While the number of techniques and procedures that surgical trainees must learn is increasing, opportunities for trainees to practice the necessary skills on patients is decreasing; the COVID-19 pandemic further limited these learning opportunities. There is a need to explore additional ways for trainees to practice and improve their performance on surgical tasks. Observing others perform tasks can improve a learner’s own performance of a task, but it is unclear how well current evidence applies to improving surgical task performance as much of the existing evidence supporting the use of observation is for non-surgical tasks. This thesis explores the influence of observing someone else demonstrate tasks on learner’s own performance of tasks relevant to surgical training. Through three experiments, we explored the influence of the type of demonstrator that a learner observes (e.g., someone who is experienced or inexperienced), and whether or not tasks that encourage the learner to think more about the quality of a demonstrator’s performance further influences the learner’s performance. The findings suggest that for learners who are new to a task, observing an experienced demonstrator is more helpful for improving performance than observing an inexperienced demonstrator. Prompting learners to think more about the quality of the demonstrator’s performance, either by requiring them to judge the demonstrator’s performance or by providing them with an expert’s judgment of the demonstrator’s performance, does not further influence the learner’s performance. The findings from this thesis provide insights into how surgical educators can optimize learner’s performance improvements on surgical tasks using observation. This thesis also provides evidence for an effective way for learners to practice surgical tasks, either in-person or remotely, before performing those tasks on patients. / Thesis / Doctor of Philosophy (PhD) / People who are training to become surgeons have a lot to learn. It is important to find ways that they can get better at tasks. We explored whether having learners watch someone else can help them get better at tasks relevant to surgery. We explored if it is better for a learner to watch someone who knows the task well or someone who is new at the task. We also explored if it is helpful for learners to think about how well the person they are watching did. We found that for learners to get better at a task, it is generally more helpful to watch someone who knows the task well. It did not help learners to think about how the person they are watching did. This helps us better understand how to help surgical learners get better at tasks from observing others before performing those tasks on patients.

Abstract Objectives: To 1) develop an electronic Knowledge Model (e-KM) of a surgical procedure, and 2) investigate the efficacy of the model in knowledge acquisition. The main purpose of the study was to develop a knowledge model of a surgical procedure (cyst removal) in an electronic medium such that it would enhance knowledge acquisition of surgical skills and to then determine the efficacy of the model. This is based on the Fits-Posner stage theory of learning motor skills that has been adopted in many surgical teaching models. Methods: Two randomized experimental studies were conducted in three phases; the total student sample size was 118 (Study 1=56, Study 2=62). In both studies, one group received face-to-face instruction from a professor while the second group employed the e-KM. Both groups were administered a multiple choice test. Analysis of variance (ANOVA), regression analysis and Pearson’s correlation methods were employed to analyze data. Descriptive statistics were used to analyze the frequency of access and its impact on test scores. Reliability was determined with Cronbach’s alpha. Results: The results showed no significant difference (p> .05) between e-KM the computer model and the surgeon instructor. There was a significant correlation between access time to video and knowledge (significant r ranged from .68 to .86, p < .01); however, increased time on task increase test scores, thus having a positive impact on knowledge acquisition. Discussion: Research findings indicate that e-KM performs as well as the human instructor and provides the additional advantage of unlimited online access through the Web while addressing many of the pressures currently plaguing medical schools such as limited resources (staff and facilities), cost of administration, access to knowledge, academic regulations, policies and competing curricula. Furthermore, e-KM provides a standardized teaching model, eliminating instructor variability and functioning as a dependable learning tool. Conclusion: In this thesis, I addressed the efficacy of e-KM on knowledge acquisition. While there was no significant difference between e-KM and the surgeon instructor on knowledge acquisition overall, students who accessed the e- KM multiple times achieved higher scores. / Experimental Medicine

The phenomenon of 'slowing down' in response to important cues in the operative field is proposed as a hallmark of expert surgical judgment. As part of a larger program of research, the purpose of this study was to explore a methodology for capturing 'slowing down' moments using a standardised task. Edited videos of 6 laparoscopic cholecystectomies were shown to 10 expert surgeons (>250 laparoscopic cholecystectomies completed). Participants were asked to think aloud while watching them as if observing each procedure in the operating room. Each session was audiotaped and transcribed. Many examples of 'slowing down' moments were identified in the transcripts, including several categories that were previously uncharacterised or undescribed. A subset of 'slowing down' moments was compared between participants. Many appeared to be inconsistent between expert surgeons, suggesting that with this methodology alone, formal teaching and assessment of the 'slowing down' phenomenon will be challenging.

The phenomenon of 'slowing down' in response to important cues in the operative field is proposed as a hallmark of expert surgical judgment. As part of a larger program of research, the purpose of this study was to explore a methodology for capturing 'slowing down' moments using a standardised task. Edited videos of 6 laparoscopic cholecystectomies were shown to 10 expert surgeons (>250 laparoscopic cholecystectomies completed). Participants were asked to think aloud while watching them as if observing each procedure in the operating room. Each session was audiotaped and transcribed. Many examples of 'slowing down' moments were identified in the transcripts, including several categories that were previously uncharacterised or undescribed. A subset of 'slowing down' moments was compared between participants. Many appeared to be inconsistent between expert surgeons, suggesting that with this methodology alone, formal teaching and assessment of the 'slowing down' phenomenon will be challenging.

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In regions of the world that experience a deficit of surgical care, educational initiatives can foster the development of a skilled surgical workforce. Implicit in training these health workers is the mandate to retain them in the country in order build capacity. Eyal’s framework presents ways in which locally relevant training can improve retention and outlines the ethical and pragmatic concerns of such initiatives. In 2006, Guyana established it’s first surgical training program, an example of locally relevant training. The University of Guyana Diploma of Surgery (UGDS) program was selected for this case study research. Consistent data collection, supported by a systemic procedure to analyze that data, is paramount to increase the effectiveness of the UGDS program. The purposes of this dissertation research were two-fold. Firstly, it sought to understand how the UGDS program influences retention and the ways in which the UGDS members contribute to capacity building and the program’s sustainability. Secondly, this program evaluation provides a useful context to inform Eyal’s framework. 8 graduates, 2 trainees, 4 faculty members and 2 persons identified as policy makers were interviewed. Interviews were conducted face to face, and then transcribed. Surveys were administered to graduates and trainees and reflective reports and presentations were coded and analyzed. Overall, the data mapped fairly well onto Eyal’s framework. The results of the study suggest that the benefits and concerns Eyal outlines would be better represented along a continuum rather than being classified as either advantageous or disadvantageous with respect to retention. While Eyal’s claims generalize across settings, he should acknowledge this limitation and consider the important role that context plays. Overall, the results suggest that the UGDS program has positively influenced retention and capacity building. Key recommendations were made to the UGDS program that aim to improve retention and capacity building. As regions continue to face challenges associated with providing adequate surgical care, fostering retention and capacity building is recommended so that a sustainable surgical workforce can meet surgical needs. / Thesis / Candidate in Philosophy

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Rater training (RT) improves the reliability of assessment tools, but has not been well studied for technical skills. This study assessed whether RT improved the psychometric properties of surgical skill assessments. Surgeons (N=47) were randomized to RT or non-training groups. The RT group underwent frame-of-reference training. Participants assessed trainees performing a suturing and knot-tying task using four assessment tools. Inter-rater reliability, initial and delayed rater agreement, and construct validity were assessed between groups. There was no significant effect of RT on the assessment tools’ reliability and validity. Reliability and validity were most robust for the global rating scale. Although there were trends towards improved reliability and validity with RT, confidence intervals were wide and overlapping. Reliability remained below the minimum desired level of 0.8 required for high-stakes testing. Although RT may represent a way to improve reliability, further study is needed to determine effective training methods. / February 2017

Background: How to optimally integrate simulation into a surgical training program is relatively unknown. We studied the effect of varying the practice schedule into either blocked or random patterns (termed contextual interference) on the long-term retention and transfer of surgical skills. Methods: 36 participants were randomized to practice 4 tasks from the Fundamental of Laparoscopic Surgery (FLS) program using one of three training schedules (blocked, random, no training). Skill was assessed using FLS scoring and hand-motion efficiency scores. Results: A positive benefit of training was seen over the controls for all 4 tasks (p<0.05). No difference was seen between the blocked and random groups in the amount of skill acquired, skill learned, or transfer of skill. Conclusion: The application of contextual interference was unable to differentiate between the blocked and random training groups. This could be due to the complexity of the tasks and/or the inexperience of the learners.