Surgical Procedure, Unspecified Clinical Trial
Official title:
Using 'Guided-Discovery-Learning' to Optimize and Maximize Transfer of Surgical Simulation
The study is a randomized experimental study comparing two forms of learning;
guided-discovery-learning and traditional instructional learning. Recruiting sixty-four
participants, the investigators plan on comparing these two groups through a procedural skill
in the form of suturing. In the case of guided-discovery-learning, the group will be allowed
a discovery phase before instruction. In contrast, the control group will receive traditional
instruction-lead-learning, in which a teacher teaches the participants a skill, and
afterwards the participants practice it. After the teaching session, both groups will
undertake a post-test of skill-level. A week later both groups will undertake a test for the
execution of the learned suturing skill to a more complex version of the original task
(Near-transfer). They will also undergo a test for the ability to transfer their learning to
a new skill (i.e. preparation for future learning), in this case a new suture (Far-transfer).
By filming these tests and having a blinded expert rater score them, the investigators will
be able to get a measurement of attained transfer of skill-level throughout the procedures.
The investigators hypothesis is that, the participants in the Guided-discovery-group will
have an equal score to that of the traditional-learning group in the ability to obtain a
skill and transfer it to a more complex version. Furthermore, the investigators hypothesize
that the Guided-discovery-group will score better than the traditional-learning group in the
case of transferring the procedural knowledge to learning a new skill.
As well as testing the efficacy of guided-discovery-learning on a procedural skill, the
investigators wish to investigate how and why it works. By filming a subset of participants
in each group, as well as using questionnaires, and focus-group interviews the investigators
will explore how participants interact in this different learning-environment compared to the
traditional instructional learning-environment.
BACKGROUND AND RATIONALE:
Technical skills are a core competency in surgical specialties. The level of technical skills
is directly linked to patient outcomes and it is an absolute requirement that surgical
trainees learn to master basic surgical skills. It is therefore a necessity that medical
students also become well equipped with these skills, such as suturing. During the last
decade, minimally invasive techniques have made their way to the operating room and improved
patient outcomes. Despite these advances it is still necessary for surgeons to master the
open surgical skills. Unexpected complication can arise in minimally invasive procedures that
require conversion to open access surgery. Furthermore, there are procedures where you cannot
use minimally invasive techniques. Because of the extensive use of minimally invasive
surgery, it is becoming more difficult for doctors as well as medical students in surgical
departments to gain the level of experience needed, to become proficient in open surgical
techniques. Pre-clinical teaching and simulation training is a possible solution to this
problem For novice learners, simulation training is an opportunity to acquire fundamental
skills such as suturing in a safe and high-feedback environment and without the difficulties
of acquiring these skills in the workplace. For more advanced trainees, simulation affords
the practice of difficult and complex procedures which may be otherwise too unsafe to acquire
during patient care. But, merely implementing simulation training is no guarantee of
educational utility, and instead thoughtful curricular integration of simulation requires
considering the role and purpose of the simulator, the student experience, debriefing, and
the intended outcomes to evaluate success.
One potential area for optimizing simulation-based training is to clarify instructors' roles
when providing guidance and direct supervision. One of the challenges with simulation
training is the amount of resources this sort of education requires. Especially the amount of
time a student spends interacting with an instructor. Supervision and instruction are key to
an effective simulation-based training, and there is mounting evidence, which suggest, that
the community needs to reconsider the balance between instruction and discovery, allowing for
a good interaction between student and teacher, encouraging learning. Therefore the question
is; on what level should simulation-based teaching be instructor-orientated? When teaching
technical medical skills, the answer to the question, whether the training should be
discovery-orientated or instructor-orientated has been thoroughly researched. Medical
Education literature has long moved away from the question of either or, and is now more
focused on, in which order discovery- and instruction-teaching should be, to provide the best
learning outcome. Recent studies has shown some positive results of
guided-discovery-learning, which in its simple form, combines both elements from discovery
and instruction-based teaching. Especially the ability to 'transfer' learning seems vastly
improved, with this teaching method. Transfer tasks faced by learners exist on spectrum with
a common challenge being new problems which are more complex or in new contexts but
essentially require replication of previously learned skills, i.e. near transfer. While near
transfer can be difficult for learners, even more challenging is transfer that requires they
apply their previous skills and understanding to learn new skills or concepts, i.e. far
transfer. Guided-discovery learning has been shown to especially positively impact this
latter type of transfer task. Thus guided-discovery may promote student-autonomy and
self-learning which subsequently enables students to take responsibility for their own future
learning.
In a pilot-study completed by the investigators research-partners at the Wilson-Centre in
Toronto, Canada, they compared groups of discovery followed by direct discovery (DD) with
instruction followed by discovery (IP). In the case of DD, the participants, where given the
materials needed to complete a simple suture, and a finished suture to look at. After the
discovery-phase, they were parred with an instructor who demonstrated how it was to be
performed. In the IP-case they were first instructed on how to perform the suture, and were
afterwards allowed to practice it. At the end of the course both groups were given a
post-test of ability, and a week-later both groups were given a retention test as well as a
transfer test. The pilot-study included 26 participants in total, divided in two groups of
13. The participants were randomized, and everything was filmed and scored by blinded raters
after an international standard. There were no significant results for the immediate
post-test as well as the retention test. But in the case of the transfer test, the DD-group
was far superior.
The investigators study will expand on the pilot-study to provide a comparison of guided
discovery to traditional instruction for the learning of suturing tasks in surgery, seeing if
Guided-discovery-learning works in a much larger research group. Using a double randomized,
mixed-methods experimental design, the investigators will investigate the effect of discovery
followed by direct instruction (DD) vs. instruction followed by practice (IP) for the
acquisition and two types of transfer of surgical skills.
The investigators hypothesize that:
1. Participants in the DD condition will be better able to transfer their knowledge to
learning a new skill (i.e., preparation for future learning).
2. Participants in the DD condition will have equivalent performance to IP on post-test,
but a similar or slightly improved performance on transfer of suturing skill to a more
complex task (near-transfer).
3. Participants in the DD condition will interact differently with instructors and will use
their learnings from the discovery phase to scaffold their learning during the direct
instruction phase as well as interacting differently with the task at hand.
EXPERIMENTAL DESIGN:
The study will be performed at CAMES, including n=64 pre-clinical medical students from the
Copenhagen University. The investigators are targeting undergraduate students, rather than
surgical residents, because they want novice learners, and they believe it is worthwhile to
establish efficacy of the intervention group using simpler tasks which can be feasibly
studied. The investigators based their sample size on the previous pilot-study which suggests
that detecting a large effect on a global rating scale (Hedges g of >0. with an alpha of 0.05
and power of 80% requires at least 13 participants per group with additional participants
recruited for potential loss to follow-up for a total of 16 per group. Participants will
receive a certificate showing completed suturing course, as an honorarium to compensate for
their time in the study.
Part 1 of this study is an experimental design with two phases that will test the efficacy of
guided discovery: Phase 1 will be a learning phase with the experimental manipulations, and
Phase 2 will take place one week later and be outcome assessment for near- and far transfer.
Part 2 of this study will be explorative seeking answers to how and why guided-discovery
works.
For Phase 1, participants will be enrolled and randomly allocated to either the DD or IP
groups. Each group consists of 8 participants. Participants will be randomized and the method
of teaching allocated on the date of teaching. This will ensure generalization and ease of
statistical analysis. In the DD group, participants will be given an example of a completed
simple interrupted suture and their own skin pad, and suturing kit. They will then attempt to
replicate the suture using the equipment and their own knowledge over 30 minutes. During the
same period of time, the IP group will be taught using an instructor. The instructor will
provide two demonstrations and explanations of the simple interrupted suture following which
the participants will attempt the suture individually on their own skin pads and suturing kit
(Modifications will be made by an experienced surgical instructor on our team ST). The
instructor will be told to provide feedback and guidance to the participants as well as
answer any questions that participants may have. After the initial time, the DD group will be
paired with an instructor who will provide two demonstrations and explanations of the suture
and then interact with participants as they attempt the suture. The IP group will practice
the suture without any further instructor guidance. At the end of the teaching session, all
participants will complete a post-test requiring them to complete two simple interrupted
sutures. Afterwards participants willing will be interview in short focus-group interviews.
This entire session is expected to last 2 hours including consent and setup time.
After a 1-week delay, participants will return for Phase 2 for the tests of near- and far
transfer. Each group will again be randomly allocated a transfer task. Two transfer tasks
will be used in this study: To test Hypothesis 1, (the impact on transfer to future
learning), participants will be taught the interrupted vertical mattress suture. To ensure
equivalency of design and to prevent biasing in favor of one group, all participants will be
taught didactically, which will involve viewing a 15-minute video designed by an expert
surgeon on our team (ST) to teach the novel suturing task. Participants will then be given
20-30 minutes to practice the suture following which they will perform two vertical matrass
sutures on a typical skin pad.
To test Hypothesis 2 (the impact on transfer of learning to a more complex version of the
initial task) participants will perform two simple interrupted sutures on a suturing pad
representing in an abdominal simulator with the added contextual change of different
instruments and suture. In both groups, participants willing, will afterwards be recorded for
a 'Think-Aloud' interview, in which they describe their approach to the suturing task
out-loud. This phase is expected to last 1.5 hours.
PERSPECTIVES:
Faculty instructors are a limited resource in formal simulation-based training during
post-graduate training. The rise of structured learning activities such as surgical boot
camps and the emphasis on greater feedback and support for trainees means that instructor
time is at a greater premium than ever before. Instructors must take time away from their
busy clinical and workplace-based education activities in order to teach. Not only does this
cost the healthcare system, the time commitment can reduce willingness to participate in
education. Additional costs may be incurred by programs that must offer financial incentives
for instructors. This trade-off between education and clinical work occurs in all academic
postgraduate programs. Given the cost and investment required to recruit faculty for
training, research is needed to maximize the efficiency of faculty involvement. The
investigators work directly contributes to this goal by identifying how instructor guidance
is most helpful to trainees. Guided-discovery may be one approach to reducing the cost of
training and instructor time in both post-graduate as well as pre-graduate learning courses.
Post-graduate training also requires that trainees develop autonomy and are able to learn new
skills or concepts effectively (stresses trainees' abilities to transfer their training when
faced with uncertainty and or complexity in future scenarios. Guided-discovery may be an
effective organizing principle for educational design that can achieve these competencies
across a wide range of disciplines and training environments. The investigators proposal
would thus establish evidence of efficacy for guided-discovery for these competency roles.
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