Thinking it Through Correlation of Mental Rehearsal Attitudinal

Thinking it Through: Correlation of Mental Rehearsal Attitudinal Gains with Performance Parameters on Two Separate Laparoscopic Cholecystectomy Trainers John T. Paige, M. D. , Qingzhao Yu, Ph. D. , Alan Marr, M. D. , Lance Stuke, M. D. , M. P. H. , John Hunt, M. D. , M. P. H. 6 th Annual Meeting of the Consortium of ACS-Accredited Education Institutes Chicago, IL March 16, 2013

Funding Support / Disclosures • Funding support: LSU Academy for the Advancement of Educational Scholarship Educational Enhancement Grant (20102011) • Disclosures: Co-editor for Simulation in Radiology

Goal • Promote the adoption of mental rehearsal in simulation-based training (SBT) to expedite learning

Objectives • Describe our laparoscopic cholecystectomy (lap CCY) SBT program • Evaluate the role of mental rehearsal in lap CCY SBT • Discuss future directions of our program and research

IDES RIDDLE

BEWARE!

Lap CCY SBT Curriculum

Why Lap CCY? • Bread and butter surgery • Morbidity risk • Introductory case • Amenable to SBT 600, 000 / yr PGY 2/3 Procedural Trainer (PT) 0. 4% = 2 X open Virtual Reality (VR) Trainer Wu YV and Linehan DC, Surg Clin North Am 2010; 90: 787 -802

Motor Skill Acquisition 1 • Fast Phase • Immediate improvement from first training session 2 • Consolidation Phase • Improvement at least 6 hrs from first session 3 • Slow Phase • Further gains across several training sessions 4 • Automatic Phase • Motor task performed automatically 5 • Retention Phase • Motor task executed in absence of any practice after long delay Gatti R et al. Neurosci Lett 2012 http: //dx. doi. org/10. 1016/j. neulet. 2012. 11. 039

Motor Learning Action Observation Motor Imagery • Observational learning • Mental rehearsal • Effective way to learn or enhance the performance of a particular motor skill • Leads to improvement in motor performance of targeted task(s) • Recruitment of brain areas involved in motor skills during observation • Recruitment similar brain areas as in action observation Gatti R et al. Neurosci Lett 2012 http: //dx. doi. org/10. 1016/j. neulet. 2012. 11. 039

Mental Rehearsal • Cognitive rehearsal of a task • • “Imagery practice” “Covert rehearsal” “Conceptualization” “Mental imagery rehearsal” Rogers RG. Obstet Gynecol Clin N Am 2006; 33: 297 -304.

Effective Characteristics of MR • • • Individual Supervised Non-directed Eyes closed Internal perspective Kinesthetic mode Schuster C. BMC Medicine 2011; 9: 75.

Prior Studies Lap CCY Training Basic Open Skills Sanders CW et al, Med Educ 2008; 42: 607 -612 Arora S et al, Ann Surg 2011; 253: 265 -270

Study Question • Is there a correlation between mental rehearsal and performance in lap CCY SBT based on the type of simulator used?

Study Design • Lap CCY surgical skills lab • Prospective analysis • Two models of SBT • Division of trainees based on PGY level

Participants • General surgical residents • PGY 1 thru 3 levels • Rotating in New Orleans region

Training Format • Standardized format • Didactic and SBT components • Distributed training

Didactic Component Pre-session reading Indications Steps Knowledge test MCQ Diagram Mental rehearsal Group Detailed

Mental Rehearsal Step by step verbal recital of lap CCY from start to finish

SBT – PT Trainer

SBT – VR Trainer

Mental Imagery Questionnaire S Arora et al. Surg Endosc. 2010; 24: 179 -187

Simulator Data Time to dissect out “critical view” Time to task completion Efficiency Accuracy Safe cautery Path length

Statistical Analysis • Calculation of scores for each MIQ item, gain scores, time to task completion (Mean values) • Paired t-test analysis of pre/ post-training scores (bonferroni adjustment) • Pearson correlations comparing MIQ scores with VR and PT scores • p< 0. 05 = significant

Results

Participants Characteristic PT Training in VOR VR Training Full completion SBT (n) 10 9 PGY 1 (n) 4 4 PGY 2 (n) 4 3 PGY 3 (n) 2 2 Self-report prior lap CCY (n) 16. 7 a 10. 5 a Self-report lap CCY expertise 2. 3 b 2. 0 b Peg transfer score (s) 115 97 1 c 1 c Partial completion SBT (n) an=7, bn=8, c. PGY 1

Results MIQ by Item Mean Pre-MR Score (SD)a Mean Post-MR Score (SD)a ∆ P-value Energized to do lap CCY 5. 5 (1. 6) 6. 0 (1. 3) 0. 5 0. 05 Confidence re: lap CCY 4. 9 (1. 7) 5. 8 (1. 0) 0. 9 <0. 001 Confidence vs colleague 5. 0 (1. 4) 5. 6 (1. 1) 0. 6 <0. 001 Helpfulness MR 5. 4 (1. 2) 5. 7 (1. 0) 0. 3 0. 13 “See” self doing lap CCY 5. 5 (1. 3) 5. 9 (1. 0) 0. 4 0. 01 Vividness images 5. 6 (1. 2) 6. 2 (1. 0) 0. 6 <0. 001 “Feel” self doing lap CCY 5. 3 (1. 3) 5. 7 (1. 0) 0. 4 0. 01 Talk thru steps 5. 8 (1. 0) 6. 3 (0. 9) 0. 5 <0. 001 an=Paired results for 17 of 19 residents completing training

Simulator Data Task Mean Pre Score, s Mean Post Score, s P value PT – Dissection critical view (n=10) 158 169 NS VR – Full procedure (n=4) 731 606 NS VR – Task 1 (n=9) 151 67 0. 007 VR – Task 2 (n=9) 124 85 0. 026 VR – Task 3 (n=9) 438 243 0. 004 VR – Task 4 (n=9) 322 196 NS

Pearson Correlation Task Pearson Correlation P value PT – Dissection critical view (n=10) 0. 645 NS VR – Task 1 (n=9) 0. 422 NS VR – Task 2 (n=9) -0. 764 0. 017 VR – Task 3 (n=9) -0. 280 NS VR – Task 4 (n=9) 0. 032 NS

Training Effectiveness

Discussion

Limitations • Small sample size • Proficiency training was not the goal • Mental rehearsal implementation weaknesses – group based, eyes open • Outcomes data not collected

Why Only One Correlation? • Most clearly imaginable • Most technically oriented of tasks • Weaknesses in training and mental rehearsal design

Conclusions • Group mental rehearsal appears to correlate with improved performance related to the two handed clipping and cutting task on VR. • Group mental rehearsal does not appear to correlate with improved performance on lap CCY training on a procedural trainer

Conclusions • Such findings may allow targeted use of mental rehearsal to accelerate skill acquisition