Peer teaching and computer-assisted learning: An effective combination for surgical skill training?

BACKGROUND: The surgical literature suggests that collaborative learning using peers may be a valid way to teach surgical skills and there is a growing interest in the use of computer-assisted learning for this purpose. Combining this evolving technology with this type of teaching would theoretically offer a number of advantages including a reduction in the amount of faculty time devoted to this task. In this study, we evaluate the efficacy of a type of collaborative learning in a computer-assisted learning environment. MATERIALS AND METHODS: We designed a prospective, randomized study comparing novice learners who were allowed to work in pairs with those who worked independently in a specially equipped computer-assisted learning classroom. Both pretest and posttest assessments were performed by videotaping this skill. Three experts then evaluated the videotapes, in a blinded fashion. Three different outcomes were assessed. RESULTS: Seventy-seven subjects were enrolled in and completed the study. Comparison of the outcome measures demonstrated no between group difference in the average performance scores or posttest times. The proportion of subjects who correctly tied a square knot was significantly lower in the computer-assisted peer teaching group when compared with the computer-assisted learning alone group (P = 0.04). CONCLUSIONS: Collaborative learning in a computer-assisted learning environment is not an effective combination for teaching surgical skills to novices.     

Transfer of training in acquiring laparoscopic skills.

BACKGROUND: Building on skills already learned in acquiring more complex or related skills is termed transfer of training (TOT). This study examined the TOT effects of previous open and laparoscopic surgical experience on a laparoscopic training module. STUDY DESIGN: Intracorporeal knot tying was chosen for evaluating TOT among three groups of surgical residents: interns (n = 11) with limited open and laparoscopic surgical experience, junior residents (n = 9) with recent and ongoing open and laparoscopic surgical experience, and senior residents (n = 8) with remote and limited laparoscopic experience but ongoing open surgical experience. After receiving a lecture, demonstration, and written instructions on three knot-tying techniques, residents rotated through three performance stations, one for each technique, over 2 days. After 15 minutes of practice, the residents were videotaped completing a test knot. Time to completion and economy of motion were recorded and analyzed. RESULTS: Junior residents had fewer performance errors than senior residents (reported as mean +/- standard error of the mean) and were significantly faster than interns. No significant differences between interns and senior residents for mean time or error performance were observed. Senior residents did not demonstrate TOT from open surgical experience to laparoscopic knot tying. No significant differences were obtained across the three sessions for errors or for time. CONCLUSION: No evidence was found for TOT from open surgical experience to newly introduced laparoscopic knot-tying techniques or from one skill training session to a different skill session at least 4 hours later. This study indicates that specific minimally invasive surgery training is needed to develop laparoscopic surgery skills.     

Housestaff performance is improved by participation in a laparoscopic skills curriculum

BACKGROUND: After the implementation of a laparoscopic skills curriculum, we studied two questions: (1) can skills curriculum participation improve performance and (2) can we identify housestaff who may benefit from early instruction in laparoscopic technical skills? METHODS: We administered a six-task laparoscopic skills curriculum to postgraduate year (PGY) 2 and PGY3 surgical housestaff. Six laparoscopic tasks were divided into two groups: generalized skills and task specific skills. All participants were evaluated during a pretest and were placed in the novice group (total score less than 600) or in the intermediate skill (IS) group (total score 600 or more). Each participant had two 1-hour practice/instruction sessions and 2 weeks for independent practice. After these sessions, a posttest was administered. RESULTS: Novices and intermediate skill participants demonstrated significant improvement in general skills and task specific skills. However, comparison of novice and IS group learners revealed that IS group learners were significantly more proficient in the performance of general skills, but the performance of task specific skills failed to demonstrate a difference between the two groups. On posttest, there was no significant difference in overall score between novices and IS participants. CONCLUSIONS: Overall ability and performance of generalized skills by all housestaff are improved with a laparoscopic skills curriculum; however, the performance of novices improved the greatest. Task specific skills did not discriminate novices from more advanced learners. Early testing of housestaff may identify those individuals who could benefit from intervention and instruction prior to performing the laparoscopic skills in the operating room.     

Visual-spatial ability, learning modality and surgical knot tying.

INTRODUCTION: The ability to mentally rotate an object in 3 dimensions has been shown with an individual's score on the Vandenberg and Kuse Mental Rotations Test. The was to determine whether this Mental Rotations Test could be used to predict performance complex surgical skill - the tying of a 1-handed surgical reef knot. In addition, we learning a spatially complex surgical skill could be achieved more effectively via a computer-based selfdirected learning approach than with a didactic lecture-based teaching method. METHODS: preclerkship medical students at the University of Western Ontario were randomized into computer-based self-directed learning group and a didactic lecture-style learning group. administration of the Mental Rotations Test, the students were taught how to tie a reef knot via the learning modality assigned to their respective group. RESULTS: Students Mental Rotations Test scores were able to tie more surgical knots in the allocated time Students learning how to tie the surgical knot via the computer-based self-directed showed improvement on their knot tying abilities more rapidly than their didactically trained colleagues. CONCLUSION: The ability to mentally rotate an object in 3 dimensions played an important initial learning of a spatially complex surgical technical skill. Our data demonstrated learning was as effective and more practical than traditional lecture-based learning.     

Self-directed practice schedule enhances learning of suturing skills

Background

Most preoperative surgical training programs experience challenges with the availability of expert surgeons to teach trainees. Some research suggests that trainees may benefit from being allowed to actively shape their learning environments, which could alleviate some of the time and resource pressures in surgical training. The purpose of this study was to investigate the effects of self-directed or prescribed practice schedules (random or blocked) on learning suturing skills.

Methods

Participants watched an instructional video for simple interrupted, vertical mattress and horizontal mattress suturing then completed a pretest to assess baseline skills. Participants were assigned to 1 of 4 practice groups: self-directed practice schedule, prescribed blocked practice schedule, prescribed random practice schedule or matched to the self-directed group (control). Practice of the skill was followed by a delayed (1 h) posttest. Improvement from pretest to posttest was determined based on differences in performance time and expert-based assessments.

Results

Analyses revealed a significant effect of group for difference in performance time of the simple interrupted suture. Random practice did not show the expected advantage for skill learning, but there was an advantage of self-directed practice.

Conclusion

Self-directed practice schedules may be desirable for optimal learning of simple technical skills, even when expert instruction is available. Instructors must also take into account the interaction between task difficulty and conditions of practice to develop ideal training environments.     

A role for error training in surgical technical skill instruction and evaluation

BACKGROUND: During the evaluation of many instances of the same basic surgical skill, we observed that there were several errors that occurred frequently. Two studies were undertaken to examine the use of these errors for improving the instruction and evaluation of the skill. MATERIALS AND METHODS: For both studies, two types of rater training videotapes were developed. One involved the use of examples of common errors (error) and the other demonstrated the skill being performed correctly (correct). A testing videotape was created consisting of 24 performances of the skill that ranged in quality of the performance. The first study was designed to assess the impact of error instruction on skill acquisition. In this study, a group of 30 senior medical students were randomly assigned to one of four different training groups: none, error only, correct only, and error+correct. Subjects were videotaped performing the skill before and after the training and three experts evaluated these performances independently using a 7-point rating scale. The second study was designed to assess the impact of error training on skill evaluation and was done using both novice and expert raters. The same group of 30 senior medical students used in the first study was used as novice raters. Following training in one of the four training groups, each subject rated the 24 performances on the testing videotape and interrater reliability was assessed for each group. Surgical faculty served as expert raters in this study and were randomly assigned to receive either error training or no training. Each subject viewed the testing videotape, rating the performances and giving "feedback" commentary. Interrater reliability was calculated for the two groups and the precision of the feedback was assessed. RESULTS: Significant improvement in posttest performance scores was seen only in the "error+correct" training group. Interrater reliability was somewhat lower for the "correct only" and "error only" training groups in both the student and faculty studies. Faculty raters receiving error training had a higher proportion of specific comments than the group that received no training although this difference was not statistically significant. CONCLUSIONS: Instruction about common errors, when combined with instruction about the correct performance enhanced the acquisition of this surgical skill. This suggests a role for the use of errors in surgical technical skill instruction. Our study provides no support for a role for error training in improving skill evaluation.     

The effect of standardized patient feedback in teaching surgical residents informed consent: results of a pilot study

PURPOSE: The purpose of this pilot study was to determine the effectiveness of using feedback from a standardized patient (SP) to teach a surgical resident (SR) informed consent (IC) protocol. METHODS: Four general case types of increasing difficulty were tested in a longitudinal experimental design format. The four types of cases were appendectomy, cholecystectomy, colorectal cancer, and breast cancer. Eight SRs of varying years of completion in medical school served as subjects-four in the experimental group (received performance feedback from an SP) and four in the control group (received no SP feedback). Both the control and experimental groups participated in two patient encounters per case type. The first patient encounter served as the pretest, and the second patient encounter was the posttest. In each encounter, an SP rated the resident on 14 measures using an open-ended seven-point rating scale adopted and modified from the Brown University Interpersonal Skill Evaluation (BUISE). Each resident also reviewed a videotape of an expert giving IC between pretest and the posttest for basic instructional protocol. Random stratified sampling was used to equally distribute the residents by postgraduate years. A total of 16 SPs were used in this study. All patient/SR encounters were videotaped. RESULTS: There was a statistically significant overall change--pretest to posttest and across cases (p = 0.001). The group effect was statistically significant (p = 0.000), with the experimental group averaging about 10 points greater than the control group. CONCLUSIONS: Standardized patient feedback is an effective modality in teaching surgical residents informed consent protocol. This conclusion is tentative, due to the limitations of sample size. The results of this study support continued research on the effects of standardized patient feedback to teach informed consent to surgical residents.     

Early exposure to haptic feedback enhances performance in surgical simulator training: a prospective randomized crossover study in surgical residents

Background In the literature of skill acquisition and transfer of skills, it often is assumed that the rate of skill acquisition depends on what has been learned in a similar context (i.e., surgical simulators providing haptic feedback). This study aimed to analyze whether the addition of haptic feedback early in the training phase for image-guided surgical simulation improves performance. Methods A randomized crossover study design was used, in which 38 surgical residents were randomized to begin a 2-h simulator training session with either haptic or nonhaptic training followed by crossover after 1 h. The graphic context was a virtual upper abdomen. The residents performed two diathermy tasks. Two validated tests were used to control for differences in visual–spatial ability: the BasIQ general cognitive ability test and Mental Rotation Test A (MRT-A). Results After 2 h of training, the group that had started with haptic feedback performed the two diathermy tasks significantly better (p < 0.05, unpaired t-test). Only the group that had started with haptic training significantly improved during the last 1-h session (p < 0.01, paired t-test). Conclusion The findings indicate that haptic feedback could be important in the early training phase of skill acquisition in image-guided surgical simulator training.     

Learning from visual force feedback in box trainers: tissue manipulation in laparoscopic surgery

Background

Currently, task time and errors are often used as performance parameters in laparoscopic training. Training with the focus on task time improvement alone results in fast, but possibly less controlled, instrument movements and therefore suboptimal tissue handling skills.

Methods

Twenty-five medical students were randomly assigned in two groups. Both groups performed a tissue manipulation task six times. During this training session, the time feedback group (n = 13) received real-time visual feedback of the task time. The force feedback group (n = 12) received real-time visual feedback of the tissue manipulation force. After the training sessions, participants in both groups performed an entirely different task without visual feedback. Task time, force, and motion parameters of this posttest were used to compare the technical skills of the medical students.

Results

The training data of the group that received force feedback showed a learning curve for the mean and max absolute force, max force area, force volume, task time, and path length of both instruments. The data from the group that received time feedback showed a learning curve for the max force, task time, and path length of both instruments. In the posttest, the parameters of mean absolute force (p = 0.039), max force (p = 0.041), and force volume (p = 0.009) showed a significant difference in favor of the group that received force feedback.

Conclusions

The learning curves and the posttest indicate that training with visual force feedback improves tissue handling skills with no negative effect on the task time and instrument motions. Conventional laparoscopic training with visual time feedback improves instrument motion and task time, but it does not improve tissue manipulation skills.     

Mental skills training effectively minimizes operative performance deterioration under stressful conditions: Results of a randomized controlled study

Background

Stress can negatively impact surgical performance, but mental skills may help. We hypothesized that a comprehensive mental skills curriculum (MSC) would minimize resident performance deterioration under stress.

Verbal feedback from an expert is more effective than self-accessed feedback about motion efficiency in learning new surgical skills

BACKGROUND: Teaching of technical surgical skills to undergraduate medical students in a laboratory setting away from the patient is not common practice. Because of the large volume of students and shortage of available teaching faculty new methods of teaching must be developed for this group of trainees. In this study we examined the effectiveness of computer-based video training, different types of computer-based motion efficiency feedback (with and without expert criteria), and expert feedback on learning of a basic technical skill in medical students. METHODS: Forty-five junior medical students were randomized into 3 groups and learned suturing and knot-tying skills. Group A received computer-generated feedback about the economy of their movements. Group B received the same motion economy feedback, as well as expert reference values. Group C received verbal feedback from an expert. All groups were pre-tested, allowed 18 practice trials, and post-tested, and their skill retention was retested after 1 month. Performance was assessed by expert analysis using an objective structured analysis of technical skill and by computer analysis (Imperial College Surgical Assessment Device [ICSAD]). RESULTS: All groups showed improvement from pre-test to post-test. However, only group C showed retention of skill on delayed performance testing. CONCLUSIONS: Verbal feedback from an expert instructor led to lasting improvements in technical skills performance. Providing information about motion efficiency did not lead to similar improvements.     

Halstedian technique revisited. Innovations in teaching surgical skills.

This paper reviews the laboratory models used to teach fundamental surgical skills in our general surgery residency. The laboratory modules allow supervision and self-instruction, practice, and videotape monitoring of the following techniques: skin incision, suturing, knot tying, hemostasis, vascular anastomosis, and intestinal anastomosis. Pigs' feet simulate human skin for exercises in skin incision, lesion excision, suturing, and basic plastic surgical techniques. Latex tubing and penrose drains allow experience in suturing, knot tying, and hemostasis. Polytetrafluoroethylene vascular prostheses permit quantification of the precision of needle passage and suturing by measurement of leakage of water through a vascular anastomosis. Reconstituted, lyophilized, irradiated bovine arteries and ileum provide models of biologic tissue for creating handsewn vascular anastomoses and sutured or stapled gastrointestinal anastomoses. A headlamp videocamera allows unobstructive recording of the resident's technical performance and provides subsequent visual feedback for self-improvement when compared to reference instructional videotapes. We feel that these innovations may enhance surgical dexterity of residents without the need for animal sacrifice. Our goal is to foreshorten the learning curve for basic surgical skills and improve performance in the clinical operating room.     

The use of video self-modelling and feedback to teach cooking skills to individuals with traumatic brain injury: a pilot study

Objective: To evaluate the effectiveness of video self-modelling plus prompting and feedback to teach a cooking skill to people with traumatic brain injury (TBI) and to examine skill generalization to a novel food item.

Research design: Multiple probe across participants.

Methods and procedures: Four individuals with TBI received instruction in cooking. They watched videotapes of themselves cooking and practiced that skill while receiving prompts and feedback. Treatment effects were evaluated by comparing performance before, during and after training and at a 2 and 4 week follow-up. Additionally, cooking performance on a novel food item was examined.

Main outcomes and results: Three of the four individuals achieved criterion performance within four training sessions. Those individuals also substantially maintained their skills 2 and 4 weeks following training and generalized their skills to a novel food item.

Conclusions: Video self-modelling plus prompting and feedback appears to be an effective treatment for teaching simple cooking skills to individuals with TBI. Further research should examine whether the video alone is sufficient for skill acquisition and evaluate the effectiveness of video self-modelling to teach other skills.     

Intracorporal suturing—driving license necessary?

Background

Intracorporeal suturing and knot tying (ICKT) in minimal invasive surgery (MIS) represents a key skill for advanced procedures. Different methods exist for measuring knot quality and performance, but the heterogeneity of these methods makes direct comparisons difficult. The aim of this study is to compare the quality of a laparoscopic knot to one that is performed open.

Methods

To compare open and laparoscopic knot-tying methods we used a surgeon's square knot. For laparoscopic knot tying we used a Pelvitrainer. The 32 participants were divided among 4 groups of different skill levels. Group 1 consisted of 6 senior physicians. Group 2 was made up of 10 first to fourth year interns. Groups 3 and 4 contained 16 medical students who had never performed either laparoscopic procedures or open sutures before. Group 3 participants received a 1-hour hands-on training in suturing, whereas group 4 participants received no prior training. Total time, knot quality, suture placement accuracy, and performance defined the parameters for assessment in this study.

Results

All participants, irrespective of education level were inferior in ICKT compared to open suturing. Only Group 1 showed no significant difference in knot quality and accuracy between the open and laparoscopic suture performance.

Conclusion

It is well documented that psychomotor skills need to be developed before more advanced skills can be put into practice. Training centres for minimally invasive surgery should be an integral part of surgical education. The variables in our study are meaningful and easy to implement. They can be used to measure personal progress and as objective parameters in the development of laparoscopic trainee education.     

Training in laparoscopic suturing skills using a new computer-based virtual reality simulator (MIST-VR) provides results comparable to those with an established pelvic trainer system

BACKGROUND: We hypothesized that the Minimally Invasive Surgery Trainer (MIST-VR; VP Medical R, London, U.K.) would be as effective as the Yale Laparoscopic Skills Course in improving laparoscopic intracorporeal suturing skills. MATERIALS AND METHODS: Each student made six attempts to tie a knot laparoscopically. Students were then randomized to train on the MIST-VR for five sessions (six skills/session) or the Yale Skills for five sessions (three skills/session) over 5 days. On completion of training, all students were evaluated by a test consisting of six attempts to tie a laparoscopic knot. RESULTS: The percentage improvement in knot tying time did not differ significantly in the pelvic trainer group (30 +/- 21%) (from 443 +/- 135 to 311 +/- 137 seconds) and the MIST-VR group (39 +/- 21%) (from 409 +/- 109 to 256 +/- 140 seconds) (P = 0.308). CONCLUSIONS: The MIST-VR is equivalent to the Yale Skills Course for training in the advanced laparoscopic skill of intracorporeal suturing.     

Comparison of video trainer and virtual reality training systems on acquisition of laparoscopic skills

Training on a video trainer or computer-based minimally invasive surgery trainer leads to improved benchtop laparoscopic skill. Recently, improved operative performance from practice on a video trainer was reported. The purpose of this study was three fold: (a) to compare psychomotor skill improvement after training on a virtual reality (VR) system with that after training on a video-trainer, (VT) (b) to evaluate whether skills learned on the one training system are transferable to the other, and (c) to evaluate whether VR or VT training improves operative performance. For the study, 50 junior surgery residents completed baseline skill testing on both the VR and VT systems. These subjects then were randomized to either a VR or VT structured training group. After practice, the subjects were tested again on their VR and VT skills. To assess the effect of practice on operative performance, all second-year residents (n = 19) were evaluated on their operative performance during a laparoscopic cholecystectomy before and after skill training. Data are expressed as percentage of improvement in mean score/time. Analysis was performed by Student's paired t-test. The VR training group showed improvement of 54% on the VR posttest, as compared with 55% improvement by the VT group. The VR training group improved more on the VT posttest tasks (36%) than the VT training group improved on the VR posttest tasks (17%) (p <0.05). Operative performance improved only in the VR training group (p <0.05). Psychomotor skills improve after training on both VR and VT, and skills may be transferable. Furthermore, training on a minimally invasive surgery trainer, virtual reality system may improve operative performance during laparoscopic cholecystectomy.     

A theory-based curriculum for enhancing surgical skillfulness

BACKGROUND: Curricula for surgical technical skills laboratories have traditionally been designed to accommodate the clinical activities of residents, so they typically consist of individual, episodic training sessions. We believe that the skills laboratory offers an opportunity to design a surgical skills curriculum based on the fundamental elements known to be important for motor skill instruction. We hypothesized that training novices with such a curriculum for a 1-month period would yield skills performance levels equivalent to those of second year surgery residents who had trained in a traditional program. STUDY DESIGN: Fourth-year medical students served as study subjects (novice group) during a 4-week senior elective. They were taught each skill during a 1-week period. Subjects received instruction by a content expert followed by a 1-week period of deliberate practice with feedback. The novice performances were videotaped both before and after the intervention, and each videotape was evaluated in a blinded fashion by experts using a validated evaluation instrument. These results were compared with skill performance ratings of first- and second-year surgery residents that had been accumulated over the previous 3 years. RESULTS: Average performance ratings for the novices substantially improved for all four skills after training. There was no marked difference between average performance ratings of postintervention novice scores when compared with the average scores in the resident group. Inter-rater agreement in scoring for the videotaped novice performances exceeded 0.87 (intraclass correlation) for all ratings of pre- and posttraining. CONCLUSIONS: These results demonstrate the effectiveness of a laboratory-based training program that includes fundamentals of motor skills acquisition.     

The Effect Of Different Corrective Feedback Methods on the Outcome and Self Confidence of Young Athletes

This experiment investigated the effects of three corrective feedback methods, using different combinations of correction, or error cues and positive feedback for learning two badminton skills with different difficulty (forehand clear - low difficulty, backhand clear - high difficulty). Outcome and self-confidence scores were used as dependent variables. The 48 participants were randomly assigned into four groups. Group A received correction cues and positive feedback. Group B received cues on errors of execution. Group C received positive feedback, correction cues and error cues. Group D was the control group. A pre, post and a retention test was conducted. A three way analysis of variance ANOVA (4 groups X 2 task difficulty X 3 measures) with repeated measures on the last factor revealed significant interactions for each depended variable. All the corrective feedback methods groups, increased their outcome scores over time for the easy skill, but only groups A and C for the difficult skill. Groups A and B had significantly better outcome scores than group C and the control group for the easy skill on the retention test. However, for the difficult skill, group C was better than groups A, B and D. The self confidence scores of groups A and C improved over time for the easy skill but not for group B and D. Again, for the difficult skill, only group C improved over time. Finally a regression analysis depicted that the improvement in performance predicted a proportion of the improvement in self confidence for both the easy and the difficult skill. It was concluded that when young athletes are taught skills of different difficulty, different type of instruction, might be more appropriate in order to improve outcome and self confidence. A more integrated approach on teaching will assist coaches or physical education teachers to be more efficient and effective.

Key points

• The type of the skill is a critical factor in determining the effectiveness of the feedback types.
• Different instructional methods of corrective feedback could have beneficial effects in the outcome and self-confidence of young athletes
• Instructions focusing on the correct cues or errors increase performance of easy skills.
• Positive feedback or correction cues increase self-confidence of easy skills but only the combination of error and correction cues increase self confidence and outcome scores of difficult skills.

Key words: Instructional cues, badminton skills, difficulty     

Surgical skill acquisition with self-directed practice using computer-based video training

BACKGROUND: Computer-based video training (CBVT) provides flexible opportunities for surgical trainees to learn fundamental technical skills, but may be ineffective in self-directed practice settings because of poor trainee self-assessment. This study examined whether CBVT is effective in a self-directed learning environment among novice trainees. METHODS: Thirty novice trainees used CBVT to learn the 1-handed square knot while self-assessing their proficiency every 3 minutes. On reaching self-assessed skill proficiency, trainees were randomized to either cease practice or to complete additional practice. Performance was evaluated with computer and expert-based measures during practice and on pretests, posttests, and 1-week retention tests. RESULTS: Analyses revealed performance improvements for both groups (all P < .05), but no differences between the 2 groups (all P > .05) on all tests. CONCLUSIONS: CBVT for the 1-handed square knot is effective in a self-directed learning environment among novices. This lends support to the implementation of self-directed digital media-based learning within surgical curricula.     

Objective assessment of training surgical skills using simulated tissue interface with real-time feedback

OBJECTIVE: We have shown previously that achieving competent performance of basic laparoscopic skills is possible in difficult conditions. We hypothesize that real-time performance feedback adds to the quality of proficiency-based simulator training for performance and forces applied to conventional surgical tools while tying square knots and running suture throws. DESIGN: A silk suture was preplaced on a simulated skin pad to assess incision closure by tying square knots and in separate trials to evaluate closure with the task of placing a running suture. The order of task performance was assigned randomly, and each task was repeated 5 times before switching to the second task. In all, 10 repetitions per task were performed by each student. After completion of the second surgical task, the cycle was repeated to test adaptation and retention of motor-skill capabilities. Half the participants were provided with a graphic display in dial format to indicate applied force. SETTING: Bench-top setup of apparatus was performed in a laboratory at Virginia Commonwealth University, Department of Surgery. PARTICIPANTS: Twelve second-year medical students with no surgical skills background participated in the study. RESULTS: Results from the knot-tying task indicated that the average force exerted on tissue forceps by the left hand in the blinded group who performed simple knots actually increased over repeated trials, as opposed to what was achieved by the group that had real-time feedback of their forces being applied. For the running suture, the task average force exerted on surgical tools by both hands was greater in the blind group relative to those viewing real-time graphic feedbacks of forces generated over repeated trials. CONCLUSION: Inclusion of real-time objective assessment in evaluation of surgical skills minimizes subjective evaluation of performance capabilities. A direct correlation between real-time feedback regarding force exerted and extent of surgical task completion was noted.