American Surgical Association
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Teaching Surgical Skills: What Kind Of Practice Makes Perfect?
Carol-anne E. Moulton, MB;BS, FRACS*, Adam Dubrowski, PhD*, Helen MacRae, MD, MA, FRCSC*, Brent Graham, MD, FRCSC*, Ethan Grober, MD*, Richard Reznick, MD, MEd, FRCSC, FACS
Univeristy Health Network, Toronto, ON, Canada

Objective: Surgical skills laboratories have become an important venue for early skill acquisition. The principles that govern training in this novel educational environment remain largely unknown; the commonest method of training, especially for CME, is a single event (massed practice). This study addresses the impact of two methods of learning (massed and distributed) on the acquisition of a new skill and transfer of that skill to a life-like model.
Methods: Thirty-eight junior surgical residents, randomly assigned to either massed (one day) or distributed (weekly) practice, were taught a new skill (microvascular anastomosis). Each group spent the same amount of time in practice. Performance was assessed pre-training, immediately post-training, and one month post-training. The ultimate test of anastomosic skill was assessed with a transfer test to a live, anaesthetized rat. Previously validated computer-based and expert-based outcome measures were used. In addition, clinically relevant outcomes were assessed.
Results: Both groups showed immediate improvement in performance but the distributed group performed significantly better on the retention test in most outcome measures [time(200vs244sec;p=.048),number of hand movements(176vs235;p=.031),path length(5.4vs8.5cm;p=.039),expert global ratings (15vs12;p=.029)]. Importantly, the distributed group also outperformed the massed group on the live rat anastomosis in all expert-based measures (global ratings 15vs7,p= .000;checklist score 20vs13,p=.001;final product analysis 5vs2,p=.000;competency for OR 12vs2,p=.001;inter-rater reliabilities α 0.67 to 0.85).
Conclusions: Our current model of training surgical skills at CME courses and structured residency curricula may be sub-optimal. Residents retain and transfer skills better if taught in a distributed manner, rather than the prevailing approach of teaching a single skill in a single session. Despite the greater logistical challenge, we need to re-structure training schedules to allow for distributed practice.

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