Clinical Pediatrics

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Handedness Effects on Procedural Training in Pediatrics Dorothy Damore, John Rutledge, Sharon Pan, Nicole Knotek and Maria Ramundo Clin Pediatr (Phila) 2009; 48; 156 originally published online Oct 2, 2008; DOI: 10.1177/0009922808323111 The online version of this article can be found at: http://cpj.sagepub.com/cgi/content/abstract/48/2/156

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Articles

Handedness Effects on Procedural Training in Pediatrics

Clinical Pediatrics Volume 48 Number 2 March 2009 156-160 © 2009 Sage Publications 10.1177/0009922808323111 http://clp.sagepub.com hosted at http://online.sagepub.com

Dorothy Damore, MD, John Rutledge, MAS, Sharon Pan, MD, PhD, Nicole Knotek, MD, and Maria Ramundo, MD Objective To determine handedness effects on procedural training. Patients and Methods Pediatric trainees and attendings from 3 institutions participated in a Web-based survey examining whether handedness affected learning procedures, the hand used to perform procedures, and if handedness training was received. Results and Conclusions Of 778 physicians, 39% completed surveys, and 11% wrote with their left hand. Learning procedures were affected in left-handed

Introduction Overall, approximately 10% of people in developed countries write with their left hand, and the percentage of left-handed individuals decreases after age 54, with only 5% writing with their left hand by age 65 and older.1 Most likely, 10% of people in undeveloped and developing countries also write with their left hand. Left-handedness is more common in men than in women,1 which may be related to testosterone levels in utero.2Scissors, Japanese kitchen knives with asymmetric cutting edges,3and musical instruments have

From the Division of Pediatric Emergency Medicine (DD) and the Department of Public Health (JR), New York Presbyterian Hospital/Weill Cornell Medical Center, New York; the Division of Emergency Medicine, New York Presbyterian Hospital/Children’s Hospital of New York, New York (SP); and the Division of Emergency Medicine, Akron Children’s Hospital, Akron, Ohio (NK, MR). There are no financial interests to be disclosed and no conflicts of interest. Address correspondence to: Dorothy Damore, New York Presbyterian Hospital, Weill Cornell Medical Center, 525 East 68th Street, New York, NY 10065; e-mail: [email protected].

physicians (60% vs 7.7%; odds ratio [OR] = 17.9; 95% confidence interval [CI] = 7.9-40.1), and they used their nondominant or both hands to perform procedures (48.6% vs 21%; OR = 3.6; 95% CI = 1.7-7.4). Few physicians received handedness training (20% vs 10.7%; P = .16). Left-handed physicians were affected learning lumbar puncture (29% vs 4%; OR = 10.0; 95% CI = 3.8-26.4), intubation (36% vs 5%; OR = 11.0; 95% CI = 4.4-27.4), and suturing (32% vs 4%; OR = 11.7; 95% CI = 4.5-30.5). Keywords: dominant handedness; procedural training; resident training

been modified for left-handed individuals. Advantages for left-handed individuals have been seen in some sports4 but not in others.1,5 Left-handed men who attended college have been found to earn more than similarly trained right-handed males, whereas lefthanded women with college education have not been found to have increased earnings.6 Of left-handed individuals surveyed in one study, 61% felt that there were disadvantages to their handedness, whereas only 34% felt that there were advantages.1 Whereas 5% felt that left-handedness had advantages in sports, another 5% felt that lefthandedness had disadvantages in sports and sporting equipment.1 Other perceived disadvantages were associated with writing, scissors, can openers, peelers, gadgets, and utensils.1 Although left-handedness has been found to have many effects on common activities, its influence on physician procedural training has not been widely studied. It has been studied in cardiopulmonary resuscitation (CPR) performance and surgical procedures. Using their dominant hand, anesthesiology residents performed better CPR.7 Handedness did not affect surgery, and obstetrics and gynecology physicians in laparoscopic training.8,9 Endoscopy

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Effects of Handedness on Procedural Training / Damore et al

training was found to be affected by handedness in one study10 and not in another.11 Schueneman et al12 found left-handed surgery residents to be more reactive to stress, more cautious, and to have greater tactile spatial skills, whereas their technical skills were rated lower. Also, left-handed dental students have performed lower in certain skills.13 Few surgery residents have received training based on handedness.14 Of left-handed surgeons surveyed, 3% received mentoring related to handedness during medical school, 10% received mentoring related to handedness during residency, 13% were provided left-handed instruments during residency, and 10% expressed concerns about being treated by another left-handed surgeon.14 The effects of right- and left-handedness have not been studied in pediatric training. This may be important in procedural training for pediatric interns and residents.

Patients and Methods Pediatric interns, residents, fellows, and attendings from 3 academic institutions participated in a Webbased survey. A copy of the survey is included in the appendix. The physicians were asked about their level of training, the hand that they used to write with, the hand that they used to perform common pediatric procedures with, and whether their handedness affected their learning procedures. The survey asked if these physicians received training based on handedness for any procedure, why handedness affected their training, and whether handedness affected their choice of residency or subspecialty. The questionnaire sought to determine whether anyone had ever guided them away from certain residencies based on handedness during medical school. The 19 procedures these physicians were asked about included drawing blood, arterial puncture, intravenous placement, central line placement, arterial line placement, intraosseous line placement, umbilical artery or vein catheter placement, urine catheterization, suprapubic tap, foley placement, lumbar puncture, hand used to hold the endotracheal tube when intubating, nasogastric or feeding tube placement, gastrostomy tube replacement, simple foreign body removal (nose, ear, or skin), suturing simple lacerations, incision and drainage of a superficial abscess, splinting of simple injuries, and injections (subcutaneous, intramuscular, or intradermal).

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Pediatric interns, residents, fellows, and attendings accessed the survey at a Web site. Completing the survey took approximately 5 minutes. The completed surveys were sent to the principal investigator from the Web site without names, identifiers, o e-mail addresses. The surveys were sent out 3 times at each institution, 2 to 4 weeks apart; 2 institutions are located in New York City and the other in northern Ohio. The Institutional Review Board at each of the hospitals approved the study with informed consent. Fisher’s exact test was used to determine whether the respondents’ handedness was associated with learning any procedure, with using their nondominant or both hands to perform any procedure except intubation, and with receiving handedness training except for intubation. All P values were 2-tailed, with P < .05 considered statistically significant. Fisher’s exact test was also used to determine whether handedness was associated with learning specific procedures. Because 19 procedures were considered, the Bonferroni adjustment was used, and P < .0026 was considered statistically significant. Odds ratios were obtained using logistic regression.

Results Of 778 physicians contacted, 39% (307) completed the survey. Response rates by institution varied from 34% to 44%. Overall, 24% to 50% of total responses came from each institution, and 11% (35) of physicians who responded wrote with their left hand. At each institution, 6% to 14% were left-handed; 37% (115) of responses were from interns, residents, and fellows, and 14% (16) wrote with their left hand. The remaining responses (192) were from attendings, and 10% (19) wrote with their left hand. Left-handed physicians were more likely to feel that handedness affected their learning any procedure or used their nondominant or both hands to perform any procedure (Table 1). Left- and right-handed physicians were similar in having received training adjusted for their handedness for any procedure (20% and 10.7%, respectively; P = .16). Left-handed physicians were more likely to feel that handedness affected their learning lumbar puncture, intubation, and suturing (Table 1). Handedness did not affect learning many procedures, including drawing blood, arterial puncture, intravenous placement, central line placement, arterial


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Table 1. Procedures Affected by Handedness Characteristic

Left-Handed

Right-Handed

OR, 95% CI

P Valuea

Handedness affected learning procedures Used nondominant or both hands Lumbar puncture Intubation Suture

60% (21/35) 48.6% (17/35) 29% (10/35) 36% (12/33) 32% (11/34)

7.7% (21/271) 21% (57/272) 4% (10/261) 5% (12/242) 4% (10/255)

17.9, 7.9-40.1 3.6, 1.7-7.4 10.0, 3.8-26.4 11.0, 4.4-27.4 11.7, 4.5-30.5

< .0001 .001 < .0001a < .0001a < .0001a

Note: OR = odds ratio; CI = confidence interval. a With Bonferroni adjustment for multiple comparisons, P < .0026 is significant.

Table 2. Procedures Unaffected by Handedness Procedure Drawing blood Arterial puncture IV placement Central line placement Arterial line placement Intraosseous line placement Umbilical artery or vein catheter placement Urine catheterization Suprapubic tap Foley placement Nasogastric or feeding tube placement Gastrostomy tube replacement Simple foreign body removal (nose, ear, skin) Incision and drainage of superficial abscess Splinting of simple injuries Injections: subcutaneous, intramuscular, or intradermal

Left-Handed

Right-Handed

P Valuea

11% (4/35) 12% (4/34) 14% (5/35) 17% (5/30) 7% (2/30) 4% (1/27) 11% (3/28) 9% (3/32) 7% (2/28) 10% (3/29) 0% (0/33) 4% (1/26) 3% (1/34) 6% (2/31) 3% (1/29) 3% (1/34)

4% (10/270) 3% (8/265) 4% (10/265) 2% (5/213) 2% (5/208) 2% (5/206) 3% (7/227) 2% (5/252) 1% (2/204) 2% (5/245) 3% (7/255) 2% (3/194) 1% (3/245) 3% (6/239) 2% (4/225) 2% (6/263)

.06 .04 .02 .003 .22 .53 .08 .05 .07 .04 1.00 .40 .41 .23 .46 .58

Note: IV = intravenous. With Bonferroni adjustment for multiple comparisons, P < .0026 is significant.

a

line placement, intraosseous line placement, umbilical artery or vein catheter placement, urine catheterization, suprapubic tap, foley placement, nasogastric or feeding tube placement, gastrostomy tube replacement, simple foreign body removal (nose, ear, or skin), incision and drainage of a superficial abscess, splinting of simple injuries, and injections (subcutaneous, intramuscular, or intradermal; Table 2). Three physicians, 2 right-handed and 1 lefthanded, replied that their choice of residency was affected by their handedness. No one responded that they were ever told during medical school to avoid any residency based on their handedness or that their handedness affected their choice of subspecialty.

Discussion In all, 11% of responding physicians wrote with their left hand, which is similar to the general population.1 Percentages of physicians who were left-handed have not been reported. Similar to our study, a left-handed population felt that their handedness affected learning.1 Also, Adusumilli et al14 found that left-handed physicians received little training based on handedness. We found that left-handedness affected learning some procedures but not others. Other studies have found that left-handedness affected the performance of certain skills like CPR,7 operative skills,12 and dental skills13 but not laparoscopy.8,9


Effects of Handedness on Procedural Training / Damore et al

There are several potential limitations to our study. First, the response rate (39%) was low, which might influence the results. Similar to other studies,7-11,13 only a small number of left-handed physicians (35) was surveyed. Also, gender information was not collected, which might be important, and it would also have been interesting to ask whether physicians have altered their teaching based on handedness. Although the number of lefthanded physicians was small, our study included 3 academic institutions and provided important initial information about the effects of handedness on learning procedures.

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intubation, and suturing. When teaching procedural skills, handedness should be considered. A larger sampling of left-handed physicians is needed to validate our findings and determine whether gender differences exist.

Appendix Handedness and Its Relationship With Procedural Training in Pediatrics 1. What is your level of training? a. Postgraduate year 1 b. Postgraduate year 2 c. Postgraduate year 3 d. Fellow year 1 or Chief Resident e. Fellow year 2 f. Fellow year 3 g. Attending < 5 years h. Attending 5-10 years i. Attending > 10 years

Conclusion We found that 60% of left-handed physicians felt that their handedness affected their learning procedures, and nearly half used their nondominant hand or both hands to perform procedures. In particular, left-handedness affected learning lumbar puncture,

2. Which hand do you use to perform the following procedures (check the hand you use)? Did your handedness affect your ability to learn any procedure(s) (check if yes)? Did you receive handedness training for the following procedures (check if yes)?

Procedure

Right

Left

a. Write b. Draw blood c. Arterial puncture d. IV placement e. Central line placement f. Arterial line placement g. Intraosseous line placement h. Umbilical artery or vein catheter placement i. Urine catheterization j. Suprapubic tap k. Foley placement l. Perform lumbar puncture m. Intubate, hand used to hold endotracheal tube n. Nasogastric or feeding tube placement o. Gastrostomy tube replacement p. Simple foreign body removal (nose, ear, skin) q. Suturing simple lacerations r. Incision and drainage of superficial abscess s. Splinting of simple injuries t. Injections: subcutaneous, intramuscular, or intradermal


Both

Handedness Affects Learning

Handedness Training

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3. If your handedness has affected your learning any procedures, why has it affected your learning (circle all that apply)? a. equipment not suited for handedness b. no or inadequate instruction for handedness c. other______________________________ 4. Did your handedness affect your choice of residency? a. Yes b. No 5. If handedness affected your choice of residency, what specialty did you feel that your handedness did not allow you to feel comfortable entering? ______________________________________ 6. Did your handedness affect your choice of subspecialty? a. Yes b. No 7. If handedness affected your choice of subspecialty, what subspecialty did you feel that your handedness did not allow you to feel comfortable entering? _____________________________________ 8. Were you ever told during medical school to avoid certain specialties due to your handedness? a. Yes b. No

4. 5.

6.

7.

8.

9.

10.

11.

12.

References

13.

1. Bradley N. British survey of left-handedness. Graphologist. 1992;10:176-182. 2. James WH. Testosterone levels, handedness and sex ratio at birth. J Theor Biol. 1988;133:261-266. 3. Hurt H III. How to succeed at knife-sharpening without losing a thumb. New York Times. http://www.nytimes.com/

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2006/09/23/business/23pursuits.html?n = Top/Reference/ Times%20Topics/People/H/Hurt,%20Harry%20III. September 23, 2006. Accessed July 25, 2008. Holtzen DW. Handedness and professional tennis. Int J Neurosci. 2000;105:101-119. Wood CJ, Aggleton JP. Handedness in ‘‘fast ball’’ sports: do left-handers have an innate advantage? Br J Psychol. 1989;80:227-240. Ruebeck CS, Harrington JE Jr, Moffitt R. Handedness and earnings. NBER Working Paper Series. www.nber. org/papers/w12387. Published July 2006. Accessed July 25, 2008. Kundra P, Dey S, Ravishankar M. Role of dominant hand position during external cardiac compression. Br J Anaesth. 2000;84:491-493. Fichera A, Prachand V, Kives S, Levine R, Hasson H. Physical reality simulation for training of laparoscopists in the 21st century: a multispecialty, multi-institutional study. JSLS. 2005;9:125-129. Powers TW, Bentrem DJ, Nagle AP, Toyama MT, Murphy SA, Murayama KM. Hand dominance and performance in a laparoscopic skills curriculum. Surg Endosc. 2005;19:673-677. Hanna G, Drew T, Clinch P, et al. Psychomotor skills for endoscopic manipulations: differing abilities between right and left-handed individuals. Ann Surg. 1997;225: 333-338. Glaser AY, Hall CB, Uribe SJ, Fried MP. The effects of previously acquired skills on sinus surgery simulator performance. Otolaryngol Head Neck Surg. 2005;133: 525-530. Schueneman AL, Pickleman J, Freeark RJ. Age, gender, lateral dominance, and prediction of operative skill among general surgery residents. Surgery. 1985;98:506-515. Canakci V, Cic¸ek Y, Canakci CF, et al. Effect of handedness on learning subgingival scaling with curettes: a study on manikins. Int J Neurosci. 2004;114:1463-1482. Adusumilli PS, Kell C, Chang JH, Tuorto S, Leitman IM. Left-handed surgeons: are they left out? Curr Surg. 2004; 61:587-591.
