1. Visual Spatial Ability – Are Surgeons Born or Made? Zackary Boom-Saad, Pamela Andreatta, EdD, Miranda L. Hillard, Anthony G. Gallagher, PhD †, Scott Langenecker, PhD, Angela Caveny, PhD, Paul G. Gauger, MD, and Rebecca M. Minter, MD University of Michigan and Royal College of Surgeons in Ireland †

2. Background “…ultimately the level of surgical technical performance at the end of training that an individual can achieve is determined by…innate ability…” 1 “…advanced trainees and experts do not score higher on carefully selected visual-spatial tests, suggesting that practice and surgical experience may supplant the influence of visual-spatial ability over time…” 2 1 MacMillan et al. Am Jour Surg 1999.:177: 274-277 2 Wanzel et al. Surgery 2003:134: 750-7

3. Hypothesis No significant baseline differences in visual-spatial, psychomotor, and minimally invasive surgical skills exist between students entering procedural and non- procedural fields.

4. Methodology: Protocol Thirty M4s Procedural Group (n=17) Non-procedural Group (n=13) 1.Visual-Spatial Ability and Psychomotor Testing 2.PicSOr and LapSim  Exercises Comparison of Group Performance

5. Subject Demographics Procedural (n=17) –General surgery –Urology –Orthopaedics –Ophthalmology –Plastic surgery –ENT –Ob/Gyn Non-procedural (n=13) –Internal medicine –Pediatrics –Med/Peds –Anesthesiology –Radiation oncology –PM&R –Pathology –Emergency Medicine –Family medicine

6. Subject Demographics Procedural: Non-Procedural: Gender Male 14 5 Female 3 8 Handedness Right 16 13 Left 1 0 Video game experience: Prior 11/17 6/13 Current 6/17 4/13

7. Mental Rotations Test

8. Surface Development Test Put picture here

9. CANTAB Cambridge Neuropsychological Test Automated Battery Three component assessments –Procedural learning and visual memory –Rapid visual information processing –Motor dexterity and reaction time

10. PicSOr Tests subject’s ability to discern orientation of a 3-D object shown in two-dimensions 1 1 Gallagher et al. Surg Endosc 2003; 17: 168-71

11. LapSim™ Virtual reality laparoscopic simulator Built-in metrics with established construct validity Performance on five basic skills tasks assessed

12. Statistical Analysis ANOVA for differences between groups on LapSim  t-tests for MRT, CANTAB, SDT, and PicSOr Pearson correlation coefficient between PicSOr and LapSim 

13. Results: MRT and SDT

14. Results: CANTAB Procedural (Mean±SD) Non-procedural (Mean±SD) Significance Procedural learning Stages completed 1 st trial Mean errors to succes Total errors (adjusted) 3.93±0.73 0.64±0.85 3.21±4.25 3.69±0.75 0.85±0.73 4.23±3.63 p=0.42 p=0.51 Rapid visual processing Mean latency Probability of false alarm Probability of hit 392±47 0.003±0.006 0.89±0.07 394±39 0.001±0.003 0.84±0.11 p=0.88 p=0.29 p=0.15 Reaction time 5-ch movement time 5-ch reaction time 327±75 312±36 377±105 315±50 p=0.17 p=0.19

15. Results – PicSOr Correlation Coefficient (Mean±SD) Procedural students 0.93 ± 0.04* Non-procedural students 0.82 ± 0.12 *p<0.01

16. Results – LapSim™ Procedural (Mean±SD) Non-procedural (Mean±SD) Significance (p value) Grasping L instr time L instr misses L instr path length L instr ang path R instr time R instr ang path Max damage 47.26±9.71 0.90±1.10 2.16±0.44 454.79±69.29 37.78±7.00 372.20±65.57 4.34±1.78 59.42±13.74 5.77±7.19 2.73±0.71 581.41±186.14 48.41±9.52 486.95±122.17 8.83±6.71 0.016 0.024 0.022 0.031 0.003 0.006 0.029

17. Results – LapSim  Procedural (Mean±SD) Non-procedural (Mean±SD) Significance (p value) Lifting and Grasping Time L instr path length L instr ang path R instr path length R instr ang path 56.10 ±16.01 1.63 ±0.31 441.04±70.50 1.63±0.29 362.31±47.83 68.03±10.22 1.98±0.41 517.66±104 1.96±0.35 424.63±61.18 0.038 0.024 0.040 0.016 0.009 Clip Applying Blood loss 0.12±0.050.21±0.140.044

18. Performance Correlation – PicSOr and LapSim  Coordination –6/8 parameters, p<0.05 Grasping –7/11 parameters, p<0.05 Lifting and Grasping –8/10 parameters, p<0.05 Clip Applying –6/9 parameters, p<0.05

19. Summary No significant difference between groups –Visual spatial ability –Pyschomotor ability Procedural students demonstrate a higher baseline performance level with respect to minimally invasive surgical skills –PicSOr performance –LapSim  performance

20. Conclusions Are surgeons born or made? –Differences in laparoscopic performance exist and can be measured –Creates possibility of performing an early needs assessment, and the ability to develop individualized curricula for MIS skills training Can individuals be trained to equivalent performance levels with focused instruction?

21. Limitations Small sample size –Type II error –Inability to stratify by specialty Laparoscopic performance assessment was based only on simulated exercises, not on actual intra-operative performance

22. Acknowledgements Association for Surgical Education Foundation – Center for Excellence in Surgical Education, Research, and Training (CESERT) United States Surgical Corporation