2017 APDS SPRING MEETINGImmediate Auditory Feedback is Superior to Other Types of Feedback for Basic Surgical Skills Acquisition
Introduction
Surgical residents suture multiple wounds daily and are required to have the skills necessary to perform these tasks without supervision.1 Surgical residents must learn the appropriate amount of force that can be applied to various types of human tissues without causing damage. Currently, feedback for surgical residents regarding the amount of force applied is provided in the operating room either via subjective assessment by their faculty stating that there was too much tension exerted on the tissue or objectively through visual feedback from a bleeding vessel, tearing of tissue, or breakage of the suture.
Though learning technical surgical skills has traditionally been in the operating room, a myriad of factors have increased challenges to training and have resulted in fewer learning opportunities for the surgical resident. Such challenges include increasing regulations limiting resident duty hours, a range of newer surgical techniques, and increased concerns regarding patient safety.2, 3, 4, 5, 6 Furthermore, although structured feedback is essential for the advancement of surgical skills, others have found that there is a discrepancy in the perception of giving and receiving feedback from faculty members to surgical residents.6, 7 Feedback given to surgical residents tends to be infrequent and without a standardized format.6, 7
Formative feedback to the learner is paramount to the successful acquisition of skills. It has been defined as “an assessment which is used for improvement (individual or program) rather than for making final decisions or accountability. The role of formative assessment is to provide information which can be used to make immediate modifications in teaching and learning.”8, 9 Summative feedback, on the other hand, has been defined as “assessments at the conclusion of a course or program … generally used for accountability purposes or to judge the value or worth of a program or course and are usually collected at or near the end of a program or course.”8, 9 Therefore, formative feedback occurs during the process of learning, providing opportunity for immediate improvement and modification of the skill while summative feedback occurs at the end of the learning experience, which is useful for improvement on subsequent trials.8, 9
Using simulation curricula has been suggested to mitigate some of the challenges to training and enhance surgical training. It has been repeatedly shown to be an effective tool to improve operative skills of residents.10, 11, 12 Specifically, force feedback simulation models have been shown to be useful for enhancing tissue handling skills.2, 13, 14 Some studies have suggested that training with real-time visual feedback of instrument motion in virtual-reality and augmented-reality simulators have a positive effect on learning.1, 2 There are multiple studies regarding skills transfer to the operating room after implementation and practice of surgical simulation curricula.6, 15, 16, 17 Participants who achieve surgical skills proficiency-based benchmarks perform better on assessments and have fewer errors in the operating room than those who do not receive simulation training.6, 15, 16, 17 Proficiency goals generally include time to complete the exercise and errors committed. Under the proficiency-based training paradigm, a trainee will practice this exercise repeatedly until he/she can meet the proficiency goal. At this point, the trainee is considered proficient (i.e., equal to an expert's performance on the specific exercise).18
A few studies have examined skills improvement using simulation-based force feedback models using different types of feedback. Hsu et al.2, 14 built a model that measures force while knot-tying. Their study provided immediate visual feedback and found that participants exerted significantly less force after training on their model.2, 14 Cutler et al.19 conducted a study on a peeling exercise simulating retinal surgery and found that adding auditory feedback resulted in less force, improved performance and greater precision. The gaps in these studies are that they do not compare proficiency training using both immediate versus delayed and type of feedback using auditory versus visual.
The aim of our study was to examine the effect of timing and type of feedback on the performance of surgical knot-tying in novice medical students using visual versus auditory and immediate versus delayed feedback. Our hypotheses included (1) participants who received any feedback regardless of timing or type of feedback would perform better than those who received no feedback, (2) participants who received immediate feedback would perform better than those who received delayed feedback, and (3) participants who received auditory feedback would perform better for surgical skills acquisition compared to those who received visual feedback regardless of timing of feedback (Table).
Section snippets
Materials and Methods
After obtaining Institutional Review Board approval, a randomized trial was conducted at the University of Texas Health Science Center at San Antonio (San Antonio, TX) from September 2016 to March 2017.
We recruited 69 first- and second-year medical students via e-mail. Participants were asked to complete a demographic questionnaire that included age, gender, years of medical school, their interest in pursuing surgery as a specialty and whether they had completed a surgical clerkship before
Demographics
Of the 69 first- and second-year medical students included in this study, 51% (n = 35) were female, 52% (n = 36) were in their second year, and the average age was 24 (range: 21–35). Furthermore, 59% (n = 41) expressed interest in pursuing a surgical specialty as a future career and none had completed a surgical clerkship before being enrolled.
Pretest Versus Posttest
Using paired t-test, we compared pretest to posttest results of all participants regardless of training condition to evaluate whether there was a
Discussion
Our study examined the effect of timing and type of feedback on the performance of surgical knot-tying in novice medical students with the aim of elucidating the optimal modality for feedback. We measured the number of trials required to reach proficiency in 5 experimental groups: no feedback (control), immediate auditory, delayed auditory, immediate visual, and delayed visual feedback. Trials were conducted on a knot-tying model that simulated a bleeding vessel that measured by the amount of
Conclusion
In a surgical force feedback simulation model, immediate auditory feedback resulted in fewer training trials to reach proficiency and fewer leaks compared to visual and delayed forms of feedback.
Acknowledgments
We would like to acknowledge Justin Hsu and Dr Kimberly Brown from University of Texas Medical Branch in Galveston for sharing their model design that was modified and expanded upon for this study. Also, we would like to acknowledge Zaid Mahmood, Will Hopper, and Sruti Nuthalapati, medical students from the University of Texas Health Science Center San Antonio School of Medicine and Melissa Heft, a college student from the University of Texas San Antonio for their kind assistance with data
References (25)
- et al.
Visual force feedback improves knot-tying security
J Surg Educ
(2014) - et al.
Force feedback vessel ligation simulator in knot-tying proficiency training
Am J Surg
(2016) - et al.
Factors compromising safety in surgery: stressful events in the operating room
Am J Surg
(2010) - et al.
Missed opportunities: a descriptive assessment of teaching and attitudes regarding communication skills in a surgical residency
Curr Surg
(2006) - et al.
A faculty toolkit for formative assessment in pharmacy education
Am J Pharm Educ
(2014) - et al.
Simulator training for laparoscopic suturing using performance goals translates to the operating room
J Am Coll Surg
(2005) - et al.
Design of vessel ligation simulator for deliberate practice
J Surg Res
(2015) - et al.
Comparing three pedagogical approaches to psychomotor skills acquisition
Am J Surg
(2012) - et al.
Implementation, construct validity, and benefit of a proficiency-based knot-tying and suturing curriculum
J Surg Educ
(2008) - et al.
Redefining simulator proficiency using automaticity theory
Am J Surg
(2007)
Teaching surgical skills—changes in the wind
N Engl J Med
Operation debrief: a SHARP improvement in performance feedback in the operating room
Ann Surg
Cited by (16)
Feedback Versus Compliments Versus Both in Suturing and Knot Tying Simulation: A Randomized Controlled Trial
2024, Journal of Surgical ResearchOptimizing surgical education through the implementation of a feedback curriculum
2022, American Journal of SurgeryCitation Excerpt :Yet, there is no formal training for faculty or senior residents on how to provide quality feedback, nor a requirement by the ACGME to do so. The “learning by doing” paradigm of this surgical education makes giving effective feedback crucial.4–6 Previous studies have shown that improving the quality of feedback provided to trainees positively impacts performance.6–9
Global versus task-specific postoperative feedback in surgical procedure learning
2021, Surgery (United States)Citation Excerpt :The latter was found to be superior for learning basic surgical skills; however, Al Fayyad et al found the opposite. In their study, concurrent (immediate) feedback was perceived as superior in learning basic surgical skills compared to summary (delayed) feedback.51 In our study, summary feedback was chosen because the students operated on a simulation model without the risk of doing any harm.
Nursing students’ perceptions towards branching path simulation as an effective interactive learning method
2020, Teaching and Learning in NursingCitation Excerpt :Moreover, all of the students in the current study agreed and strongly agreed that the immediate feedback helped them understand the case scenarios. According to behaviorism, immediate feedback is superior to delayed feedback in developing professional skills such as history-taking skills, self-assessment, psychomotor skills, and physical examination (Al Fayyadh et al., 2017). In the study of Kovach and Rababa (2014), nurses’ clinical competences in pain management for PWD were improved as a result of them receiving immediate feedback in BPS.
Feasibility of an Operation™-Style Enhanced Low-Fidelity Ear Simulator for Otomicroscopy Training.
2024, Journal of Laryngology and Otology