Simulation is effective for the acquisition of fundamental surgical skills through goal-directed practice. There is little evidence, however, to guide educators on how to best implement simulation within the curriculum. We investigated 1) whether practicing a basic simulator task (peg transfer, PT) facilitates learning a more complex skill (intracorporeal suture, ICS) and 2) compared the effect of training to mastery on the PT task (overtraining) with training to the passing level (standard training) on learning the ICS task.
98 laparoscopic simulator naïve participants were evaluated in the FLS PT and ICS tasks at baseline using standard metrics. Participants were randomized to one of three PT training groups: controls (no PT practice), standard training (PT practice to the passing FLS score (235)), and overtraining (PT practice to mastery level (252)). All participants were trained by a blinded educator in ICS until the passing FLS score (370) was achieved. The learning curves for ICS were analyzed by estimating the learning plateau (asymptote) and learning rate (number of trials to reach 95% of plateau) using nonlinear regression. Skill retention was assessed by retesting participants on both tasks one month after completing ICS training. The groups were compared using ANOVA. Effectiveness of skill transfer was calculated using the Transfer Effectiveness Ratio (TER), relating time needed to learn ICS to time invested in PT practice. Data are presented as mean (SD). * p<0.05.
77 participants completed the study: 28 controls, 26 standard and 23 overtrained. ICS learning curve plateau rose with increasing PT practice (452(10) vs. 459(10) vs. 467(10), p<0.01). There was a trend toward higher initial ICS score (128(107) vs. 127(110) vs. 183 (106), p=0.13) and faster learning rate (15(4) vs. 14(4) vs. 13(4) trials, p=0.10) with increasing PT training. At retention testing, initial PT score was lower in the control group (202(27) vs. 236(8) vs. 242(17), p<0.01), but did not differ between standard and overtraining (p=0.5). There were no differences in ICS retention scores. PT training took 20(10) minutes for standard training and 39(20) minutes for overtraining (p<0.01). ICS training time was 53(17) minutes for controls, 47(15) minutes for standard and 42(17) minutes for overtrained participants (p=0.05); post hoc analysis revealed that the overtrained participants saved an average of 11(5) minutes in ICS training compared to controls (p=0.04). However, the TER for was 0.165 for the overtraining group and 0.160 for the standard training group, suggesting that PT mastery practice took longer than the time saved on ICS training.
For novices, initial training using the PT task facilitates learning ICS. Overtraining on PT, however, proved to be an inefficient strategy for learning ICS, as there were only minor differences in ICS learning plateaus despite a significant time investment.