Supporting Procedural and Perceptual Learning in ...

Proceedings of the Human Factors and Ergonomics Society 58th Annual Meeting - 2014

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Supporting Procedural and Perceptual Learning in Laparoscopic Surgery 1

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Lou,Y., 1Flinn, J. T., 1Ganapathy, S., 2Weyhrauch, P., 2Niehaus, J., 2Myers. B., 1Cao, C. G. L. Department of Biomedical, Industrial and Human Factors Engineering, Wright State University 2 Charles River Analytics, Cambridge, MA

Expertise in surgical performance requires mastery of both technical skills such as suturing, and nontechnical skills such as perceptual and procedural knowledge. “Refresher-training” after skill decay due to nonuse should consider the fact that non-technical skills often decay faster than technical skills. To support the re-learning of perceptual and procedural knowledge, this study examined the effectiveness of different design factors for digital training material. The factors considered included modality/fidelity of representation (illustration/cartoon vs. realistic/video images) and task difficulty (easy, medium, and difficult). Results suggest that low fidelity images are better for perceptual learning, and are equally effective as high fidelity images for procedural learning. The level of difficulty of the procedures did not affect performance in this study of novices, but may be an important factor with more experienced trainees. Time and error results indicate that refresher training in perceptual and procedural knowledge should begin with a procedural task to review surgical steps, followed by a perceptual task, to achieve greater efficiency and effectiveness.

Copyright 2014 Human Factors and Ergonomics Society. DOI 10.1177/1541931214581161

INTRODUCTION Despite the invention of laparoscopic surgery in the early 1900s, it was not widely used until the 1980s (Spaner, & Warnock, 1997). Now, almost 98% of cholecystectomies are laparoscopic (Wayand, 2004). Laparoscopic surgery has become more common according to the US Food and Drug Administration (FDA), and more than 2 million Americans each year experience laparoscopic surgery (Fuller, Scott, Ashar, & Corrado, 2003). Reductions in post-op pain, incisions, and chance of hemorrhage are all reasons why laparoscopic surgery is preferred over other alternatives. However, laparoscopic surgery skills require additional training over the skills needed to perform traditional open surgery. A great deal of past research has focused on the training of technical skills, such as suturing and knot-tying (Ritter, & Scott, 2007), resulting in standardized certification programs such as the Fundamentals of Laparoscopic Surgery (FLS) curriculum that is endorsed by the American College of Surgeon (ACS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). This paper concerns the non-technical aspect of surgical training, such as perceptual and procedural skills, as non-technical skills play an equally important role in determining surgical skill acquisition and retention (Yule, Flin, Patterson-Brown, Maran, & Rowley, 2006). Despite the long training schedules and constant practice, skill decay is observed after periods of nonuse or non-practice (Arthur, Bennett, Stanush, & Mcnelly, 1998). According to the meta-analysis of Arthur et al. (1998), after more than 365 days of nonuse and non-practice, the average participant was performing at less than 92% of their performance level before the non-practice interval. The neuroscience of human memory indicates that there are three types of abilities (job knowledge, decision skills, and execution skills) that are located and controlled in different areas of the brain (Gabrieli, 1998). The

job knowledge category is based on the recall of domain specific information, such as job-related terms and rules; the decision category hinges on cognitive processing of the domain specific information such as trouble-shooting faulty equipment and decision-making (Allen, Secundo, Salas, & Morgan, 1983), and the execution category refers to both the perceptual and motor requirement of a task such as target acquisition and tracking (Fleishman, & Parker, 1962). A study by Wisher, Sabol, Ellis, and Ellis (1999) showed that the patterns of forgetting that occur in decision skills, procedural and perceptual-motor skills are different. For example, gross motor skills decayed after approximately 10 months while cognitive skills such as knowledge of procedures decayed within approximately 6 months. In military medicine, loss of specialized skill and knowledge is a great concern for those military surgeons returning to general practice after deployment. It takes a huge amount of time for the personnel in the US military medical community (as in the civilian community) to learn knowledge and skills to perform lifesaving tasks. However, it is difficult for military surgeons to maintain their specialized knowledge and ability after a period of time performing combat casualty care in a military deployment cycle (Perez et al., 2013). The ultimate goal of this research is to develop an effective refresher training system that is appropriate for surgeons with varying degrees of skill decay. The purpose of this study was to determine how well re-learning perceptual and procedural knowledge in laparoscopic surgery (i.e., identifying anatomy and knowing operational sequences) can be supported by digital material after skill decay. The fidelity and complexity of the digital re-learning material needed to support learning/re-learning was examined. We hypothesized that simulation fidelity would have differential effects on the learning and retention of perceptual and procedure knowledge in laparoscopic surgery. That is, (1) realistic visual representation of the surgical site is more

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important for learning and remembering perceptual knowledge than for procedural knowledge and (2) a less realistic-looking visual representation of the surgical site is sufficient for the purpose of learning and remembering procedural steps in surgery. METHODS The objective of this study was to evaluate how two types of skills (perceptual and procedural) were affected by two types of information presentation (illustration representation vs. realistic representation), and three levels of task complexity (easy, medium, and difficult). Based on a cognitive task analysis with experts, who were surgeons with over 20 years of experience, a set of tasks in the laparoscopic cholecystectomy procedure was identified (Grosdemouge, Weyhrauch, Niehaus, Schwaitzberg, & Cao, 2012). These tasks included perceptual skills and procedural skills. Perceptual tasks related to identifying anatomy, identification of points where incision had to be made, and angle of presentation of the image. Procedural tasks included identifying steps and sequences in the cholecystectomy procedure. These tasks were used to design the teaching material and the refresher material in this experiment. Participant Twelve participants (6 male, 6 female) were recruited from the general public. Participants were novices who had no previous medical or surgical experience. The average age was 31.5 years. Apparatus Teaching material was compiled based on the text Atlas of Minimally Invasive Surgery (Jones, Maithel, & Schneider, 2006). This material covered the basic anatomy and procedure for laparoscopic cholecystectomy and was prepared using Microsoft PowerPoint. The images, videos, and questions presented during the experimental task were displayed using a custom-developed software program, which also recorded participants' responses automatically. This software, the Mobile Interactive Storyboard Tool (MIST), was developed in C++ using the Microsoft XNA framework and Direct X API (application programming interfaces). The MIST software allowed for the customizable arrangement of media and interactive elements required for the experiment.

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process until they had all three correct answers. This ensured that participants had in fact learned the material presented. To ensure that all trials are performed based on longer term memory rather than short-term memory, participants were asked to work on a Sudoku puzzle for 10 minutes following the training period. Following this, participants performed the experimental task (refresher task), which involved answering a series of questions about anatomy or steps in a laparoscopic cholecystectomy procedure, depending on the experimental condition (Table 1). The questions were presented at various points in the cholecystectomy procedure by the MIST program. Participants responded to the questions using the mouse by clicking on specific areas in the scene, or selecting options in a multiple choice question. The program indicated whether they were correct or incorrect after they gave their response. If incorrect, participants were given a second chance to answer the question. In this study, two representations of different fidelity levels (represented by two different modalities) were used to present the refresher material: illustrated and realistic. Figure 1 shows the screenshot of the illustrated condition and realistic condition. Three different levels of task difficulty (easy, medium and difficult), representing the difficulty of the surgical case, were used (Figure 2). Six participants began with the perceptual condition first and the other 6 participants had the procedural condition first (randomly assigned). Within each condition, all combinations of the modalities and difficulty of the surgical case were presented in a random order. At the end of the experiment, participants were asked for subjective feedback on their preference of realism of the surgical scenes, and any comments on their choices during the experiment. Table 1 Example Questions in Perceptual and Procedural Conditions Perceptual Condition

Procedural Condition

Locate the cystic artery by clicking the correct structure.

What is the next step in the cholecystectomy procedure? A. Clip the Cystic Artery B. Clip the Cystic Duct C. Divide the Cystic Artery D. Divide the Cystic Duct

Click on the cystic artery to indicate where clips should be placed.

Choose how many clips are needed on the cystic artery? A. 1 B. 2 C. 3 D. 4 E. 5 How will the clips be positioned on the cystic artery?

Task and Procedure Initially, participants were shown a 10-minute PowerPoint presentation (teaching material) with a brief introduction of the relevant anatomy, the surgical steps and instrumentations used in a cholecystectomy procedure. At the end of the presentation, they were required to answer three basic questions based on what they have learned. If any one of the answers was incorrect, participants had to repeat the learning Downloaded from pro.sagepub.com by guest on October 28, 2015


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Figure 1. Sample screenshots of the Illustration Representation (top) and Realistic Representation (bottom) of a surgical step in Laparoscopic Cholecystectomy.

Figure 2. Sample screenshots of the Easy (top), Medium (middle), and Difficult (bottom) representations of Laparoscopic Cholecystectomy measures. Time to task completion was determined as the response time for answering the questions in each condition. Time for playing embedded videos was excluded from this measure. Error was the total number of incorrect responses for each trial. RESULTS Performance data in the perceptual and procedural conditions were separately analyzed using repeated

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measurements 3-way ANOVA with order, fidelity and difficulty level as factors.

Perceptual - Time

Perceptual Knowledge

Perceptual-Procedural

200

Time(seconds)

Error. Only fidelity (F=5.32, p=0.04) and task difficulty (F=11.22, p