How to select aspirant laparoscopic surgical trainees: establishing concurrent validity comparing Xitact LS500 index performance scores with standardized psychomotor aptitude test battery scores

BACKGROUND: Although a controversial topic in medical education, the selection of aspirant surgical trainees is a subject that needs to be addressed. In the view of preventing surgical trainee drop-outs and of appropriate allocation of limited resources, it is an issue critical to the profession. Traditional methods of selection are often subjective, and do not seem to correlate with skill needed for surgery. Standardized neuropsychometric test batteries may be useful in helping to select aspirant laparoscopic surgeons. Our study attempts to link surgical novices' psychometric ability test battery data with actual performance outcome on an objective, validated, and reproducible surgical laparoscopic task using virtual-reality simulation. MATERIALS AND METHODS: Thirty-three novices with no laparoscopic surgical experience participated. Each participant performed the Xitact LS500 Virtual Reality cholecystectomy clip-and-cut module 30 times. Individual learning curves were computed and patterns were assessed. Participants were examined using the aptitude test battery including the Abstract Reasoning test, the Space Relations test, the Gibson Spiral Maze test, and the Crawford Small Parts Dexterity tester. RESULTS: Over 900 virtual-reality simulation tasks were generated and assessed. Of the participants, 93.3% were able to complete the virtual-reality simulation 30 times and all elements of our aptitude test battery. The abstract reasoning test is the only test correlating significantly to Xitact test outcome. This test is highly correlated to the space relations test. Both tests have discriminative power, comparing groups of performers. CONCLUSIONS: The present study addresses the concurrent validity in aptitude testing, comparing scores of surgical novices on the Xitact LS500 laparoscopic cholecystectomy virtual-reality simulation with performance scores on a battery of standardized psychometric aptitude tests. The abstract reasoning and the space-relation test have predictive and selective value, identifying individuals who have good laparoscopic surgical virtual-reality performance. Aspiring laparoscopic surgeons who score below 25 on either test, that is, an expected 36%, would have to be further assessed using Xitact surgical task performance. The group of participants scoring above 35 on the Abstract Reasoning test and above 45 on the Space Relations test, that is, an expected 18% of the population, is unlikely to mal-perform on Xitact. The other 46% could very well benefit from Xitact simulation and assessment when the opportunity is present.     

Correlation of manual dexterity with USMLE scores and medical student class rank

INTRODUCTION: Surgical programs often rely on objective measures of medical school cognitive performance, including United States Medical Licensing Exams (USMLE) scores and class rank, to predict success of an applicant in their training program. Although job applicants in non-medical fields often undergo dexterity testing prior to being hired, this has not been widely used in the selection process for surgical residency applicants. Thus, successful identification of applicants likely to succeed in surgical fields remains elusive. Given this difficulty, we wondered if performance on tests of manual dexterity would correlate with USMLE board scores and medical school class rank. METHODS: Fourth year medical students underwent a clinical study of dexterity testing using the Stromberg Dexterity Test (gross motor), the O'Conner Tweezer Test (fine motor), and the MIST-VR laparoscopic simulator (Mentice Corporation, Gothenberg, Sweden). Performance times were compared with USMLE Step I & II scores and class rank, as well as a self-assessment of manual dexterity. RESULTS: A total of 113 medical students participated. Gross motor dexterity was significantly correlated with class rank (P = 0.04) and USMLE Step I score (P = 0.04). Fine motor dexterity and MIST-VR performance did not correlate with class rank or USMLE scores. Self-assessment of good manual dexterity correlated with faster performance times on the MIST-VR laparoscopic simulator (0.0174). CONCLUSIONS: Gross motor skill is associated with objective measures of medical school cognitive performance, such as class rank and USMLE scores. Furthermore, self-assessment of dexterity may predict baseline laparoscopic abilities. Further research is necessary to determine whether such dexterity testing could be helpful in identifying applicants who possess the ability to develop into competent surgeons.     

The Role of Anxiety in Simulation-Based Dexterity and Overall Performance: Does It Really Matter?

Background: Essential Skills in the Management of Surgical Cases (ESMSC) is an international undergraduate surgical masterclass which combines ex vivo, dry lab and high fidelity in vivo simulation-based learning (SBL). It consists of 32 stations of skills-based learning, including open reduction internal fixation (ORIF) of fractures. Current literature suggests early involvement in skills-based learning at the undergraduate level is vital. Aims: To compare students' dexterity and skills-based performance with demographic and educational background parameters. Methods: 112 medical students from European Union countries including the United Kingdom, Germany, Greece, Cyprus, Germany, and Bulgaria were selected from a competitive pool of candidates to attend the course. Students undertook ORIF in an ex vivo swine model, and in a simulated fracture on a bamboo rod. Skills-based performance was assessed by two consultant surgeons with validated direct observation of procedural skills (DOPS) forms. Anxiety was self-assessed using the Westside Anxiety Scale prior to the ORIF stations. Dexterity was measured with the O'Connor tweezer dexterity test. Results: Female students had significantly higher dexterity scores (median difference 7, p =.003). Right-handed students achieved higher dexterity than left-handed students (median difference 7, p =.043). There was no difference in students' performance across different medical schools, and across year groups (p <.05 for any correlation). Self-reported anxiety was not correlated with high fidelity skills-based performance (r = 0.032, p =.74). Conclusion: Anxiety does not seem to play a significant role in Simulation Skills-Based learning. Undergraduate surgical curricula should incorporate SBL-based modules to enhance practical skills learning and motivate future orthopedic surgeons.     

Objective comparison of manual dexterity in physicians and surgeons

Recent interest in the assessment of manual dexterity of surgical residency applicants prompted an investigation of psychomotor skills in surgeons and physicians. The Purdue Pegboard and Minnesota Manual Dexterity tests were given to 57 subjects. Analysis of the data revealed no significant difference in dexterity between medical and surgical residents, suggesting that medical students do not select specialty training programs because of the presence or absence of manual skills. The data also revealed that surgical staffmen performed substantially worse than those in the other groups on some of the tests, possibly because of an older average age. The authors conclude from their data that manual dexterity tests should not be used in assessing candidates for surgical residency training positions.     

Visual-spatial ability correlates with efficiency of hand motion and successful surgical performance

BACKGROUND: This study examines the influence of visual-spatial ability and manual dexterity on surgical performance across 3 levels of expertise. METHODS: Dental students, surgical residents, and staff surgeons completed standardized tests of manual dexterity and visual-spatial ability and were assessed objectively while performing the rigid fixation of an anterior mandible on bench model simulations. Outcome variables included expert assessment of technical performance and efficiency of hand motion during the procedure (recorded using electromagnetic sensors). RESULTS: Visual-spatial scores correlated significantly with surgical performance scores within the group of dental students (r=.40 to.73), but this was not the case for residents or staff surgeons. For all groups, manual dexterity did not correlate with hand motion parameters. There were no differences between groups in visual-spatial ability or manual dexterity, but highly significant differences were seen in surgical performance scores (P<.001), in that surgeons outperformed residents, who in turn outperformed students. CONCLUSIONS: Among novices, visual-spatial ability is associated with skilled performance on a spatially complex surgical procedure. However, advanced trainees and experts do not score any higher on carefully selected visual-spatial tests, suggesting that practice and surgical experience may supplant the influence of visual-spatial ability over time. Thus, the use of these tests for the selection of residents is not currently recommended; they may be of more use in identifying those novice trainees (ie, those with lower test scores) who might benefit most from brief supplementary instruction on specific technical tasks.     

Measuring normal hand dexterity values in normal 3-, 4-, and 5-year-old children and their relationship with grip and pinch strength.

After surgery for trauma or correction of congenital anomaly, hand function is difficult to evaluate in children because there are no reference norms on children 3 to 5 years old. The purpose of this study was to determine whether reproducible normative values for hand dexterity and grip and pinch strength could be obtained in young children using simple tests that could be administered quickly within the attention span of a 3- to 5-year-old. The Functional Dexterity Test (FDT), a pegboard test validated for adults and older children, seemed to meet our requirements for dexterity. The FDT was administered to a convenience sample of normal children in a prekindergarten school who were grouped according to age: 3-year-olds (n = 17), 4-year-olds (n = 24), and 5-year-olds (n = 22). Hand dominance was determined. The task was demonstrated by 1 of the 2 testers. The child was asked to turn the pegs over in the pegboard without using the free hand or balancing the peg against the chest. Both hands were tested. Grip and pinch strengths were measured in both hands in a consistent manner. All the children were tested with the arm at the side and the elbow at 90 degrees. A dynamometer was used for grip strength and a pinch meter was used to measure key (lateral) and tripod pinch strengths. Means and SDs were calculated for each age group, and the dependent values of dexterity, strength, and dominance were correlated. Dexterity and strength scores were significantly different by age group. A good FDT score in the dominant hand was predictive of a good score in the nondominant hand. Grip and pinch strength correlated poorly with functional dexterity. The normative values established in this study for children in the 3- to 5-year-old range can be referenced for disability estimates and establishing goals for children after surgery or hand injury.     

A warm-up laparoscopic exercise improves the subsequent laparoscopic performance of Ob-Gyn residents: a low-cost laparoscopic trainer.

INTRODUCTION: Residents traditionally acquire surgical skills through on-the-job training. Minimally invasive laparoscopic techniques present additional demands to master complex surgical procedures in a remote 2-dimensional venue. We examined the effectiveness of a brief warm-up laparoscopic simulation toward improving operative proficiency. METHODS: Using a "Poor-Man's Laparoscopy Simulator," 12 Ob/Gyn residents and 12 medical students were allocated 10 minutes to transfer 30 tablets with a 5-mm grasper from point A to point B via laparoscopic visualization in a warm-up exercise. Participants repeated the exercise following a 5-minute pause. Mean scores, expressed in seconds/tablet, and overall improvement (percentage difference between warm-up and follow-up) were analyzed according to postgraduate standing (PGY14), dexterity skills, and pertinent vocational activities. RESULTS: Significant improvements were noted for both residents (+25%) and medical students (+29%), P<0.0001. Scores between the 2 groups, however, were not significant (P=0.677). Proficiency was not influenced by PGY standing. Interestingly, the best (8.73 sec/pill) and the worst (25 sec/pill) scores were attained by a medical student and a chief resident, respectively, suggesting the contribution of individual aptitude. CONCLUSION: A brief warm-up exercise before an actual laparoscopic surgical procedure significantly improves subsequent laparoscopic performance.     

Developing assessments of surgical skills for the GMC Performance Procedures

INTRODUCTION: The objectives were to: (i) establish how 'typical' consultant surgeons perform on 'generic' (non-specialist) surgical simulations before their use in the General Medical Council's Performance Procedures (PPs); (ii) measure any differences in performance between specialties; and (iii) compare the performance of group of surgeons in the PPs with the 'typical' group. VOLUNTEERS AND METHODS: Seventy-four consultant volunteers in gastrointestinal surgery (n=21), vascular surgery (n=11), urology (n=10), orthopaedics (n=15), cardiothoracic surgery (n=10) and plastic surgery (n=7), plus 9 surgeons undertaking phase 2 of the PPs undertook 7 simple simulations in the skills laboratory. The scores of the volunteers were analysed by simulation and specialty using ANOVA. The scores of the volunteers were then compared with the scores of the surgeons in the PPs. RESULTS: There were significant differences between simulations, but most volunteers achieved scores of 75-100%. There was a significant simulation by specialty interaction indicating that the scores of some specialties differed on some simulations. The scores of the group of surgeons in the PPs were significantly lower than the reference group for most simulations. CONCLUSIONS: Simple simulations can be used to assess the basic technical skills of consultant surgeons. The simulation by specialty interaction suggests that whilst some skills may be generic, others are not. The lower scores of the surgeons in the PPs suggest that these tests possess criterion validity, i.e. they may help to determine when poor performance is due to lack of technical competence.     

A novel robotic system for single-port laparoscopic surgery: preliminary experience

Background

The concept of single-access procedures has gained greater attention from general surgeons during the past 5 years. Despite this wide momentum, these procedures pose several changes for the surgeon, such as impaired eye-hand coordination and restricted manipulation. In this context, robotic-assisted surgery represents a promising technology to enhance the dexterity of laparoscopic surgeons.

Methods

A novel teleoperated robotic system for minimally invasive surgery (MIS) called SPRINT (Single-Port lapaRoscopy bImaNual roboT) has been developed. SPRINT is a master-slave robotic platform designed for bimanual interventions through a single-access port. The system is basically composed by two main arms having a maximum diameter of 18 mm and a stereoscopic-camera (Karl-Storz, Tuttlingen, Germany). The arms may be inserted into a cylindrical introducer that has a maximum diameter of 30 mm. The surgeon console is composed of two master manipulators, a foot-switch, and a 3D full-HD display.

Results

In an animal study, a small-bowel enteroenterostomy and the ligation of a mesenteric vessel bundle have been performed. As preliminary experience, the system has been placed within the peritoneal cavity through an incision of approximately 10 cm: the robot has been suspended in an open fashion, due to some mechanical constraints of the current prototype. The procedures have been performed in an authorized laboratory on a female pig of approximately 50 Kg.

Conclusions

Two typical surgical maneuvers have been performed successfully with the SPRINT surgical platform: an intestinal anastomosis and a vessel ligation. Moreover, the speed, precision, and force with which the SPRINT robot executed the commands by the surgeon controlling the master console have been subjectively described as adequate to the tasks. Based on this preliminary demonstration, bimanual robot solutions, such as the SPRINT robot, may offer more dexterity and precision to single-port techniques in the next future.     

The performance of master surgeons on the Advanced Dundee Endoscopic Psychomotor Tester: contrast validity study

HYPOTHESIS: The contrast validity of the Advanced Dundee Endoscopic Psychomotor Tester (ADEPT) was determined by comparing the performance of "master surgeons" with that of surgical trainees (also called junior surgeons) on the system. DESIGN: Twenty master surgeons and 20 junior surgeons were tested on the ADEPT system. The master surgeons, all of consultant grade, were recruited as established experts of national or international standing in laparoscopic surgery. The junior surgeons were participants of essential laparoscopic courses at the start of their higher surgical training. The ADEPT end points used in the study were instrument error, execution time, and task completion. An analysis of variance was used for the data analysis, with statistical significance set at.05. RESULTS: Master surgeons incurred a significantly lower instrument error rate than surgical trainees (P =.007), with no significant difference in execution time and the task completion score (P =.42 and P =.40, respectively). CONCLUSION: The ADEPT system has contrast validity because master surgeons completed the tasks more accurately without sacrificing execution time.     

What do master surgeons think of surgical competence and revalidation?

BACKGROUND: There has been on-going debate and public interest in surgical competence in recent years. METHODS: A Delphi reiterative opinion survey was conducted among master surgeons on selection of surgical trainees, methods of assessment of progress of surgical trainees, and revalidation of established consultant surgeons. RESULTS: Selection-the current methods of trainee selection were considered inadequate and in need of revision. The important attributes recognized by group are cognitive factors, innate dexterity, and personality. Important aspects of personality include decision-making ability, insight, team spirit, and emotional stability. Assessment during training-the majority view was that this should be based on clinical judgement/skills, operative skills, and cognitive ability. Assessment of technical ability should be based on standardized checklists. Research within training programs was encouraged but academic achievement does not reflect surgical competence. There was a majority verdict for an exit clinical examination. Revalidation-the group agreed on the need for competence checks during the professional career of surgeons. These should cover knowledge, clinical, operative, and humanistic skills; but expressed concern on the feasibility of a revalidation system that can reliably assess the range of skills needed for surgical competence. There was a majority vote against an internal appraisal system. External assessment by nationally appointed 'assessors' was considered preferable. CONCLUSIONS: Both selection and assessment of surgical trainees require changes and standardization. Although revalidation is necessary, concern was expressed on the reliability and validity of existing and proposed systems.     

某高校医学生假期日常行为调查

目的了解医学生日常行为,为医学生今后假期学习生活提供指导,增强医学生自主学习能力。 方法以河北某医学院的医学生为调查对象,调查其基本情况、睡眠状况、学习情况、娱乐及运动情况,随机抽取本科生及硕士生共960人。 结果（1）假期期间仅8.12%的医学生睡眠质量差,且硕士生明显多于本科生,本科生的睡眠障碍得分高于硕士生,硕士生的入睡时间、睡眠时间得分明显高于本科生;（2）硕士生假期自主学习的能力优于本科生,硕士生的自我效能、学习控制、学习意义、制定学习计划及学习评价得分明显高于本科生;（3）医学生主要通过电子设备学习专业知识,本科生多通过书籍（83.43%）及观看相关教学视频（72.93%）学习,硕士生学习专业知识的途径多为文献阅读（78.46%）及论文撰写（56.15%）,硕士生学习专业性突出;本科生英语学习多为背单词（80.63%）,硕士生以英文文献阅读（59.62%）为主;78.44%的医学生按时听网络直播课程,其中51.39%的学生认为其效果不如课堂授课;（4）58.13%的医学生每天使用电子设备娱乐时间超过4 h,不同年级间无明显差异;（5）每日运动时间超过30 min的医学生占22.19%,其中硕士生明显多于本科生。 结论假期医学生睡眠质量一般,硕士生的睡眠质量明显差于本科生。硕士生假期自主学习能力优于本科生;本科生、硕士生对于专业知识和英语学习重点不同。本科生及硕士生每日使用电子设备娱乐时间均较长。每日运动时间超过30 min的硕士生明显多于本科生。     

Influence of medical students' past experiences and innate dexterity on suturing performance

Background

Medical students often site their ability to excel at technical tasks as justification for choosing surgery as a career path. We sought to investigate how medical students' dexterity skills and past experiences correlated with suturing performance.

Methods

Sixty-four 3rd-year medical students were surveyed about previous experiences that involved manual dexterity. Technical skills were then measured using a validated test of manual dexterity and subcuticular closure of a pig's foot incision. Spearman's rank correlation coefficients determined correlation between variables.

Results

Previous experiences, self-assessment of dexterity, prior suturing, and current interest in surgery did not significantly correlate with manual dexterity or suturing skill scores. Innate manual dexterity score was the only significant correlating factor to suture skill score (Spearman's rank correlation coefficient = .336; P = .007).

Conclusions

Innate manual dexterity skills are predictive of initial surgical suturing performance regardless of past student experiences. Interventions aimed at improving early surgical technique should be optimally focused on dexterity training.     

Neuropsychologic predictors of operative skill among general surgery residents

The present study develops a rating scale method for evaluating operative skills, assesses the predictive utility of neuropsychologic tests of nonverbal cognitive and psychomotor abilities in accounting for individual differences in surgical skills, and compares the efficiency of these measures with those of traditional residency selection criteria. According to a multifactorial design, 120 general surgery residents were tested with a neuropsychologic test battery and then rated by attending surgeons on surgical skills exhibited during the course of 1445 surgical procedures. Analysis of the neuropsychologic battery resulted in three factors (complex visuo-spatial organization, stress tolerance, psychomotor abilities) that were statistically unrelated to traditional measures such as Medical College Admission Test and National Board scores. Multiple regression analyses indicated that academic predictors, taken alone, either do not correlate (National Board scores) or correlate negatively (Medical College Admission Test scores) with the surgery ratings. Conversely, neuropsychologic test scores show significant positive correlation (r = 0.68) with the ratings. When both sets of predictor variables are combined, a multiple regression coefficient of 0.80 is found with the ratings, with more than two thirds of the predictive power attributable to the neuropsychologic test scores. These tests may provide a useful addition to traditional methods of predicting operative skills.     

Double gloving and practice attitudes among surgeons

BACKGROUND: Exposure to blood and body fluids while operating places surgeons at risk. Double gloving is a safety measure, which decreases this risk. However, many surgeons do not incorporate this precaution into their personal practice. This study evaluates surgeons' gloving practices and hepatitis status. METHODS: A questionnaire was sent to all consultant surgeons and residents in the surgical specialties in the Capital Health region, University of Alberta. A double mail-out design was used. A second questionnaire, containing information on safety issues, was sent to the general surgeons (consultants and residents) who did not double glove to ascertain whether this information would change their practice. RESULTS: In all, 268 surgeons and residents were sent the original questionnaire; 170 replied (63.4% response rate.) Fifty-seven percent of the respondents do not double glove (none of the urologists double glove versus 87% of orthopedic surgeons). The most common reason sited was a decrease in manual dexterity (46%). Ninety-seven percent of respondents are immunized for hepatitis B with 53% having had their titres recently checked. Thirty-seven general surgeons received the evidence on safety issues but only 9 (23%) of them would change their practice as a result of this information. CONCLUSIONS: The majority of surgeons and residents do not double glove. Even when provided with good evidence of efficacy, few surgeons contemplate adopting safety techniques.     

The examination assessment of technical competence in vascular surgery

BACKGROUND: The European Board of Surgery Qualification in Vascular Surgery is a pan-European examination for vascular surgeons who have attained a national certificate of completion of specialist training. A 2-year study was conducted before the introduction of a technical skills assessment in the examination. METHODS: The study included 30 surgeons: 22 candidates and eight examiners. They were tested on dissection (on a synthetic saphenofemoral junction model), anastomosis (on to anterior tibial artery of a synthetic leg model) and dexterity (a knot-tying simulator with electromagnetic motion analysis). Validated rating scales were used by two independent examiners. Composite knot-tying scores were calculated for the computerized station. The stations were weighted 35, 45 and 20 percent, respectively. RESULTS: Examiners performed better than candidates in the dissection (P<0.001), anastomosis (P=0.002) and dexterity (P=0.005) stations. Participants performed consistently in the examination (dissection versus anastomosis: r=0.79, P<0.001; dexterity versus total operative score: r=-0.73, P<0.001). Interobserver reliability was high (alpha=0.91). No correlation was seen between a candidate's technical skill and oral examination performance or logbook-accredited scores. CONCLUSION: Current surgical examinations do not address technical competence. This model appears to be a valid assessment of technical skills in an examination setting. The standards are set at a level appropriate for a specialist vascular surgeon.     

The Functional Dexterity Test: Test–retest reliability analysis and up-to date reference norms

Study designClinical measurement.IntroductionAmong the available tests for fine finger dexterity, the Functional Dexterity Test (FDT) has been indicated as a valid instrument to measure outcome in different conditions.Purpose of the studyTo analyze test–retest reliability, to study the influence of gender, age and hand dominance on the FDT score, and to collect reference norms for adult and elderly age-groups.MethodsTest–retest reliability was calculated with the Intraclass Correlation Coefficient (ICC) and Standard Error of Measurement (SEM) in a subgroup of 324 healthy volunteers. An enlarged sample of 698 subjects, tested at least once, was used to present stratified data for age group, sex, and hand dominance, and ANOVA was used to investigate statistically significant differences between groups.ResultsThe FDT showed excellent reliability (ICC > 0.90; SEM: <2 s for net times; <3 s for total scores). Age, gender and hand dominance significantly influenced FDT scores (p < 0.05), but no interaction between variables was found.ConclusionsFDT is confirmed as reliable, and up-to-date reference norms over a broad range of ages of the Italian adult population have been provided.Level of evidenceNA.     

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.     

Using manual dexterity to predict the quality of the final product in the small bowel anastomosis after a period of training

ObjectiveThe use of aptitude tests in the selection of surgeons has gained recent attention. Few have described its relevance in predicting the acquisition of surgical techniques. We aim to show whether assessing manual dexterity can predict the quality of the final product after a period of training.MethodsThirty-six medical students had their manual dexterity assessed completed bench model small bowel anastomosis in 8 consecutive sessions. The fine details (accuracy (number of sutures that traversed full thickness) and number of sutures placed) and gross details (bowel apposition) of quality of final product was objectively assessed.ResultsManual dexterity correlated with grade only in the initial sessions (Pearson correlation coefficient, r = ?.578, P < .01). There was no significant correlation with the fine details with any session.ConclusionsThere was a correlation with manual dexterity and outcome measures in the initial sessions of training with grade only. This relationship was eliminated by the end of training sessions. This suggests that the outcome of procedures after a period of training cannot be predicted by measuring manual dexterity skills.