Board 344 - Research Abstract An Exploration of Communication between Surgical Instructors and Trainees and the Effect of Standardized Communication and a Simulated On-Screen Frame of Reference Tool Employed during Urologic Laparoscopic Training (Submission #347)

Introduction/Background Intraoperative training is paramount to surgical education. A significant number of teaching hours during surgical residency are spent in the operating room (OR) and despite the established value of surgical simulation in standardized settings outside of the OR,1 the teaching that occurs in the high-stakes intraoperative environment cannot take place elsewhere. Operative teaching involves intricate interactions between surgeons and learners in a complex setting where time is of the essence and patient safety is vital.2,3 Economic pressures, work hour restrictions, interruptions, unpredictability, elevated stress, physical challenges, scarce resources and team communication issues are some of the challenges that can influence teaching in the OR.4–6 Trainees require a proficient surgeon to guide their operative learning. Research has shown that clinical teachers rarely use the established teaching principles of encouraging dialogue, asking questions, and giving meaningful feedback.7–9 It is still unclear, however, how these teaching principles, including that of communication are used in the OR, especially in laparoscopic surgery.8 Significant advancements and increased utilization of minimally invasive surgical approaches call for research that provides insight into communication in this unique setting. This study tested a novel, simulated on screen frame of reference tool and standardized communication for teaching during laparoscopic surgery. We are currently exploring the tool’s use in the OR. Methods Two versions of simulated on screen systems were developed: one with a clock design and x:y triangulation and the other an alphanumeric coordinate grid. These were transparent overlays designed to cover the endoscopic video screens in laparoscopic OR suites. A series of standardized verbal commands were developed for each of the overlays. An example for the clock overlay included, “move to the 12:00 position” and for the alphanumeric grid, “move to 2, C”. Sixty three medical students were randomized to three groups. All subjects performed three trials of six simulated laparoscopic transfer tasks. Group 1 (control) performed tasks with no overlay or standardized communication. Group 2 performed tasks using the clock and x:y triangulation overlay and Group 3 performed tasks using the alphanumeric grid overlay. Groups 2 and 3 received standardized communication specific to their overlay. Time to task completion and error scores were calculated (errors included incorrect placement during transfer). We are currently observing live urologic cases, using qualitative methodology to compare traditional laparoscopic training with laparoscopic training using the on screen frame of reference and standardized communication. Results In the simulated experiment, between and within group, analyses showed that Group 2 was significantly faster than the Control Group (p<0.05) and Group 3 (p>0.05) across all three trials. Group 2 had fewer errors than the control group across trials 1 and 3 (p<0.05), but similar error scores to Group 3. Although Group 3 had similar time to completion as the Control Group, Group 3 had statistically fewer errors (P<0.05). Live urologic cases are currently being video and audio recorded and transcribed, and qualitative analysis will continue until conceptual saturation is reached for each condition. Conclusion Using a frame of reference overlay and standardized communication for directing laparoscopy promotes safe and efficient endoscopic teaching in a simulated environment. Both groups that used an overlay and standardized communication had significantly fewer errors than the control group. The use of this tool during actual live cases is currently being evaluated by qualitative researchers and the findings will allow for a rich description of how communication and instruction is used in the OR during laparoscopic training. Our novel onscreen frame of reference tool, combined with a standardized communication system for instructing and directing during laparoscopic surgery can prove to be groundbreaking in the facilitation of safer, more effective communication and training in the OR. References 1. Stefanidis D, Arora S, Parrack DM, et al. Research priorities in surgical simulation for the 21st Century. Am J Surg, 2012, 203(1):49–53. 2. Ferguson C M. Mandatory resident work hour limitations. J Am Coll Surg, 2005, 200(4):637–638. 3. Greenfield LJ. Limiting resident duty hours, Am J Surg, 2003, 185(1):10–12. 4. Svensson MS, Luff P, & Heath C. Embedding instruction in practice: contingency and collaboration during surgical training. Sociol Health Illn, 2009, 31(6):889–906. 5. Wetzel CM, Kneebone RL, Woloshynowych M, et al. The effects of stress on surgical performance. Am J Surg, 2006, 191(1):5–10. 6. Blom EM, Verdaasdonk EG, Stassen LP, et al. Analysis of verbal communication during teaching in the operating room and the potential for surgical training. Surg Endosc, 2007, 21(9):1560–1566. 7. Lingard L, Reznick R, Espin S, Regehr, G. & DeVito I. Team communications in the operating room: talk patterns, sites of tension, and implications for novices, Acad Med, 2002, 77(3):232–237. 8. Claridge JA, Calland JF, Chandrasekhara V, et al. Comparing resident measurements to attending surgeon self-perceptions of surgical educators. Am J Surg, 2003, 185(4):323–327. 9. Moore A, Butt D, Ellis-Clarke J & Cartmill, J. Linguistic analysis of verbal and non-verbal communication in the operating room. ANZ J Surg, 2010; 80: 925–929. Disclosures None.

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