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.     

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.     

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.     

Effects of a laparoscopic course on student interest in surgical residency.

BACKGROUND: The number of surgical residency applicants has been declining. Early introduction of the discipline of surgery is thought to stimulate early interest in surgical residency. This study investigated the hypothesis that a laparoscopic skills course introduced in preclinical years would stimulate student interest in entering surgical residency. METHODS: Preclinical medical students participated in a laparoscopic skills training course. All students underwent an animate laboratory at the beginning and at the end of the course. Students were divided into 4 separate groups: virtual reality, box trainer, both trainers, and control group. Before and after the course, students were asked their residency interest. First- and second-year medical students participated in the course. RESULTS: Before the course, 56% of the students desired to go into general surgery or a surgical subspecialty. After the course, 49% of the students expressed interest in entering general surgery or a surgical subspecialty. A decrease occurred in students who desired to go into surgical subspecialty residency from 31% to 15% (P = NS), and an increase occurred in students who desired to go into general surgery residency from 25% to 34% (P = NS). No statistically significant difference was seen in the 4 individual training subgroup analyses. CONCLUSIONS: Participation in a laparoscopic skills course does not affect medical student interest in entering surgical residency. A trend was noted in students choosing general surgery over surgical subspecialty training after this course. Surgical educators need to investigate methods to encourage preclinical medical student interest in surgical residencies.     

Effectiveness of suturing training with 10-0 nylon under fixed and maximum magnification (x 20) using desk type microscope

BACKGROUND: Microvascular anastomosis using 10-0 nylon needs a higher level of technical dexterity compared with routine neurosurgical maneuvers. Although this technique remains an important part of treating complex intracranial aneurysms or cerebrovascular disease, the surgeon's clinical experience in using this technique is not so common. METHODS: To improve dexterity and maneuverability in the limited clinical case volume, we developed an easily accessible training system, using commercially available desk type microscope and simply suturing neighboring fibers of the gauze with 10-0 nylon under fixed and highest (x 20) magnification. RESULT: This training system is somewhat of a drawback compared to the simulation of a real clinical setting. However, because of the extremely easy availability and accessibility of the dark type microscope repeated training and the accumulation of more than 10000 stitches, on average, was accomplished. This resulted in a steep learning curve of the technique. CONCLUSION: For residency and post-residency year young neurosurgeons, who need to brush up their skills due to lower surgical case volume compared with what senior neurosurgeons have experienced this easily available training would contribute to establishing daily and long-lasting microsurgical practice.     

New Technologies for the Surgical Curriculum

The aim of a surgical residency program is to produce competent professionals displaying the cognitive, technical, and personal skills required to meet the needs of society. Current changes to the delivery of healthcare necessitate the development of new models of training. These can be supported with the development of new technologies to train and assess surgical practitioners. This article describes recent developments within Imperial College London with regard to eye tracking, noninvasive brain imaging, and an innovative mentoring scheme for the new surgical curriculum. The concept of eye tracking is described, together with surgical application for this technique in terms of dexterity analysis during minimally invasive procedures. We have also begun to understand spatial localization within the brain cortex during surgical knot-tying tasks. The aim is to develop a map of the cortex with regard to surgical novices and experienced surgeons and then to develop the hypothesis that a translational process of cortical plasticity occurs during training. Finally, the article is intended to describe a training scheme that goes beyond dexterity, and moves toward the development of a successful surgeon through surgical mentoring. It is hoped that some of these tools will enhance the training of future surgeons in order to continue to provide a high-quality service to our patients.     

A role for aptitude testing in surgery?

Recent interest in the selection of surgical trainees has been directed towards the use of aptitude tests. Using mainly senior surgeons' ratings of trainees' surgical ability for comparison, specific areas of objective investigation have included manual dexterity, spatial ability, personality, and decision-making ability. While certain spatial ability tests have been shown to correlate with ratings of surgical skill, tests of manual dexterity have not. Personality variables, specifically, show how surgeons deal with stress and decision-making ability, and are considered to be important within the profession. Although aptitude tests are being used in medical recruitment, there is still widespread disagreement over their inclusion and their validity. It is proposed that the use of aptitude testing in surgery is limited by three principal factors: there are too few well-designed studies investigating the basic psychological and psychomotor abilities considered to be specific to surgical skill; the use of subjective ratings of surgical ability as the independent variable in most studies; and the fact that, as yet, there is no working definition of superior surgical ability.     

Psychomotor testing and the ability to perform an anastomosis in junior surgical trainees.

Ten junior surgical trainees underwent objective testing of manual dexterity and visuospatial ability and were required to carry out five consecutive anastomoses on fresh porcine jejunum. Anastomoses were scored by a single observer and a cumulative error score (CES) derived for each procedure. In the first anastomosis there was little correlation between the psychomotor test results and the anastomosis scores. In subsequent trials there were significant negative correlations between aspects of manual dexterity and the CES. Over the five anastomoses there were significant negative correlations between improvement and manual dexterity, but there was a positive correlation between improvement and visuospatial ability (rs = 0.76, P < 0.005). Visuospatial skills are more important than pure motor ability in predicting the capacity to perform an anastomosis and tests of manual dexterity may be misleading in this context.     

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.     

Importancia de las habilidades no técnicas en la práctica quirúrgica actual

The significance of technical skills and manual dexterity for surgeons is an indisputable fact. However, the systematic study of medical errors has revealed that a significant percentage of these errors are caused by factors related to non-technical skills. The review presented in this article intends to describe and explore the relevance of these non-technical skills, including: situational awareness, decision-making, leadership and communication. In conclusion, the authors propose that adequate importance needs to be given to these aptitudes to provide safe clinical care.     

Surgical training and simulation laboratory at Baystate Medical Center

The work hour restrictions imposed by the surgical residency review committee, without a curriculum change, essentially reduces training programs by 30%. The logical result of this is the risk that a higher percentage of surgeons beginning independent practice will fall below the competence level. We believe that simulation will play a vital role in the curriculum to enhance the clinical environment and make the learning environment better and more efficient. Baystate Medical Center (Springfield, Mass) is an affiliate of Tufts University School of Medicine and provides tertiary medical care for the western portion of the state. Our surgical residency program has developed and maintained a simulation center specifically to augment training of surgical knowledge and manual skills. We are also actively involved in education research and curriculum design locally and on a national level. Our center is rapidly becoming a multidisciplinary environment incorporating other residency and clinical programs within the health system and beyond. We are actively pursuing the development of novel assessment technology that will not only integrate the simulation center with the clinical arena but also link educational and clinical outcomes. This will allow us to automatically tailor the educational environment to the individual needs of the learner as they change over time, as well as look at quality improvement related to our educational and research endeavors.     

Computer-assisted training system for knee arthroscopy

This paper presents an educational method for minimally invasive surgery, conceived in collaboration with educationalists and arthroscopists, and an integrated system to train a priori knowledge and to exercise manual dexterity. The approach is generally suitable for minimally invasive surgery interventions but has been developed specifically for knee arthroscopy. Based on a classification of the knowledge, the system provides multimedia modules to train anatomical and procedural knowledge and a surgical simulator for training perceptual motor skills. We have tested the system in making three surgeons perform a series of tests. The results show that performance increases with the degree of experience. We also delivered a usability questionnaire and evaluated the appreciation by the surgeons. The test results and the appreciation showed by the surgeons encourage the prosecution of the research.     

Can Interview Prior to Laparoscopic Simulator Training Predict a Trainee's Skills?

BACKGROUND: Our institute started laparoscopic simulator training for medical students in 2006. During the training, we observed considerable interindividual differences in laparoscopic skills among those students. This study aimed to investigate the predictive factors that affect laparoscopic skill by assessing the students' training results data. METHODS: Forty-three, fifth-year medical students were asked several questions and were divided into 2 groups depending on their answers. The participants performed an object-positioning module on a ProMIS simulator (Haptica, Inc., Dublin, Ireland). Execution time, instrument path length, and economy of movement for each trial were recorded on ProMIS. Comparisons of mean performance measures between the 2 groups were made using a Mann-Whitney U test. RESULTS: Interest about laparoscopic surgery and accomplishment in playing piano did not affect the skillfulness significantly. The students who had an interest in television (TV) games completed the task in less time (p = 0.046) and had a shorter left instrument path length (p = 0.012). The students who thought themselves manually dexterous completed the task in less time (p = 0.008). The students who were confident about driving completed the task in less time (p = 0.0247). DISCUSSION: In our interview, the factors that had a relationship to laparoscopic skills were favorableness to TV games, manual dexterity, and confidence about driving. These results were expected because TV games and driving a car require the same abilities as laparoscopic surgery. Psychomotor, perceptual, or visuospatial ability are essential for good performance. In conclusion, our study suggests that the interview can be an effective measure to examine the aptitude of medical students without the use of a simulator.     

Surgical handicraft: teaching and learning surgical skills

Surgeons choose their profession with a strong desire to excel at manual therapeutic skills. Although we mime our mentors, we have often received the torch of technique in the absence of a systematic program to optimally develop our manual dexterity. The operating room is the ultimate arena to refine one's technical ability, but a surgical skills laboratory should assume increasing importance in introducing the trainee to the many nuances of the fine manual motor skills necessary for optimal surgical technique. Surgical educators should address the science of surgical handicraft in a manner similar to the science of preoperative and postoperative surgical principles that have been espoused over the past 40 years. Although it has been euphemistically said that "you can teach a monkey to operate," few of us have broken the process down into the basic elements to accomplish such a goal. In view of the increasing complexity of operations and equipment, the constraints on animal laboratories and teaching caseloads, and the mounting economic and medico-legal pressures, the development of optimal surgical skills should be a major objective of every surgical training program. By developing novel programs and scientifically evaluating the results of such endeavors, surgical faculties may find increased academic rewards for being a good teacher.     

Simulation in surgical training using freeze dried material

The acquisition of manual dexterity and surgical skills is usually achieved in the operating theatre under supervision. We describe an efficient way of learning intestinal anastomosis procedures with the use of gamma irradiated, lyophilized porcine or bovine tissues together with a purpose designed holding jig. Preliminary evaluation of this method with untrained subjects showed that they were able to improve their performance. Because the tissues are sterile, health hazards are avoided and no special laboratory facilities are required. This approach has promise as an aid to evaluation as well as training.     

How Will the Introduction of Primary Certificate Training Programs Change Vascular Surgery Training Programs?

New requirements for vascular surgery training allow several routes to Board eligibility in the specialty. Individuals can enter vascular residency directly from medical school, after 3 years of surgical residency, or after completion of the traditional 5 years of surgery training. Vascular surgery program directors will be faced with the challenges of obtaining institutional support, designing an acceptable educational program, and working closely with the general surgery program director to ensure both programs are successful. Faculty in the vascular program may find working with residents right out of medical school or after only 3 years of surgery training to be a challenge, especially in terms of developing the requisite technical skills. Residents must be able to demonstrate mastery of the six competencies in addition to the skills of vascular surgery. Because, in some ways, this new vascular training scheme is an experiment in redesigning all surgical education, the vascular community will need to carefully evaluate the results by monitoring the practices of those who graduate from these programs.     

The Development of a Novel Perfused Cadaver Model With Dynamic Vital Sign Regulation and Real-World Scenarios to Teach Surgical Skills and Error Management

The landscape of graduate medical education has changed dramatically over the past decade and the traditional apprenticeship model has undergone scrutiny and modifications. The mandate of the 80-hour work-week, the introduction of integrated residency programs, increased global awareness about patient safety along with financial constraints have spurred changes in graduate educational practices. In addition, new technologies, more complex procedures, and a host of external constraints have changed where and how we teach technical and procedural skills. Simulation-based training has been embraced by the surgical community and has quickly become an essential component of most residency programs as a method to add efficacy to the traditional learning model.The purpose of this paper is twofold: (1) to describe the development of a perfused cadaver model with dynamic vital sign regulation, and (2) to assess the impact of a curriculum using this model and real world scenarios to teach surgical skills and error management. By providing a realistic training environment our aim is to enhance the acquisition of surgical skills and provide a more thorough assessment of resident performance.Twenty-six learners participated in the scenarios. Qualitative data showed that participants felt that the simulation model was realistic, and that participating in the scenarios helped them gain new knowledge, learn new surgical techniques and increase their confidence performing the skill in a clinical setting. Identifying the importance of both technical and nontechnical skills in surgical education has hastened the need for more realistic simulators and environments in which they are placed. Team members should be able to interact in ways that allow for a global display of their skills thus helping to provide a more comprehensive assessment by faculty and learners.     

Learning curve using robotic surgery

The da Vinci (Intuitive Surgical, Inc., Sunnyvale, CA) surgical system is being used by an increasing number of surgeons across several surgical specialties. The robotic interface is different not only to open surgery, but also to laparoscopy because it involves remote surgical control, stereoscopic vision, and lack of haptic feedback. As the transition is made from traditional open to robotic surgery, factors such as learning of robotic skills, assessment of pro.ciency in robotics, and structured training for urologists in practice and residents assumes importance. Understanding how the robotic surgical technique is learned and how such learning can be best assessed will enable us to de.ne protocols for training and set standards for pro.ciency. Learning curve and surgical dexterity are two parameters that are used to compare surgical learning and training. This article presents the current gold standard for assessing skill training and compares surgical skill acquisition and pro.ciency using conventional laparoscopy and robotic interfaces.     

A new web-based operative skills assessment tool effectively tracks progression in surgical resident performance

PURPOSE: The study aim was to demonstrate that a new database tool for assessment of surgical resident operative skills discerns predictable progression in those skills over successive residency years for specific index case types. METHODS: A Web-based interactive database (OpRate) was used to assess selected aspects of resident operative performance as determined by supervising attending surgeons in a medium-sized residency (5-6 residents per postgraduate year [PGY]). This assessment consisted of (1) 3 questions pertaining to patient information, technical, and disease-specific preparedness; (2) 4 laparoscopic technical skills questions pertaining to tissue handling, dexterity, planning, and ability to function independently; and (3) similar open technical skills questions, with the addition of 2 questions defining knot tying ability. Two years of assessment data were examined for cholecystectomy (CH), appendectomy (AP), colon resection (CR), ventral hernia repair (VH), and inguinal hernia repair (IH). Mean scores for total, technical, and preparedness responses, as well as each response area were compared for successive training years for each case type. Mean performance data between postgraduate years were compared by ANOVA, and interitem reliability was assessed by Cronbach's alpha determinations. RESULTS: OpRate data for 579 cases (142 CH, 67 AP, 73 CR, 202 IH, and 95 VH) were examined. Significant incremental increases in open and laparoscopic technical skills scores by training year were observed for all case types (ANOVA, p < 0.0001). Individual technical skills as well as technical and disease-specific preparedness response areas also demonstrated significant improvement by successive training year. Cronbach's alpha determinations were 0.80-0.94 for the preparedness test items and the skills performance scores for all assessed procedures. CONCLUSIONS: Our early results show that the OpRate assessment tool is effective in identifying expected changes in operative performance across successive training years, with a satisfactory level of internal consistency for the test items. As such, the use of this database tool may offer the opportunity to (1) define performance benchmarks for specific levels of training and (2) identify areas where focused training may be required for specific residents.     

Effective surgical residents strongly influence medical students to pursue surgical careers

BACKGROUND: There is a paucity of data about the influence of surgical residents on the career choices of medical students. We hypothesized that medical students exposed to effective surgical residents would be more likely to pursue careers in surgery. STUDY DESIGN: From 1998 to 2003, 108 surgical residents were evaluated by medical students rotating on the third-year clerkship. Residents were scored on a 4-point scale (1 = outstanding to 4 = poor). The career choices of all medical students were also tabulated. RESULTS: We examined 2,632 evaluations on 108 residents. Medical students who eventually pursued surgical residency training were exposed to surgical residents who were more effective clinical teachers, role models, and overall residents. In addition, medical students exposed to the highest-rated residents were more likely to pursue surgical residency training compared with students exposed to the least effective residents (12% versus 4.9%, p = 0.022). CONCLUSIONS: These data suggest that surgical residents who are effective educators and mentors influence medical students to pursue surgical careers. Efforts to provide more leadership and teaching workshops to surgical residents may not only create better future surgeon educators, but may also increase the number of students pursuing surgical training.