1. 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

2. Funding Support / Disclosures Funding support: LSU Academy for the Advancement of Educational Scholarship Educational Enhancement Grant (2010- 2011)Funding support: LSU Academy for the Advancement of Educational Scholarship Educational Enhancement Grant (2010- 2011) Disclosures: Co-editor for Simulation in RadiologyDisclosures: Co-editor for Simulation in Radiology

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

4. Objectives Describe our laparoscopic cholecystectomy (lap CCY) SBT programDescribe our laparoscopic cholecystectomy (lap CCY) SBT program Evaluate the role of mental rehearsal in lap CCY SBTEvaluate the role of mental rehearsal in lap CCY SBT Discuss future directions of our program and researchDiscuss future directions of our program and research

5. IDES RIDDLE

6. BEWARE!

7. Lap CCY SBT Curriculum

8. Why Lap CCY? Bread and butter surgery Morbidity risk Introductory case Amenable to SBT Wu YV and Linehan DC, Surg Clin North Am 2010;90:787-802 2010;90:787-802 Procedural Trainer (PT) Virtual Reality (VR) Trainer

9. 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

10. Motor Learning Action Observation Observational learning Effective way to learn or enhance the performance of a particular motor skill Recruitment of brain areas involved in motor skills during observation Motor Imagery Mental rehearsal Leads to improvement in motor performance of targeted task(s) 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

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

12. Effective Characteristics of MR IndividualIndividual SupervisedSupervised Non-directedNon-directed Eyes closedEyes closed Internal perspectiveInternal perspective Kinesthetic modeKinesthetic mode Schuster C. BMC Medicine 2011;9:75.

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

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

15. Study Design Lap CCY surgical skills labLap CCY surgical skills lab Prospective analysisProspective analysis Two models of SBTTwo models of SBT Division of trainees based on PGY levelDivision of trainees based on PGY level

16. Participants General surgical residentsGeneral surgical residents PGY 1 thru 3 levelsPGY 1 thru 3 levels Rotating in New Orleans regionRotating in New Orleans region

17. Training Format Standardized formatStandardized format Didactic and SBT componentsDidactic and SBT components Distributed trainingDistributed training

18. Didactic Component Mental rehearsal GroupDetailed Knowledge test MCQDiagram Pre-session reading IndicationsSteps

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

20. SBT – PT Trainer

21. SBT – VR Trainer

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

23. Simulator Data Time to task completion EfficiencyAccuracy Safe cautery Path length Time to dissect out “critical view”

24. Statistical Analysis Calculation of scores for each MIQ item, gain scores, time to task completion (Mean values)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)Paired t-test analysis of pre/ post-training scores (bonferroni adjustment) Pearson correlations comparing MIQ scores with VR and PT scoresPearson correlations comparing MIQ scores with VR and PT scores p< 0.05 = significantp< 0.05 = significant

25. Results

26. Participants Characteristic PT Training in VOR VR Training Full completion SBT (n) 109 PGY 1 (n) 44 PGY 2 (n) 43 PGY 3 (n) 22 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) 11597 Partial completion SBT (n) 1c1c1c1c 1c1c1c1c a n=7, b n=8, c PGY 1

27. Results MIQ by Item Item Mean Pre-MR Score (SD) a 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) 0.50.05 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) 0.30.13 “See” self doing lap CCY 5.5 (1.3) 5.9 (1.0) 0.40.01 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) 0.40.01 Talk thru steps 5.8 (1.0) 6.3 (0.9) 0.5<0.001 a n=Paired results for 17 of 19 residents completing training

28. Simulator Data Task Mean Pre Score, s Mean Post Score, s P value PT – Dissection critical view (n=10) 158169NS VR – Full procedure (n=4) 731606NS VR – Task 1 (n=9) 151670.007 VR – Task 2 (n=9) 124850.026 VR – Task 3 (n=9) 4382430.004 VR – Task 4 (n=9) 322196NS

29. Pearson Correlation Task P value PT – Dissection critical view (n=10) 0.645NS VR – Task 1 (n=9) 0.422NS VR – Task 2 (n=9) -0.7640.017 VR – Task 3 (n=9) -0.280NS VR – Task 4 (n=9) 0.032NS

30. Training Effectiveness

31. Discussion

32. Limitations Small sample sizeSmall sample size Proficiency training was not the goalProficiency training was not the goal Mental rehearsal implementation weaknesses – group based, eyes openMental rehearsal implementation weaknesses – group based, eyes open Outcomes data not collectedOutcomes data not collected

33. Why Only One Correlation? Most clearly imaginableMost clearly imaginable Most technically oriented of tasksMost technically oriented of tasks Weaknesses in training and mental rehearsal designWeaknesses in training and mental rehearsal design

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

35. Conclusions Such findings may allow targeted use of mental rehearsal to accelerate skill acquisitionSuch findings may allow targeted use of mental rehearsal to accelerate skill acquisition