Article – Steven Andersen | MD, PhD, DMSc

Ten tips for performing your first peer review: the next step for the aspiring academic plastic surgeon

stevenarild — Wed, 13 Oct 2021 06:30:43 +0000

Segmentation of temporal bone anatomy for patient-specific virtual reality simulation

stevenarild — Sat, 27 Feb 2021 16:36:23 +0000

Objectives: Virtual reality (VR) simulation for patient-specific pre-surgical planning and rehearsal requires accurate segmentation of key surgical landmark structures such as the facial nerve, ossicles, and cochlea. The aim of this study was to explore different approaches to segmentation of temporal bone surgical anatomy for patient-specific VR simulation.

Methods: De-identified, clinical computed tomography imaging of 9 pediatric patients aged 3 months to 12 years were obtained retrospectively. The patients represented normal anatomy and key structures were manually segmented using open source software. The OTOPLAN (CAScination AG, Bern, Switzerland) otological planning software was used for guided segmentation. An atlas-based algorithm was used for computerized, automated segmentation. Experience with the different approaches as well as time and resulting models were compared.

Results: Manual segmentation was time consuming but also the most flexible. The OTOPLAN software is not designed specifically for our purpose and therefore the number of structures that can be segmented is limited, there was some user-to-user variation as well as volume differences compared with manual segmentation. The atlas-based automated segmentation potentially allows a full range of structures to be segmented and produces segmentations comparable to those of manual segmentation with a processing time that is acceptable because of the minimal user interaction.

Conclusion: Segmentation is fundamental for patient-specific VR simulation for pre-surgical planning and rehearsal in temporal bone surgery. The automated segmentation algorithm currently offers the most flexible and feasible approach and should be implemented. Further research is needed in relation to cases of abnormal anatomy.

Content validity evidence for a simulation-based test of handheld otoscopy skills

stevenarild — Wed, 26 Aug 2020 18:50:31 +0000

Purpose: At graduation from medical school, competency in otoscopy is often insufficient. Simulation-based training can be used to improve technical skills, but the suitability of the training model and assessment must be supported by validity evidence. The purpose of this study was to collect content validity evidence for a simulation-based test of handheld otoscopy skills.

Methods: First, a three-round Delphi study was conducted with a panel of nine clinical teachers in otorhinolaryngology (ORL) to determine the content requirements in our educational context. Next, the authenticity of relevant cases in a commercially available technology-enhanced simulator (Earsi, VR Magic, Germany) was evaluated by specialists in ORL. Finally, an integrated course was developed for the simulator based on these results.

Results: The Delphi study resulted in nine essential diagnoses of normal variations and pathologies that all junior doctors should be able to diagnose with a handheld otoscope. Twelve out of 15 tested simulator cases were correctly recognized by at least one ORL specialist. Fifteen cases from the simulator case library matched the essential diagnoses determined by the Delphi study and were integrated into the course.

Conclusion: Content validity evidence for a simulation-based test of handheld otoscopy skills was collected. This informed a simulation-based course that can be used for undergraduate training. The course needs to be further investigated in relation to other aspects of validity and for future self-directed training.

Design and validation of a cross-specialty simulation-based training course in basic robotic surgical skills

stevenarild — Tue, 28 Jul 2020 18:47:41 +0000

Background: The aim of this study was to design and validate a cross-specialty basic robotic surgical skills training program on the RobotiX Mentor virtual reality simulator.

Methods: A Delphi panel reached consensus on six modules to include in the training program. Validity evidence was collected according to Messick’s framework with three performances in each simulator module by 11 experienced robotic surgeons and 11 residents without robotic surgical experience.

Results: For five of the six modules, a compound metrics-based score could significantly discriminate between the performances of novices and experienced robotic surgeons. Pass/fail levels were established, resulting in very few novices passing in their first attempt.

Conclusions: This validated course can be used for structured simulation-based basic robotic surgical skills training within a mastery learning framework where the individual trainee can practice each module until they achieve proficiency and can continue training on other modalities and more specific to their specialty.

Reliable assessment of surgical technical skills is dependent on context: an exploration of different variables using Generalizability theory

stevenarild — Tue, 23 Jun 2020 18:40:30 +0000

Purpose: Reliable assessment of surgical skills is vital for competency-based medical training. Several factors influence not only the reliability of judgements but also the number of observations needed for making judgments of competency that are both consistent and reproducible. The aim of this study was to explore the role of various conditions-through the analysis of data from large-scale, simulation-based assessments of surgical technical skills-by examining the effects of those conditions on reliability using Generalizability theory.

Method: Assessment data from large-scale, simulation-based temporal bone surgical training research studies in 2012-2018 were pooled, yielding collectively 3,574 assessments of 1,723 performances. The authors conducted generalizability analyses using an unbalanced random-effects design, and they performed decision studies to explore the effect of the different variables on projections of reliability.

Results: Overall, five observations were needed to achieve a Generalizability coefficient > 0.8. Several variables modified the projections of reliability: increased learner experience necessitated more observations (5 for medical students, 7 for residents, and 8 for experienced surgeons); the more complex cadaveric dissection required fewer observations than virtual reality simulation (2 vs. 5 observations); and increased fidelity simulation graphics reduced the number of observations needed from 7 to 4. The training structure (either massed or distributed practice) and simulator-integrated tutoring had little effect on reliability. Finally, more observations were needed during initial training when the learning curve was steepest (6 observations) compared with the plateau phase (4 observations).

Conclusions: Reliability in surgical skills assessment seems less stable than it is often reported to be. Training context and conditions influence reliability. The findings from this study highlight that medical educators should exercise caution when using a specific simulation-based assessment in other contexts.

Effects on cognitive load of tutoring in virtual reality simulation training

stevenarild — Thu, 02 Apr 2020 11:56:56 +0000

Aims: According to the guidance hypothesis, tutoring during technical skills training can result in tutoring over-reliance, reflected in a negative effect on performance when tutoring is discontinued. In this study, we wanted to explore if similar effects would be found for cognitive load.

Methods: Two cohorts of novice medical students were recruited for distributed virtual simulation training (five practice blocks of three procedures): 16 participants received intermittent simulator-integrated tutoring and 14 participants served as a reference cohort and did not receive simulator-integrated tutoring. Cognitive load during simulation was estimated using secondary task reaction time. Linear mixed models were used to account for repeated measurements.

Results: Overall, the tutored cohort had a significantly higher cognitive load than the reference cohort (mean difference = 7 %, p=0.006). Simulator-integrated tutoring did seem to lower cognitive load when active but also caused the tutored cohort to have a substantially higher cognitive load in subsequent performances where it was turned off (mean difference = 7 %, respectively, p<<0.001).

Conclusions: Concurrent feedback by simulator-integrated tutoring causes tutoring over-reliance and modifies cognitive load. This suggests that tutoring, in addition to degrading motor skills learning also affects the cognitive processes involved.

Developing a national e-learning course in Otorhinolaryngology: the Danish experience

stevenarild — Sun, 23 Feb 2020 12:06:20 +0000

PURPOSE: E-learning provides a flexible and effective approach to learning and is increasingly used in otorhinolaryngology (ORL). We developed a national theoretical e-learning course for ORL trainees and describe our experiences with implementation as well as piloting the e-learning course.
METHODS: E-learning course content was developed as structured multiple-choice quizzes for the European core curriculum textbook. An open source learning management system was adapted for a self-paced e-learning course. We piloted the e-learning course as a non-mandatory option for the 15 residents participating in the Danish four-day national training course in rhinology in February 2019. A post-course survey was sent out to the participants and used in the evaluation along with activity data from the learning management system.
RESULTS: Fourteen out of 15 trainees participated in the e-learning course. Nine participants completed >95 % of the course. The activity data demonstrated that participants with the highest completion rate typically began well in advance of the course (>2 months). Overall the e-learning course was rated positively in relation to learning and as preparation for the national training course. Participants responded that the level of the e-learning course was higher than and also at times in slight incongruity with the content of the national curriculum. Participants would like protected study time for e-learning activities in their residency program. All participants responded that they would use e-learning in relation to future national training courses.
CONCLUSIONS: Developing a national e-learning course is feasible and is well-received by trainees as well as other educational stakeholders.

Ultra-high-fidelity virtual reality mastoidectomy simulation training—a randomized, controlled trial

stevenarild — Fri, 07 Feb 2020 01:21:46 +0000

PURPOSE: Ultra-high-fidelity (UHF) graphics in virtual reality (VR) simulation might improve surgical skill acquisition in temporal bone training. This study aims to compare UHF VR simulation training with conventional, screen-based VR simulation training (cVR) with respect to performance and cognitive load (CL).

METHODS: In a randomized trial with a cross-over design, 24 students completed a total of four mastoidectomies in a VR temporal bone surgical simulator: two performances under UHF conditions using a digital microscope and two performances under conventional conditions using screen-based VR simulation. Performances were assessed by two blinded raters using an established assessment tool. In addition, CL was estimated as the relative change in secondary-task reaction time during simulation when compared with individual baseline measurements. Data were analyzed using linear mixed model analysis for repeated measurements.

RESULTS: The mean final-product performance score was significantly lower in UHF VR simulation compared to cVR simulation [mean difference 1.0 points out of 17 points, 95% CI (0.2–1.7), p = 0.02]. The most important factor for performance during UHF simulation was the ability to achieve stereovision (mean difference = 3.4 points, p < 0.001). Under the UHF VR condition, CL was significantly higher than during cVR (28% vs. 18%, respectively, p < 0.001).

CONCLUSION: UHF graphics in VR simulation training reduced performance and induced a higher CL in novices than conventional, screen-based VR simulation training. Consequently, UHF VR simulation training should be preceded by cVR training and might be better suited for the training of intermediates or experienced surgeons.

Development and validation of an assessment tool for technical skills in handheld otoscopy

stevenarild — Sat, 25 Jan 2020 18:01:54 +0000

OBJECTIVE: Handheld otoscopy requires both technical and diagnostic skills, and is often reported to be insufficient after medical training. We aimed to develop and gather validity evidence for an assessment tool for handheld otoscopy using contemporary medical educational standards.
STUDY DESIGN: Educational study.
SETTING: University/teaching hospital.
SUBJECTS AND METHODS: A structured Delphi methodology was used to develop the assessment tool: nine key opinion leaders (otologists) in undergraduate training of otoscopy iteratively achieved consensus on the content. Next, validity evidence was gathered by the video-taped assessment of two handheld otoscopy performances of 15 medical students (novices) and 11 specialists in otorhinolaryngology using two raters. Standard setting (pass/fail criteria) was explored using the contrasting groups and Angoff methods.
RESULTS: The developed Copenhagen Assessment Tool of Handheld Otoscopy Skills (CATHOS) consists 10 items rated using a 5-point Likert scale with descriptive anchors. Validity evidence was collected and structured according to Messick’s framework: for example the CATHOS had excellent discriminative validity (mean difference in performance between novices and experts 20.4 out of 50 points, p<0.001); and high internal consistency (Cronbach’s alpha=0.94). Finally, a pass/fail score was established at 30 points for medical students and 42 points for specialists in ORL.
CONCLUSION: We have developed and gathered validity evidence for an assessment tool of technical skills of handheld otoscopy and set standards of performance. Standardized assessment allows for individualized learning to the level of proficiency and could be implemented in under- and postgraduate handheld otoscopy training curricula, and is also useful in evaluating training interventions.

Understanding the effects of structured self-assessment in directed, self-regulated simulation-based training of mastoidectomy: a mixed methods study

stevenarild — Mon, 23 Dec 2019 08:00:08 +0000

OBJECTIVE: Self-directed training represents a challenge in simulation-based training as low cognitive effort can occur when learners overrate their own level of performance. This study aims to explore the mechanisms underlying the positive effects of a structured self-assessment intervention during simulation-based training of mastoidectomy.

METHODS: A prospective, educational cohort study of a novice training program consisting of directed, self-regulated learning with distributed practice (5×3 procedures) in a virtual reality temporal bone simulator. The intervention consisted of structured self-assessment after each procedure using a rating form supported by small videos. Semi-structured telephone interviews upon completion of training were conducted with 13 out of 15 participants. Interviews were analysed using directed content analysis and triangulated with quantitative data on secondary task reaction time for cognitive load estimation and participants’ self-assessment scores.

RESULTS: Six major themes were identified in the interviews: goal-directed behaviour, use of learning supports for scaffolding of the training, cognitive engagement, motivation from self-assessment, self-assessment bias, and feedback on self-assessment (validation). Participants seemed to self-regulate their learning by forming individual sub-goals and strategies within the overall goal of the procedure. They scaffolded their learning through the available learning supports. Finally, structured self-assessment was reported to increase the participants’ cognitive engagement, which was further supported by a quantitative increase in cognitive load.

CONCLUSIONS: Structured self-assessment in simulation-based surgical training of mastoidectomy seems to promote cognitive engagement and motivation in the learning task and to facilitate self-regulated learning.