link to Article
Xeroulis  GJPark  JMoulton  CA  et al.  Teaching suturing and knot-tying skills to medical students: a randomized controlled study comparing computer-based video instruction and (concurrent and summary) expert feedback. Surgery 2007;141 (4) 442- 449
PubMed Link to Article
Pearson  AMGallagher  AGRosser  JC  et al.  Evaluation of structured and quantitative training methods for teaching intracorporeal knot tying. Surg Endosc 2002;16 (1) 130- 137
PubMed Link to Article
Stefanidis  DKorndorffer  JR  JrHeniford  BTScott  DJ Limited feedback and video tutorials optimize learning and resource utilization during laparoscopic simulator training. Surgery 2007;142 (2) 202- 206
PubMed Link to Article
Ende  J Feedback in clinical medical education. JAMA 1983;250 (6) 777- 781
PubMed Link to Article
Rogers  DARegehr  GHowdieshell  TR  et al.  The impact of external feedback on computer-assisted learning for surgical technical skill training. Am J Surg 2000;179 (4) 341- 343
PubMed Link to Article
Mahmood  TDarzi  A The learning curve for a colonoscopy simulator in the absence of any feedback: no feedback, no learning. Surg Endosc 2004;18 (8) 1224- 1230
PubMed Link to Article
Porte  MCXeroulis  GReznick  RK  et al.  Verbal feedback from an expert is more effective than self-accessed feedback about motion efficiency in learning new surgical skills. Am J Surg 2007;193 (1) 105- 110
PubMed Link to Article
Seymour  NEGallagher  AGRoman  SA  et al.  Virtual reality training improves operating room performance: results of a randomized, double-blinded study. Ann Surg 2002;236 (4) 458- 463
PubMed Link to Article
Stefanidis  DKorndorffer  JRMarkley  SSierra  RHeniford  BTScott  DJ Closing the gap in operative performance between novices and experts: does harder mean better for laparoscopic simulator training? J Am Coll Surg 2007;205 (2) 307- 313
PubMed Link to Article
Gallagher  AGRitter  EMChampion  H  et al.  Virtual reality simulation for the operating room: proficiency-based training as a paradigm shift in surgical skills training. Ann Surg 2005;241 (2) 364- 372
PubMed Link to Article
Hamstra  SJDubrowski  ABackstein  D Teaching technical skills to surgical residents: a survey of empirical research. Clin Orthop Relat Res 2006;449108- 115
PubMed
Aggarwal  RGrantcharov  TPEriksen  JR  et al.  An evidence-based virtual reality training program for novice laparoscopic surgeons. Ann Surg 2006;244 (2) 310- 314
PubMed Link to Article
Stefanidis  DKorndorffer  JR  JrMarkley  S  et al.  Proficiency maintenance: impact of ongoing simulator training on laparoscopic skill retention. J Am Coll Surg 2006;202 (4) 599- 603
PubMed Link to Article
Satava  RMGallagher  AGPellegrini  CA Surgical competence and surgical proficiency: definitions, taxonomy, and metrics. J Am Coll Surg 2003;196 (6) 933- 937
PubMed Link to Article
Stefanidis  DKorndorffer  JR  JrSierra  R  et al.  Skill retention following proficiency-based laparoscopic simulator training. Surgery 2005;138 (2) 165- 170
PubMed Link to Article
Gonzalez  RBowers  SPSmith  CD  et al.  Does setting specific goals and providing feedback during training result in better acquisition of laparoscopic skills? Am Surg 2004;70 (1) 35- 39
PubMed
Stefanidis  DScerbo  MWKorndorffer  JR  Jr  et al.  Redefining simulator proficiency using automaticity theory. Am J Surg 2007;193 (4) 502- 506
PubMed Link to Article
Wickens  CDHollands  JEngineering Psychology and Human Performance. Upper Saddle River, NJ Prentice Hall Inc2000;
Aggarwal  RGrantcharov  TMoorthy  K  et al.  An evaluation of the feasibility, validity, and reliability of laparoscopic skills assessment in the operating room. Ann Surg 2007;245 (6) 992- 999
PubMed Link to Article
Moorthy  KMunz  YDosis  ABello  FDarzi  A Motion analysis in the training and assessment of minimally invasive surgery. Minim Invasive Ther Allied Technol 2003;12 (3) 137- 142
PubMed Link to Article
Van Sickle  KR McClusky  DA  IIIGallagher  AG  et al.  Construct validation of the ProMIS simulator using a novel laparoscopic suturing task. Surg Endosc 2005;19 (9) 1227- 1231
PubMed Link to Article
Ritter  EMKindelan  TWMichael  C  et al.  Concurrent validity of augmented reality metrics applied to the fundamentals of laparoscopic surgery (FLS). Surg Endosc 2007;21 (8) 1441- 1445
PubMed Link to Article
Stefanidis  DScott  DJKorndorffer  JR  Jr Do metrics matter? time versus motion tracking for performance assessment of proficiency-based laparoscopic skills training. J Soc Simulation Healthcare
Shiffrin  RMSchneider  W Controlled and automatic human information processing II: perceptual learning, automatic attending, and a general theory. Psychol Rev 1977;48 (2) 127- 190
Link to Article
Stefanidis  DScerbo  MWSechrist  CMostafavi  AHeniford  BT Do novices display automaticity during simulator training? Am J Surg 2008;195 (2) 210- 213
PubMed Link to Article
Korndorffer  JR  JrScott  DJSierra  R  et al.  Developing and testing competency levels for laparoscopic skills training. Arch Surg 2005;140 (1) 80- 84
PubMed Link to Article
Ritter  EMScott  DJ Design of a proficiency-based skills training curriculum for the fundamentals of laparoscopic surgery. Surg Innov 2007;14 (2) 107- 112
PubMed Link to Article
Moulton  CADubrowski  AMacRae  H  et al.  Teaching surgical skills: what kind of practice makes perfect? a randomized, controlled trial. Ann Surg 2006;244 (3) 400- 409
PubMed
Stefanidis  DKorndorffer  JR  JrBlack  FW  et al.  Psychomotor testing predicts rate of skill acquisition for proficiency-based laparoscopic skills training. Surgery 2006;140 (2) 252- 262
PubMed Link to Article
Ritter  EM McClusky  DA  IIIGallagher  AG  et al.  Perceptual, visuospatial, and psychomotor abilities correlate with duration of training required on a virtual-reality flexible endoscopy simulator. Am J Surg 2006;192 (3) 379- 384
PubMed Link to Article
Issenberg  SB McGaghie  WCPetrusa  ER  et al.  Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Med Teach 2005;27 (1) 10- 28
PubMed Link to Article
Hall  KGMagill  RA Variability of practice and contextual interference in motor skill learning. J Mot Behav 1995;27 (4) 299- 309
PubMed Link to Article
Shea  JBMorgan  RL Contextual interference effects on the acquisition, retention, and transfer of a motor skill. J Exp Psychol [Hum Learn] 1979;5 (2) 179- 187
Link to Article
Ali  MRMowery  YKaplan  B  et al.  Training the novice in laparoscopy: more challenge is better. Surg Endosc 2002;16 (12) 1732- 1736
PubMed Link to Article
Immenroth  MBurger  TBrenner  J  et al.  Mental training in surgical education: a randomized controlled trial. Ann Surg 2007;245 (3) 385- 391
PubMed Link to Article

Figures

Place holder to copy figure label and caption
Figure 1.

The typical learning characteristics of different individuals during simulation training. Each trainee (solid line) achieves the expert-derived performance goal at different training durations. When the training duration is chosen arbitrarily (dashed line, arrow), some trainees will not have achieved the desired performance level and others will have trained for too long. Given the variability of individual skill acquisition rates, time-based curricula prevent some trainees from reaching the desired skill level, while others train longer than needed.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Schematic representation of a suggested simulator curriculum for cognitive and manual skills training, adjusted to the level of the trainee. The line represents the academic year; boxes, individual training sessions.

Graphic Jump Location

Tables

References

Fried  GMFeldman  LSVassiliou  MC  et al.  Proving the value of simulation in laparoscopic surgery. Ann Surg 2004;240 (3) 518- 525
PubMed Link to Article
Haluck  RSSatava  RMFried  G  et al.  Establishing a simulation center for surgical skills: what to do and how to do it. Surg Endosc 2007;21 (7) 1223- 1232
PubMed Link to Article
Aggarwal  RMoorthy  KDarzi  A Laparoscopic skills training and assessment. Br J Surg 2004;91 (12) 1549- 1558
PubMed Link to Article
Korndorffer  JR  JrDunne  JBSierra  R  et al.  Simulator training for laparoscopic suturing using performance goals translates to the operating room. J Am Coll Surg 2005;201 (1) 23- 29
PubMed Link to Article
Ahlberg  GEnochsson  LGallagher  AG  et al.  Proficiency-based virtual reality training significantly reduces the error rate for residents during their first 10 laparoscopic cholecystectomies. Am J Surg 2007;193 (6) 797- 804
PubMed Link to Article
Korndorffer  JR  JrStefanidis  DScott  DJ Laparoscopic skills laboratories: current assessment and a call for resident training standards. Am J Surg 2006;191 (1) 17- 22
PubMed Link to Article
Gould  JC Building a laparoscopic surgical skills training laboratory: resources and support. JSLS 2006;10 (3) 293- 296
PubMed
American College of Surgeons Division of Education, ACS/APDS Surgical Skills Curriculum for Residents: Phase I. American College of Surgeons Web site. http://www.facs.org/education/surgicalskills.html. Accessed November 12, 2007
Aggarwal  RDarzi  A Organising a surgical skills centre. Minim Invasive Ther Allied Technol 2005;14 (4) 275- 279
PubMed Link to Article
Magill  RLearning and Control: Concepts and Applications. New York, NY McGraw Hill2004;
Ericsson  KA Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med 2004;79 (10) ((suppl)) S70- S81
PubMed Link to Article
Chang  LPetros  JHess  DT  et al.  Integrating simulation into a surgical residency program: is voluntary participation effective? Surg Endosc 2007;21 (3) 418- 421
PubMed Link to Article
Kolkman  WVan de Put  MAVan den Hout  WB  et al.  Implementation of the laparoscopic simulator in a gynecological residency curriculum. Surg Endosc 2007;21 (8) 1363- 1368
PubMed Link to Article
Stefanidis  DAcker  CSwiderski  DHeniford  BTGreene  FL Challenges during the implementation of a laparoscopic skills curriculum in a busy general surgery residency program [published online ahead of print February 26, 2008]. J Surg Educ 2008;65 (1) 4- 7
PubMed Link to Article
 Program requirements. American College of Surgeons Web site. http://www.facs.org/education/accreditationprogram/requirements.html. Accessed October 16, 2008
Yoo  MCVillegas  LJones  DB Basic ultrasound curriculum for medical students: validation of content and phantom. J Laparoendosc Adv Surg Tech A 2004;14 (6) 374- 379
PubMed Link to Article
Scott  DJBergen  PCRege  RV  et al.  Laparoscopic training on bench models: better and more cost effective than operating room experience? J Am Coll Surg 2000;191 (3) 272- 283
PubMed Link to Article
Hamilton  ECScott  DJKapoor  A  et al.  Improving operative performance using a laparoscopic hernia simulator. Am J Surg 2001;182 (6) 725- 728
PubMed Link to Article
Aggarwal  RGrantcharov  TMoorthy  K  et al.  A competency-based virtual reality training curriculum for the acquisition of laparoscopic psychomotor skill. Am J Surg 2006;191 (1) 128- 133
PubMed Link to Article
Fried  GM Lessons from the surgical experience with simulators: incorporation into training and utilization in determining competency. Gastrointest Endosc Clin N Am 2006;16 (3) 425- 434
PubMed Link to Article
Peters  JHFried  GMSwanstrom  LL  et al.  Development and validation of a comprehensive program of education and assessment of the basic fundamentals of laparoscopic surgery. Surgery 2004;135 (1) 21- 27
PubMed Link to Article
Hodges  NJFranks  IM Modelling coaching practice: the role of instruction and demonstration. J Sports Sci 2002;20 (10) 793- 811
PubMed Link to Article
Rosser  JCHerman  BRisucci  DA  et al.  Effectiveness of a CD-ROM multimedia tutorial in transferring cognitive knowledge essential for laparoscopic skill training. Am J Surg 2000;179 (4) 320- 324
PubMed Link to Article
Takiguchi  SSekimoto  MYasui  M  et al.  Cyber visual training as a new method for the mastery of endoscopic surgery. Surg Endosc 2005;19 (9) 1204- 1210
PubMed Link to Article
Xeroulis  GJPark  JMoulton  CA  et al.  Teaching suturing and knot-tying skills to medical students: a randomized controlled study comparing computer-based video instruction and (concurrent and summary) expert feedback. Surgery 2007;141 (4) 442- 449
PubMed Link to Article
Pearson  AMGallagher  AGRosser  JC  et al.  Evaluation of structured and quantitative training methods for teaching intracorporeal knot tying. Surg Endosc 2002;16 (1) 130- 137
PubMed Link to Article
Stefanidis  DKorndorffer  JR  JrHeniford  BTScott  DJ Limited feedback and video tutorials optimize learning and resource utilization during laparoscopic simulator training. Surgery 2007;142 (2) 202- 206
PubMed Link to Article
Ende  J Feedback in clinical medical education. JAMA 1983;250 (6) 777- 781
PubMed Link to Article
Rogers  DARegehr  GHowdieshell  TR  et al.  The impact of external feedback on computer-assisted learning for surgical technical skill training. Am J Surg 2000;179 (4) 341- 343
PubMed Link to Article
Mahmood  TDarzi  A The learning curve for a colonoscopy simulator in the absence of any feedback: no feedback, no learning. Surg Endosc 2004;18 (8) 1224- 1230
PubMed Link to Article
Porte  MCXeroulis  GReznick  RK  et al.  Verbal feedback from an expert is more effective than self-accessed feedback about motion efficiency in learning new surgical skills. Am J Surg 2007;193 (1) 105- 110
PubMed Link to Article
Seymour  NEGallagher  AGRoman  SA  et al.  Virtual reality training improves operating room performance: results of a randomized, double-blinded study. Ann Surg 2002;236 (4) 458- 463
PubMed Link to Article
Stefanidis  DKorndorffer  JRMarkley  SSierra  RHeniford  BTScott  DJ Closing the gap in operative performance between novices and experts: does harder mean better for laparoscopic simulator training? J Am Coll Surg 2007;205 (2) 307- 313
PubMed Link to Article
Gallagher  AGRitter  EMChampion  H  et al.  Virtual reality simulation for the operating room: proficiency-based training as a paradigm shift in surgical skills training. Ann Surg 2005;241 (2) 364- 372
PubMed Link to Article
Hamstra  SJDubrowski  ABackstein  D Teaching technical skills to surgical residents: a survey of empirical research. Clin Orthop Relat Res 2006;449108- 115
PubMed
Aggarwal  RGrantcharov  TPEriksen  JR  et al.  An evidence-based virtual reality training program for novice laparoscopic surgeons. Ann Surg 2006;244 (2) 310- 314
PubMed Link to Article
Stefanidis  DKorndorffer  JR  JrMarkley  S  et al.  Proficiency maintenance: impact of ongoing simulator training on laparoscopic skill retention. J Am Coll Surg 2006;202 (4) 599- 603
PubMed Link to Article
Satava  RMGallagher  AGPellegrini  CA Surgical competence and surgical proficiency: definitions, taxonomy, and metrics. J Am Coll Surg 2003;196 (6) 933- 937
PubMed Link to Article
Stefanidis  DKorndorffer  JR  JrSierra  R  et al.  Skill retention following proficiency-based laparoscopic simulator training. Surgery 2005;138 (2) 165- 170
PubMed Link to Article
Gonzalez  RBowers  SPSmith  CD  et al.  Does setting specific goals and providing feedback during training result in better acquisition of laparoscopic skills? Am Surg 2004;70 (1) 35- 39
PubMed
Stefanidis  DScerbo  MWKorndorffer  JR  Jr  et al.  Redefining simulator proficiency using automaticity theory. Am J Surg 2007;193 (4) 502- 506
PubMed Link to Article
Wickens  CDHollands  JEngineering Psychology and Human Performance. Upper Saddle River, NJ Prentice Hall Inc2000;
Aggarwal  RGrantcharov  TMoorthy  K  et al.  An evaluation of the feasibility, validity, and reliability of laparoscopic skills assessment in the operating room. Ann Surg 2007;245 (6) 992- 999
PubMed Link to Article
Moorthy  KMunz  YDosis  ABello  FDarzi  A Motion analysis in the training and assessment of minimally invasive surgery. Minim Invasive Ther Allied Technol 2003;12 (3) 137- 142
PubMed Link to Article
Van Sickle  KR McClusky  DA  IIIGallagher  AG  et al.  Construct validation of the ProMIS simulator using a novel laparoscopic suturing task. Surg Endosc 2005;19 (9) 1227- 1231
PubMed Link to Article
Ritter  EMKindelan  TWMichael  C  et al.  Concurrent validity of augmented reality metrics applied to the fundamentals of laparoscopic surgery (FLS). Surg Endosc 2007;21 (8) 1441- 1445
PubMed Link to Article
Stefanidis  DScott  DJKorndorffer  JR  Jr Do metrics matter? time versus motion tracking for performance assessment of proficiency-based laparoscopic skills training. J Soc Simulation Healthcare
Shiffrin  RMSchneider  W Controlled and automatic human information processing II: perceptual learning, automatic attending, and a general theory. Psychol Rev 1977;48 (2) 127- 190
Link to Article
Stefanidis  DScerbo  MWSechrist  CMostafavi  AHeniford  BT Do novices display automaticity during simulator training? Am J Surg 2008;195 (2) 210- 213
PubMed Link to Article
Korndorffer  JR  JrScott  DJSierra  R  et al.  Developing and testing competency levels for laparoscopic skills training. Arch Surg 2005;140 (1) 80- 84
PubMed Link to Article
Ritter  EMScott  DJ Design of a proficiency-based skills training curriculum for the fundamentals of laparoscopic surgery. Surg Innov 2007;14 (2) 107- 112
PubMed Link to Article
Moulton  CADubrowski  AMacRae  H  et al.  Teaching surgical skills: what kind of practice makes perfect? a randomized, controlled trial. Ann Surg 2006;244 (3) 400- 409
PubMed
Stefanidis  DKorndorffer  JR  JrBlack  FW  et al.  Psychomotor testing predicts rate of skill acquisition for proficiency-based laparoscopic skills training. Surgery 2006;140 (2) 252- 262
PubMed Link to Article
Ritter  EM McClusky  DA  IIIGallagher  AG  et al.  Perceptual, visuospatial, and psychomotor abilities correlate with duration of training required on a virtual-reality flexible endoscopy simulator. Am J Surg 2006;192 (3) 379- 384
PubMed Link to Article
Issenberg  SB McGaghie  WCPetrusa  ER  et al.  Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Med Teach 2005;27 (1) 10- 28
PubMed Link to Article
Hall  KGMagill  RA Variability of practice and contextual interference in motor skill learning. J Mot Behav 1995;27 (4) 299- 309
PubMed Link to Article
Shea  JBMorgan  RL Contextual interference effects on the acquisition, retention, and transfer of a motor skill. J Exp Psychol [Hum Learn] 1979;5 (2) 179- 187
Link to Article
Ali  MRMowery  YKaplan  B  et al.  Training the novice in laparoscopy: more challenge is better. Surg Endosc 2002;16 (12) 1732- 1736
PubMed Link to Article
Immenroth  MBurger  TBrenner  J  et al.  Mental training in surgical education: a randomized controlled trial. Ann Surg 2007;245 (3) 385- 391
PubMed Link to Article

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 53

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Articles Related By Topic
Related Collections
PubMed Articles