A competency-based surgery residents teaching and training program including a biomechanical and kinesiological approach was developed in order to improve procedural learning and mastery of invasive skills. Principles of biomechanics and kinesiology have been taught and applied to many aspects of surgical tasks, including instrument holding and manipulation, body positioning and posture, segments alignment. Results demonstrate more precise movements and more efficient performance of surgical tasks in residents participating in the program

Martin, M.

Prince, F.

Therrien, R.

English

ISBS (International Society of Biomechanics in Sports): Conference Proceedings Archive

Biomechanics Symposia 2001 / University of San Francisco204A BIOMECHANICAL AND KINESIOLOGICAL APPROACH IN THE TEACHING OFEFFICIENT SURGICAL SKILLS TO MEDICAL STUDENTSRené G. Therrien, François Prince1, Marcel MartinUniversity of Sherbrooke, Sherbrooke (Quebec), Canada1University of Montreal, Montreal (Quebec), CanadaA competency-based surgery residents teaching and training program including abiomechanical and kinesiological approach was developed in order to improve procedurallearning and mastery of invasive skills.  Principles of biomechanics and kinesiology havebeen taught and applied to many aspects of surgical tasks, including instrument holdingand manipulation, body positioning and posture, segments alignment.  Resultsdemonstrate more precise movements and more efficient performance of surgical tasksin residents participating in the program.KEY WORDS : surgical skills, occupational biomechanics, teaching, movement                           efficiencyINTRODUCTION: Performance of invasive skills form an important part of residency training insurgery.  The learning process is very often based mostly on theoretical knowledgeaccompanied with observation of surgeons at work and some form of instruction given to juniorresidents by senior residents (Mandel, Lentz & Goff, 2000; Rogers, Regehr, Gelula, Yeh,Howdieshell & Webb, 2000; Cauraugh, Martin & Komer-Martin, 1999; Martin, Vashisht, Frezza,Ferone, Lopez, Pahuja & Spence, 1998).  The need for better training of residents has alreadybeen emphasized by many authors (Anastakis, Hamstra & Matsumoto, 2000).  While Reznick(1993) “encouraged operative teachers to follow simple learning principles…” and to “… providepositive feedback on multiple procedural skills…” as part of residents’ training, Cauraugh et al.(1999) have indicated that “perceptual-motor capabilities and experiences should beincorporated into the curriculum as more than a supplement to anatomical knowledge”, in orderfor the residents to develop expertise in operative skills.  In order to overcome manydeficiencies in procedural knowledge (how to do) exhibited by surgery residents, the educationcurriculum and training experience should include opportunities for the residents to increasetheir ability to properly manipulate and control surgical instruments as well as some form ofvisual feedback on their procedural performance (Cauraugh et al., 1999). Moreover, visuo-spatial and visuo-motor abilities should be developed and practiced in such a way as to optimizesurgical skills performance (Anastakis et al., 2000; Cauraugh et al., 1999)Contribution of biomechanics and kinesiology: Biomechanics and Kinesiology cancontribute in many ways to the general expertise of surgery residents, more specifically in thedevelopment of their procedural knowledge.  A first contribution deals with the correctness ofsurgical movements and includes four phases : 1) the observation and biomechanical analysisof the surgical movements performed by the resident; 2) the comparison of the execution modeswith biomechanical efficiency principles; 3) the proposition of appropriate corrections, usingvideo-feedback and 4) a re-evaluation of the surgical task, after appropriate training andpractice.  Biomechanics and Kinesiology can also contribute to the sequencing of surgicalmovements for a particular surgery.  The analysis and the breaking down of each movementsequence into precise steps will facilitate the mental representation of the individual movementsto perform.  Principles from occupational biomechanics can also be applied to the analysis ofthe resident’s posture and to the optimisation of both body position and surgery tableadjustments in order to allow for more precise and less fatiguing movements.  Proper holdingand manipulation of surgical instruments can also benefit from biomechanics.  A proper holdingtechnique will allow for more precision, a wider range of movement, better control on force andpressure and will induce less fatigue.  Application of biomechanical principles will also providebetter stabilization of the segment performing the surgical task.  This is mostly achieved throughthe use of an intermediate support for the performing limb.  Alignment of mechanical axes isBiomechanics Symposia 2001 / University of San Francisco205another biomechanical principle that should be taught and practiced in order to reduce fatigue ofhand, wrist and forearm of the operating limb.  Once proper holding techniques andmanipulation skills are mastered, once segments are stabilized and mechanical axes aligned,then the resident can search for optimum surgical performance, while trying to adopt thepostural attitude that will produce the least amount of muscular fatigue.METHODS: Such a biomechanical and kinesiological approach was developed andincorporated into a competency-based training program for first year postdoctoral surgeryresidents at the University of Sherbrooke.  Residents who were on campus formed theparticipants group, while those who were beginning their training in hospitals located in othercities served as controls.  During the first ten (10) weeks of their residency, the program wasoffered once a week, for a period of four (4) consecutive hours, to the residents of theparticipants group.  Each session aimed at developing competency in a specific surgicalprocedure to be performed on cadavers in the anatomy laboratory and included the followingphases : 1) First, the surgical procedure was explained and described.  2) Then, each residentperformed the surgical procedure on a cadaver, while being filmed with three (3) video cameraspositioned above and each side of the cadaver.  3) Afterwards, residents were assigned to smallgroups who practiced the procedure on cadavers under the supervision of a surgeon as well asexperts in biomechanics and kinesiology, who pointed out procedural errors and proposed moreappropriate and less fatiguing techniques, while explaining underlying principles.  4) Then eachresident was filmed again while performing on another cadaver.  5) During the following week,the videos were analysed at the biomechanics laboratory.  6) Feedback accompanied withpertinent video sequences was then given to the residents; inappropriate movements werepointed out and more appropriate techniques were proposed.  Ways of optimising theprocedural strategies were discussed and emphasized.RESULTS: Continuous qualitative evaluation of residents competency by expert surgeons whileperforming surgical tasks both on cadavers and in the actual operating room situation revealedthat participants 1) had better control of instruments, 2) exhibited more hand skill and precisionwhile performing surgical tasks, 3) had more precise mental representation of the different stepsinvolved in a particular surgery procedure, 4) took less time to perform specific surgicalprocedure, and 5) seemed less fatigued after long surgical tasks. A standardized battery of tests(OSCE) evaluating practical clinical skills was also administered to the participants and to thecontrol groups after the program as well as three months later (Table 1).Table 1  Performance of Residents on Practical Tests (OSCE)Participants(n=9)______________Non-participants(n=5)_______________M STD M STDOSCE score : After the program 85.1 %* ± 6.0 50.5% ± 20.0OSCE score 3 months after the program 92.9%* ± 5.7 64.6% ± 14.7* p < .01 (Wilcoxon)DISCUSSION AND CONCLUSION: Quantitative evaluation of surgical skill performances ofresidents both after the program and three (3) months later clearly indicate that participantsBiomechanics Symposia 2001 / University of San Francisco206have developed a higher level of procedural knowledge and skills than non-participants and thatthis difference between the two groups persists during the following months of their residencytraining.  Moreover, qualitative evaluation of residents performing surgical procedures hasallowed evaluators to observe faster improvement of participants in many aspects of thesurgical tasks, namely better holding technique and segments alignment, allowing for greaterprecision and force control, as well as less fatiguing postures.   The main educational outcomeof this program is a learning experience for the resident.  It allows the resident to better visualizethe execution of specific surgical movements and to address proper movement correction.Moreover, residents have shown a great interest in the program, mostly because of the activepart they are taking in their learning process.  This was particularly reflected in their desire forbetter understanding and wider application of biomechanical and kinesiological principles for theimprovement of their surgical skills.REFERENCES:Anastakis, D.J., Hamstra, S.J. & Matsumoto, E.D. (2000). Visual-spatial abilities in   surgicaltraining. American Journal of Surgery, 179 (6), 469-471.Cauraugh, J. H., Martin, M. & Komer-Martin, K. (1999).  Modeling surgical expertise for motorskill acquisition.  American Journal of Surgery, 177, 331-336.Mandel, L. P., Lentz, G. M. & Goff, B. A. (2000).  Teaching and evaluating surgical skills.Obstetrics and Gynecology, 95 (5), 783-785.Martin, M., Vashisht, B., Frezza, E., Ferone, T., Lopez, B., Pahuja, M. & Spence, R.K. (1998).Competency-based instruction in critical invasive skills improves both resident performance andpatient safety. Surgery, 124 (2), 313-317.Reznick, R.K. (1993). Teaching and testing technical skills. American Journal of Surgery, 165,358-361.Rogers, D.A., Regehr, G., Gelula, M., Yeh, K.A., Howdieshell, T.R. & Webb, W. (2000). Peerteaching and computer-assisted learning: An effective combination for surgical skill training?Journal of Surgical Research, 92 (1) 53-55.

A BIOMECHANICAL AND KINESIOLOGICAL APPROACH IN THE TEACHING OF EFFICIENT SURGICAL SKILLS TO MEDICAL STUDENTS

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A BIOMECHANICAL AND KINESIOLOGICAL APPROACH IN THE TEACHING OF EFFICIENT SURGICAL SKILLS TO MEDICAL STUDENTS

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