motivation is a prerequisite for learning but cannot be relied on as the sole driving source for a successful training program. Surgical residents and practicing surgeons are affected by long working hours, limited free time, and seemingly endless clinical responsibilities. Not surprisingly, studies on voluntary participation of skills training in a busy residency showed the participation rate as between 6 and 14% [41, 43]. Also, 82% of ACVS residents reported that lack of time was the main barrier to practice [15].
These studies showed that providing dedicated regular time for mandatory training, known ahead of time to trainees and their faculty, greatly improved participation. For a laboratory with limited resources, this may be hard to accomplish. In the VALT laboratory, we have had success with mandatory training sessions but with timing flexibility through an online sign‐up policy, so each trainee can choose the time that works best for him or her without affecting the clinic or crowding the laboratory. The importance of dedicated laboratory personnel, keeping track of the trainees' sessions, and the commitment from faculty in supporting the training cannot be stressed enough. In addition, external motivation can be gained from training feedback and scheduled skills assessments. Further external motivation may be gained by performance requirements on simulators before OR participation [41], Importantly, we have found an inverse relationship between motivation for simulation training and clinical experience [7], regardless of skill level, underscoring the importance of initiating simulation training early in a laparoscopic surgeon's career.
Feedback
Regular feedback during simulation training is not only a tool for motivation but is also essential for skills acquisition and retention. As already discussed, motion metrics serve as instant feedback during VR training and are likely one of the most important advantages to that type of simulation training. However, verbal feedback from experts has been shown more effective than motion metrics [44]. Specific and individualized feedback and subsequent training tailored to address that feedback have been shown to greatly improve OR performance [45].
Opportunity to Practice
Currently, the opportunity for simulation training is severely limited for veterinary surgeons and residents. Hopefully, veterinary surgery will show a similar development to that occurring over the past decade among MD surgeons. In 2006, only 55% of residency programs had training laboratories [12], but by 2008, such laboratories became a requirement [9]. In 2019, approximately 36% of ACVS resident training programs had access to a simulator [15]. Unfortunately, as many as 48% of residents perceived that training was not encouraged by senior faculty [15]. Despite lacking support from senior faculty, 88% of ACVS residents thought that simulation training increases OR performance [15].
Ideally, all trainees should have easy access to simulation training at their practices. This preference is based on the fact that distributed practice leads to better skills acquisition and retention compared with intense extended practice [41, 46]. The optimal distribution is presently considered to be one‐hour sessions with a maximum of two sessions per day interspersed by a rest period, allowing the brain the opportunity to internalize the learning [47]. Approximately 10 hours of practice has been demonstrated to lead to fundamentals of laparoscopic surgery (FLS) competency [24]. Skill decay will ensue after rigorous training, but with ongoing practice in small amounts at six months intervals, performance has been shown to be maintained at a high level [47].
Self‐Directed Training
Most veterinarians in practice do not and will not have easy access to simulation training curricula. Fortunately, MISTELS‐type exercises lend themselves well to self‐study because there are well‐defined training goals that are easy to monitor. Self‐study guidelines based on performance time have been demonstrated, showing that reliable achievement of 53‐s peg transfer, 50‐s pattern cut, 87‐s ligature loop, 99‐s extracorporeal suturing, and 96‐s intracorporeal suturing times are associated with a 84% chance of passing the FLS test [48], thus demonstrating basic skills competency. Laparoscopic suturing may require training proctored by experienced surgeons, and we encourage self‐study trainees to seek instruction for those exercises. Examples of available training are listed on the VALS website (www.valsprogram.org). Independent training on fresh cadavers may also be highly valuable, prior to or after commercially available live animal model courses. The self‐trained surgeon is encouraged to start with basic surgeries until ample experience of laparoscopic entry and instrument manipulation has been gained.
Miscellaneous Training; Video and Serious Games
Video gaming ability has frequently been shown to be associated with various laparoscopic skills in both human [49–51] and veterinary medicine [52–54]. There are important similarities between MIS and video gaming in the two‐dimensional visual and observation of hand movements' effects on a screen, which can explain this association. However, other studies have not been able to demonstrate such associations [29, 55]. A recent meta‐analysis found inconsistent results and concluded that there was limited evidence that video gaming enhances surgical simulation performance [51]. It is possible that video games designed with the added objective to educate may become more consistently beneficial. The concept of interactive computer applications with the goal to educate in an entertaining fashion is known as “serious games.” A systematic review concluded that serious gaming can be beneficial for training both technical and decision‐making skills [56]. To our knowledge, no serious games have been developed for MIS training of veterinarians yet.
A few nonsurgical psychomotor skills have been associated with improved laparoscopic skills. Chopstick use and handicraft experience have been demonstrated to be associated with higher scores on laparoscopic task simulators [54, 55]. A causative relationship has, however, not been demonstrated, so training programs may need more evidence before adding these activities into a training curriculum.
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