Teaching suturing and knot-tying skills to medical students: A randomized controlled study comparing computer-based video instruction and (concurrent and summary) expert feedback

doi:10.1016/j.surg.2006.09.012

Surgery

Volume 141, Issue 4, April 2007, Pages 442-449

https://doi.org/10.1016/j.surg.2006.09.012 Get rights and content

Background

We carried out a prospective, randomized, 4-arm study including control arm, blinding of examiners to determine effectiveness of computer-based video instruction (CBVI) and different types of expert feedback (concurrent and summary) on learning of a basic technical skill.

Methods

Using bench models, participants were pre-tested on a suturing and instrument knot-tying skill after viewing an instructional video. The students were subsequently assigned randomly to 4 practice conditions: no additional intervention (control), self study with CBVI, expert feedback during practice trials (concurrent feedback), and expert feedback after practice trials (summary feedback). All participants underwent 19 trials of practice, over 1 hour, in their assigned training condition. The effectiveness of training was assessed both at an immediate post-test and 1 month later at a retention test. Performance was evaluated using both expert-based (Global Rating Scores) and computer-based assessment (Hand Motion Analysis). Data were analyzed using repeated-measures ANOVA.

Results

There were no differences in GRS between groups at pre-test. The CBVI, concurrent feedback and summary feedback methods were equally effective initially for the instruction of this basic technical skill to naive medical students and displayed better performance than control (control, 12.71 [10.79 to 14.62]; CBVI, 16.39 [14.38 to 18.40]; concurrent, 16.97 [15.79 to 18.15]; summary, 16.09 [13.57 to 18.62]; P < .001 each). At retention. however, only CBVI and summary feedback groups retained superior suturing and knot-tying performance versus control (control, 8.13 [6.94 to 9.85]; CBVI, 11.92 [10.19 to 14.99] P = .037; concurrent, 9.80 [8.55 to 13.45] P = .635; summary, 111.19 [10.27 to 14.29] P = .037). Hand motion data displayed a similar pattern of results. There were no group differences in the rate of learning (P > .05).

Conclusion

Our study showed that CBVI can be as effective as summary expert feedback in the instruction of basic technical skills to medical students. Thoughtfully incorporated into technical curricula, CBVI can make efficient use of faculty time and serve as a useful pedagogic adjunct for basic skills training. Additionally, our study provides evidence supporting an increased role of summary feedback to effectively train novices in technical skills.

Section snippets

Participants

Sixty Year 1 medical students at a single academic centre were recruited to participate in this study. Approval was obtained from the Health Sciences II University of Toronto Research Ethics Board and all students signed an informed consent.

Study design

The design was a prospective, randomized, 4-arm study including a control arm with blinding of the examiners. Participants were pre-tested on a suturing and instrument knot-tying skill (simple interrupted knots with 3 square throws) after viewing an

Expert assessment

Inter-rater reliability of the GRS, as evaluated by intra-class correlation coefficient was 0.904, indicating that evaluators were able to reliably distinguish between inferior and superior performances. There were no significant differences between groups at pre-test F(3,57) = .81, P = .494.

A repeated-measures analysis of variance (ANOVA) evaluating the effects of time (pre vs post vs retention) and group (control, CBVI, concurrent feedback, and summary feedback) showed a powerful main effect

Discussion

New technologies may have important educational advantages, but without proper validation, and support training for staff and students, they could prove to be an ineffective investment. Consequently, computer-based training should not be haphazardly introduced into curricula without proper empirical assessment of its optimal use. Similarly, commenting on the utility of virtual reality simulation, Gallagher et al¹⁴ stated that only thoughtful incorporation into a well-planned curriculum can take

Conclusion

This study questioned the statement that all practice is equal, and provided evidence supporting computer-assisted learning, and an increased role of summary feedback to effectively train novices in technical skills. It showed that CBVI can be as effective as summary expert feedback in the instruction of basic technical skills to medical students. Thoughtfully incorporated into training curricula, CBVI can make efficient use of faculty time and serve as a useful pedagogic adjunct for basic

References (31)

M.M. Carr et al.
Comparison of computer-assisted instruction and seminar instruction to acquire psychomotor and cognitive knowledge of epistaxis management
Otolaryngol Head Neck Surg
(1999)
D.A. Rogers et al.
Computer-assisted learning versus a lecture and feedback seminar for teaching a basic surgical technical skill
Am J Surg
(1998)
A.N. Summers et al.
Acquisition of surgical skills: a randomized trial of didactic, videotape, and computer-based training
Surgery
(1999)
V. Datta et al.
The use of electromagnetic motion tracking analysis to objectively measure open surgical skill in the laboratory-based model
J Am Coll Surg
(2001)
V. Datta et al.
The relationship between motion analysis and surgical technical assessments
Am J Surg
(2002)
A. Bandura et al.
Analysis of memory codes cumulative rehearsal in observational learning
J Res Pers
(1974)
D.A. Rogers et al.
The impact of external feedback on computer-assisted learning for surgical technical skill training
Am J Surg
(2000)
D.J. Anastakis et al.
Assessment of technical skills transfer from the bench training model to the human model
Am J Surg
(1999)
E.D. Grober et al.
Laboratory based training in urological microsurgery with bench model simulators: a randomized controlled trial evaluating the durability of technical skill
J Urol
(2004)
V. Datta et al.
Comparison of Bench test evaluations of surgical skill with live operating performance assessments
J Am Coll Surg
(2004)

M.M. Carr et al.

Internet-based otolaryngology case discussions for medical students

J Otolaryngol

(2002)

T. Greenhalgh

Computer assisted learning in undergraduate medical education

BMJ

(2001)

R.A. Schmidt et al.

New conceptualizations of practice: common principles in three paradigms suggest new concepts for training

Psychol Sci

(1992)

R.A. Magill et al.

A visual model and knowledge of performance as sources of information for learning a rhythmic gymnastic skill

Int J Sport Psychol

(1996)

R.A. Magill

Motor learning: concepts and applications

(2001)

Cited by (231)

Automated measurement extraction for assessing simple suture quality in medical education[Formula presented]
2024, Expert Systems with Applications
Practicing open-wound suturing requires feedback, but evaluation of each suture practice takes instructors’ time and is often subjective. Recent work showed that deep-learning models can automate the evaluation by analyzing an image or a video of suturing into either pass or fail. However, they lacked fine-grained feedback offered by previous systems that required specialized devices or manual annotations. This work introduced a system that automatically extract geometric measurements from a suture practice end-product image for further evaluation. We proposed the suture instance segmentation task and a hand-crafted algorithm to extract interpretable metrics from an image. We collected two new simple suture datasets consisting of 240 images with instance segmentation and physical measurement annotations. The experiment results shows that current deep-learning model can accurately segment suture instances and the extracted measurements from our system are highly correlated with physical measurements from humans.
Nodo-Tie: an innovative, 3-D printed simulator for surgical knot-tying skills development
2023, Surgery Open Science
Clinical simulators are an important resource for medical students seeking to improve their fundamental surgical skills. Three-dimensional (3-D) printing offers an innovative method to create simulators due to its low production costs and reliable printing fidelity. We aimed to validate a 3-D printed knot-tying simulator named Nodo-Tie.
We designed a 3-D printed knot-tying simulator integrated with a series of knot-tying challenges and a designated video curriculum made accessible via a quick-response (QR) code. The Nodo-Tie, which costs less than $1 to print and assemble, was distributed to second-year medical students starting their surgical clerkship. Participants were asked to complete a survey gauging the simulator's usability and educational utility. The time between simulator distribution and survey completion was eight weeks.
Students perceived the Nodo-Tie as easy-to-use (4.6 ± 0.8) and agreed it increased both their motor skills (4.5 ± 0.9) and confidence (4.5 ± 0.8) for tying surgical knots in the clinical setting. Many students agreed the Nodo-Tie provided a stable, durable surface for knot-tying practice (83.7%, n = 41) and that they would continue to use it beyond their participation in the study period (91.7%, n = 44).
Medical students found this interactive, 3-D printed knot-tying simulator to be an effective tool to use for self-directed development of their knot-tying skills. Given the Nodo-Tie's low cost, students were able to keep the Nodo-Tie for use beyond the study period. This increases the opportunity for students to engage in the longitudinal practice necessary to master knot-tying as they progress through their medical education.
Clinical simulators provide proactive learners with reliable, stress-free environments to engage in self-directed surgical skills development. The Nodo-Tie, a 3-D printed simulator, serves as a cost-effective, interactive tool for medical students to develop their knot-tying abilities beyond the clinical setting.
Comparison of Instructor-Led and Video-Based Instruction in Teaching Suturing to Medical Students
2023, Journal of Surgical Research
We conducted a single-blind, prospective, randomized, 3-arm controlled trial to compare the efficacy of interactive and noninteractive video-based with instructor-led teaching in acquiring and retaining basic surgical skills.
Participants were pretested after providing written instruction using a simulator. After the pretest, students were randomized to three groups: noninteractive video-based instruction (NIVBI), instructor-led teaching with concurrent feedback, and interactive video-based instruction (IVBI). An immediate post-test and a retention test were performed 1 mo after the practice session's end to assess the efficacy of practice conditions. Two experts blinded to the experimental condition evaluated performance using expert-based assessment. Data were analyzed using SPSS.
There were no differences in expert-based assessments between groups at the pretest. All three groups showed significant improvements in expert-based scores between the pretests and post-tests as well as between pretests and retention tests (P < 0.0001). Instructor-led teaching and IVBI were equally effective initially for teaching this skill to naive medical students and showed better performance than NIVBI (P < 0.0001 each). At retention, IVBI displayed superior performance compared to NIVBI and the instructor-led group (P < 0.0001 each).
Our result showed that video-based instruction could be as effective as instructor-led teaching in acquiring basic surgical skills. These findings support the idea that with thoughtful incorporation into technical skill curricula, video-based instruction may efficiently use faculty time and serve as a helpful adjunct for basic surgical skills training.
Development of a mobile tele-education system to assist remote otolaryngology learning during COVID-19 pandemic
2023, Computer Methods and Programs in Biomedicine Update
Developing clinical thinking competence (CTC) is crucial for physicians, but effective methods for cultivation and evaluation are a significant challenge. Classroom teaching and paper-and-pencil tests are insufficient, and clinical field learning is difficult to implement, especially during the COVID-19 pandemic. Simulation learning is a useful alternative, but existing methods, e.g., OSCE, 3D AR/VR, and SimMan, have limitations in terms of time, space, and cost.
This study aims to present the design and development of an Otolaryngology Mobile Tele-education System (OMTS) to facilitate CTC learning, and to evaluate the system's usability with senior otolaryngology experts.
The OMTS system utilizes the convenience of mobile learning and the touch function of mobile devices to assist users (medical students or post-graduate physicians) in learning CTC remotely. Clinical knowledge and system functions in the OMTS system are defined by senior experts based on required CTC learning cases. Through simulated clinical case scenarios, users can engage in interactive clinical inquiry, practice required physical and laboratory examinations, make treatment decisions based on simulated responses, and understand and correct learning problems through a diagnostic report for effective learning. Usability testing of the OMTS system was evaluated by three senior otolaryngology experts using measurements of content validity, system usability, and mental workload during their available time and location.
Statistical results of experts' evaluation showed that the OMTS system has good content validity, marginal-to-acceptable system usability, and moderate mental workload. Experts agreed that the system was efficient, professional, and usable for learning, although the practicality of the clinical inquiry and hands-on practice functions could be improved further.
Based on the OMTS system, users can efficiently hands-on practice and learn clinical cases in otolaryngology, and understand and correct their problems according to the diagnostic report. Therefore, the OMTS system can be expected to facilitate CTC learning according to experts’ evaluation.
Is Online Video-Based Education an Effective Method to Teach Basic Surgical Skills to Students and Surgical Trainees? A Systematic Review and Meta-analysis
2022, Journal of Surgical Education
Online education has been increasingly utilized over the past decades. The COVID-19 pandemic accelerated the transition of conventional face-to-face curricula to online platforms, with limited evidence for its teaching efficacy. This systematic review aims to assess the effectiveness of online video-based education compared with standard conventional education in teaching basic surgical skills to surgical trainees and students undergoing medical training.
We performed a literature search in Embase, Medline, Cochrane CENTRAL and Scopus from inception until February 2022. Studies included were randomised controlled trials (RCTs) and observational studies. We included randomised controlled trials only for meta-analysis. The primary outcome was surgical skill proficiency. The secondary outcomes were participant perception, confidence and satisfaction. Two authors independently assessed the search results for eligibility, extracted the data and assessed the risk of bias using the Cochrane Risk of Bias tool 2. Where appropriate, we performed random effects meta-analyses of the pooled study data to calculate a standardized mean difference.
A total of 11 studies met the inclusion criteria totaling 715 participants; 603 were included in qualitative analysis and 380 in meta-analysis. All included studies were assessed as having a low risk of bias. The majority of studies found no significant difference between conventional and video-based education in teaching basic surgical skills, three studies found video-based education was superior and one study found conventional education was superior. There was no statistically significant difference in skill proficiency between the two groups (standardized mean difference of -0.02 (95% CI: -0.34, 0.30); p=0.90). Video-based education results in an equivalent improvement in confidence and satisfaction rates. Additional benefits of video-based education include convenience, accessibility and efficiency.
Basic surgical skills can be taught as effectively through online video-based education as conventional teaching methods. Online education should be utilized as an adjunct to medical curricula beyond the COVID-19 era.
A novel method for strabismus surgery education using an asynchronous video module
2022, Journal of AAPOS
Conjunctival closure is an important step in strabismus surgery and a fundamental surgical skill that requires dexterity and understanding of general surgical principles. Traditionally, ophthalmology residents have improved their surgical technique in supervised wet labs. Social distancing guidelines during the COVID-19 pandemic may have limited the ability for direct supervised surgical teaching. We developed a safe, reusable, low-cost teaching module that allows residents to train independently to develop skills necessary for conjunctival closure. This module uses stepwise teaching and video instruction to improve resident confidence and preparedness in conjunctival suturing.

View all citing articles on Scopus

Supported in part by Bell University Labs Health Communications Laboratory. The authors declare independence from funder.

Approval for this study was obtained from the IRB (Health Sciences II University of Toronto REB-protocol reference 12410) and all students signed an informed consent.

View full text

Original communicationTeaching suturing and knot-tying skills to medical students: A randomized controlled study comparing computer-based video instruction and (concurrent and summary) expert feedback

Background

Methods

Results

Conclusion

Section snippets

Participants

Study design

Expert assessment

Discussion

Conclusion

Otolaryngol Head Neck Surg

Am J Surg

Surgery

J Am Coll Surg

Am J Surg

J Res Pers

Am J Surg

Am J Surg

J Urol

J Am Coll Surg

Internet-based otolaryngology case discussions for medical students

J Otolaryngol

Computer assisted learning in undergraduate medical education

BMJ

New conceptualizations of practice: common principles in three paradigms suggest new concepts for training

Psychol Sci

A visual model and knowledge of performance as sources of information for learning a rhythmic gymnastic skill

Int J Sport Psychol

Motor learning: concepts and applications

Original communication
Teaching suturing and knot-tying skills to medical students: A randomized controlled study comparing computer-based video instruction and (concurrent and summary) expert feedback