- Email: [email protected]
Video Gaming Enhances Psychomotor Skills But Not Visuospatial and Perceptual Abilities in Surgical Trainees
ORIGINAL REPORTS
Video Gaming Enhances Psychomotor Skills But Not Visuospatial and Perceptual Abilities in Surgical Trainees A. M. Kennedy, MD,* E. M. Boyle, MD,* O. Traynor, FRCS,* T. Walsh, FRCS,† and A. D. K. Hill, FRCS* *Royal College of Surgeons in Ireland, Dublin, Ireland, and †James Connolly Memorial Hospital, Blanchardstown, Ireland INTRODUCTION: There is considerable interest in the iden-
tification and assessment of underlying aptitudes or innate abilities that could potentially predict excellence in the technical aspects of operating. However, before the assessment of innate abilities is introduced for high-stakes assessment (such as competitive selection into surgical training programs), it is essential to determine that these abilities are stable and unchanging and are not influenced by other factors, such as the use of video games. The aim of this study was to investigate whether experience playing video games will predict psychomotor performance on a laparoscopic simulator or scores on tests of visuospatial and perceptual abilities, and to examine the correlation, if any, between these innate abilities. METHODS: Institutional ethical approval was obtained. Thirty-
eight undergraduate medical students with no previous surgical experience were recruited. All participants completed a selfreported questionnaire that asked them to detail their video game experience. They then underwent assessment of their psychomotor, visuospatial, and perceptual abilities using previously validated tests. The results were analyzed using independent samples t tests to compare means and linear regression curves for subsequent analysis. RESULTS: Students who played video games for at least 7 hours per week demonstrated significantly better psychomotor skills than students who did not play video games regularly. However, there was no difference on measures of visuospatial and perceptual abilities. There was no correlation between psychomotor tests and visuospatial or perceptual tests. CONCLUSIONS: Regular video gaming correlates positively with psychomotor ability, but it does not seem to influence visuospatial or perceptual ability. This study suggests that video game experience might be beneficial to a future career in surCorrespondence: Inquiries to Anne-Marie Kennedy, MD, National Surgical Training Centre, Royal College of Surgeons in Ireland, 121 St. Stephens Green, Dublin 2, Ireland; fax: (353) 213-5641; e-mail: [email protected]
414
gery. It also suggests that relevant surgical skills may be gained usefully outside the operating room in activities that are not related to surgery. (J Surg 68:414-420. © 2011 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: innate ability, psychomotor ability, visuospa-
tial ability, perceptual ability, surgical training COMPETENCY: Medical Knowledge, Systems Based Practice,
Practice Based Learning and Improvement
INTRODUCTION There is considerable interest in the identification and assessment of the innate abilities of surgical trainees as these abilities have the potential to predict technical operative performance.1 Although technical skill is only one desirable competency for a surgeon, it is vital for successful surgical practice. Technical skill is thought to be influenced by innate or inborn psychomotor, visuospatial, and perceptual abilities.2 Technical skill may be likened to a motor skill where a good technique is the result of a specific combination of innate abilities in addition to practice that is applied to a particular task. Skill contrasts with ability, which is considered a set of innate attributes that determine potential for a given activity. It is believed that abilities are present at birth, are relatively unchanging through life, and are not generally affected by training or other possible intervention.3 Psychomotor ability is the ability to perform body motor movements with precision, coordination, or strength. Expert technical skill is considered a combination of both innate psychomotor ability and practice or experience. Visuospatial ability (the ability to generate, retain, retrieve, and transform wellstructured visual images) is thought to be essential in the interpretation of images, such as those generated by X-ray, computed tomography, magnetic resonance imaging, or ultrasound. When interpreting such images, medical personnel have to picture mentally and infer the patients’ three-dimensional
Journal of Surgical Education • © 2011 Association of Program Directors in Surgery Published by Elsevier Inc. All rights reserved.
1931-7204/$30.00 doi:10.1016/j.jsurg.2011.03.009
(3D) anatomy from a two-dimensional (2D) image.4 In the same way, the ability to interpret images has become even more important given the expansion of minimally invasive techniques in surgery. In addition to visuospatial ability, pictorial depth perception (the ability to use visual clues from a 2D image to perceive objects’ distances and layout in 3D space) is also considered important in laparoscopic surgery.5 Operating surgeons manipulate instruments in 3D space while viewing 2D images on a monitor, and they must deal also with challenges like the fulcrum effect, loss of binocular vision, and difficulties with depth perception and image quality. Overcoming the technical challenges associated with surgery in general and laparoscopic surgery in particular makes demands on the surgeon’s visuospatial, perceptual, and psychomotor abilities. It has been shown, for example, that differences in innate abilities can predict the rate of endoscopy skill acquisition.6,7 Therefore, the assessment of these abilities may be an appropriate part of the selection process for trainees for higher surgical training as the results of such assessments may indicate which candidates are best suited to a career in surgery.8 This is particularly relevant as surgery requires a lengthy training period. However, before the widespread introduction of innate ability testing to a selection process, it is essential to determine that these abilities are innate (ie, unchanging from birth) and are not influenced by surgical practice or experience. If this were the case, then those trainees who gained more operative experience might be at an unfair advantage. In addition, the impact of nonsurgical abilities and dexterities, such as video gaming ability on laparoscopic surgical skills, is not yet fully understood, which might be a confounding factor. Recent studies have provided evidence for the beneficial effects of video games on both visual attention and hand– eye coordination. Green and Bavelier9 assessed video gaming enhancement of visual attention and spatial distribution, both of which might be relevant to surgical practice. A positive correlation was found between video gaming and visual attention processing. In addition, Rosser et al10 demonstrated that surgeons who played video games in the past for more than 3 hours/week made 37% fewer errors, were 27% faster, and scored 42% better overall on a laparoscopic training course than surgeons who never played video games. It has been suggested that younger surgeons might acquire skills in laparoscopic surgery more rapidly than their elder colleagues, possibly because they have been exposed to video games at a young age and, thus, have had more experience with screen-mediated task execution.11 However, Rosenberg et al12 showed that although video game aptitude seems to predict the baseline level of laparoscopic skill in the novice surgeon, practicing video games did not improve laparoscopic skill significantly. However, other studies provide conflicting and contrary evidence for the positive benefits of video games. Harper et al13 concluded that game playing is correlated inversely with the ability to learn robotic suturing but that there is a positive relationship between the ability to learn robotic suturing and
musical or athletic ability. In addition, Madan et al14 considered that nonsurgical skills, including video game experience, did not predict baseline scores on a surgical simulator. To date, studies have focused on the effect of video gaming on hand eye coordination/psychomotor abilities. Proficiency at a motor skill is considered a combination of both innate psychomotor ability and practice; in other words, practice makes perfect. However, it is still uncertain if video gaming has an influence on other innate abilities, such as visuo-spatial or perceptual abilities. We therefore wished to test the following two hypotheses: (a) video game experience will predict psychomotor performance on a laparoscopic simulator and (b) video game experience will have no influence of tests of visuo-spatial and perceptual abilities (if they are indeed innate abilities).
MATERIALS AND METHODS Institutional ethics approval was granted for this study. In all, 38 undergraduate medical students from the Royal College of Surgeons in Ireland volunteered to participate in the study. No participating students had any previous operative surgical experience. All students gave their consent to participate in the study. All participants completed a self-reported questionnaire that asked them to detail their video-game participation. They were asked to categorize themselves according to the following criteria: (1) played video games for at least 7 hours per week in the 3 of the last 5 years or (2) do not/have not played video games. All participants were then tested on the following 3 tasks: 1. Psychomotor ability was measured by performance on the ProMIS laparoscopic surgical simulator (Haptica, Dublin, Ireland). The “Instrument Handling-Locating and Coordinating” module was used. In this module, the bimanual use of laparoscopic instruments is tested. Two real instruments (right and left hand) are used to touch targets and maintain a steady position in a virtual abdomen. Once inside the simulator, all instruments are tracked in 3D space, generating assessment metrics. These metrics comprise time taken, instrument path length, and instrument smoothness scores, which are recorded objectively and saved by the simulator. 2. Perceptual ability was measured with the Pictoral Surface Orientation (PicSOr) “cube and arrow” test.15 This computerbased test works by generating 2 objects: a target cube and a rotating probe that connects by its tip with the slanting upper surface of the cube. The aim of the task is to set the rotating arrow so that it appears to be at a 90° angle to the surface of the cube. This requires the subjects to reconstruct 3D objects from their 2D representations with minimal depth cues. This test has been validated previously as a predictor of endoscopic simulator performance.16 3. Visuospatial ability was measured with the cube comparison, card rotation, and map planning tests taken from the
Journal of Surgical Education • Volume 68/Number 5 • September/October 2011
415
25.00
20.00
Time 15.00
10.00
5.00
Gamers
Non-gamers
FIGURE 1. Boxplot shows scores for the “time” component of the psychomotor task for gamers and nongamers.
Kit of Factor-Referenced tests.17 These timed, paper-based tests require subjects to manipulate both 2D and 3D objects, and to navigate maps. As they are scored with negative marking, trainees are required to answer as quickly as possible without sacrificing accuracy. Statistical Analysis A statistical analysis was performed using SPSS version 15 (SPSS, Inc, Chicago, Illinois). Shapiro Wilk tests were used to determine normality. Independent samples t tests were used for the nominal variables. A linear regression analysis and a multivariate analysis of variance were used to assess significant relationships. Correlations were examined using the Pearson product–moment correlation coefficient. The significance level was set at 0.05.
RESULTS All participants completed all assessments and there were no missing data. The average age of the participants was 25.6 years (⫾2.8 years). In total, 16 of the 38 participants played video games (“gamers”) according to the criteria outlined in the methods section. No participants had any previous laparoscopic surgical or simulator experience. Psychomotor Results A significant difference was found between gamers and nongamers for the time score t27.75 ⫽ –2.14, p ⬍ 0.04 (Fig. 1). 416
There was also a significant difference between gamers and nongamers for the instrument path length score t25.04 ⫽ –2.35, p ⬍ 0.027 (Fig. 2). No significant difference was found between the groups for the instrument smoothness score t(31) ⫽ 1.12, p ⬍ 0.27 (Table 1). A linear regression model was used to explore these relationships. Regression modeling showed that video game experience did not explain significantly the variation in the time score F1,31 ⫽ 4.15, p ⫽ 0.05. Video game experience only explained 11.8% of the variation in the time. However, video game experience did explain significantly the variation in the instrument path length score F1,31 ⫽ 4.90, p ⬍ 0.03. A direct relationship was found between the video game experience and the path length score (those with video game experience had shorter path lengths, ie, performed better). Linear regression modeling showed that video game experience did not explain significantly the variation in the instrument smoothness score F1,31 ⫽ 1.24, p ⬍ 0.27. Video game experience explained only 3.9% of the variation in the instrument smoothness variable.
Perceptual and Visuospatial Results No significant differences were found between gamers and nongamers for the PicSOr score, card rotation, cube comparison, or map planning scores (Figs. 3 and 4, Table 1). No significant correlations were observed between the PicSOr score, card rotation, cube comparison, or map planning scores with time, path length, or economy of movement scores
Journal of Surgical Education • Volume 68/Number 5 • September/October 2011
35.00
30.00
25.00
Path Length 20.00
15.00
10.00
5.00
Gamers
Non-gamers
FIGURE 2. Boxplot shows scores for the “path length” component of the psychomotor task for gamers and nongamers.
(ie, between the tests of visuospatial and perceptual ability and the test of psychomotor ability).
DISCUSSION The impact of video games on psychomotor abilities is a topic of much research, and there is good evidence of skills transfer between playing video games and performance on surgical simulators. It is likely that frequent and repetitive video game playing can improve psychomotor abilities. A recent review of the link between video games and surgical ability concluded that there is some evidence that training on video games over a short periods can improve laparoscopic ability.18 Hislop et al19 determined that playing video games, which involves looking at objects on a screen that are altered by unwatched hand movements, improves time scores on an endo-
vascular simulator. Fleming20 reported that Dr Kanav Kohel and Dr Marshall Smith demonstrated that surgical residents who practiced on the Nintendo Wii (Nintendo of America, Inc., Redmond, Washington) video game before performing a simulated case scored nearly 50% higher on tool control and overall performance than other trainees. In fact, Reilly21 reported that Kohel and Smith are now working on developing a new, Wii-based software package that will serve as a relatively low-cost training solution for trainee surgeons in developing countries. In this study, video gamers significantly outperformed nongamers on 2 metrics recorded by the ProMIS simulator—time and instrument path length. However, it is important to note that this is a correlational study; cause or effect cannot be concluded definitively. Some students may possess superior psychomotor abilities that increase their interest in pursuits involv-
TABLE 1. Scores for the Psychomotor, Perceptual, and Visuospatial Tests for Gamers and Nongamers
Psychomotor Time, min Path length, mm Economy Perceptual PicSOr Visuospatial Card rotation test Cube comparison test Map planning test
Gamer Mean (SD)
Nongamer Mean (SD)
p Value
10.25 (2.52) 11.5 (3.38) 2203.87 (599.67)
12.87 (4.41) 15.98 (7.20) 2566.72 (1133.13)
0.040 0.027 0.273
0.87 (0.12)
0.170
0.92 (0.10) 111.63 (21.04) 22.06 (8.91) 26.4 (5.62)
103.36 (32.72) 18.64 (10.26) 24.18 (5.79)
0.380 0.290 0.180
SD, standard deviation. Journal of Surgical Education • Volume 68/Number 5 • September/October 2011
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PicSor
1.25
1.00
Mean
0.75
0.50
0.25
0.00
Gamers
Non-gamers
FIGURE 3. Scores for the perceptual test (PicSor) for gamers and nongamers.
ing manual dexterity, such as video games. Other students may simply enjoy playing video games and are, therefore, more likely to practice frequently, thus improving their motor skills. In addition, there may be other confounding variables, including interests in pursuits such as sports or music. Although an increasing number of studies are exploring the relationship between video game experience and psychomotor abilities, there has been little work on the influence of video games on visuospatial and perceptual abilities. Theoretically, there should be no influence as visuospatial and perceptual abilities are considered innate and, therefore, unaffected by influences such as video game use. This theory is in keeping with the findings in our study. We found that there was no significant difference in baseline visuospatial and perceptual abilities between gamers and nongamers. This finding indicates that as expected, visuospatial and perceptual abilities are resistant to the influence of experience and practice on video games. However, Li et al22 demonstrated unsuspected plastic potentiality in the adult visual system. They showed that playing video games resulted in enhanced contrast sensitivity (the ability to detect small increments in shades of gray on a uniform background). Green and Bavelier9 showed also that video game playing enhances visual attention capacity and spatial distribution. It is important to consider that the tests we used, although they were validated tools, tested only some components of innate abilities. For example, the Kit of Factor Referenced Tests can assess 23 different abilities, including elements such as memory, fluency, 418
and reasoning. However, not all these components may be relevant to surgical performance. Therefore, it might be advisable to perform a similar study with more participants to investigate this point even more or to examine different aspects of innate abilities. Video games have become a routine part of many people’s recreational time, particularly for teenagers and young adults. It is predicted that the worldwide video game industry will grow from $29 billion in 2005 to $44 billion in 2011.23 Therefore, it is logical to explore the positive benefits for teaching of video games, given their broad and persistent populist appeal. Indeed, the United States military are already using video games such as Delta Force 2 (NovaLogic Inc, Calabasas, California) as part of their training strategies.24 The results of these studies should stimulate a debate on how to include video game play as an adjunct to laparoscopic skills training,10 and the surgical community could therefore consider using video games as another educational tool in curricula tailor-made for individual surgical trainees. Perhaps trainees with superior skills for video games could use games as part of their training program, whereas those with little or no video game skill could use other training modalities.25 However, before attempting the individualization of laparoscopic training, a thorough initial assessment and determination of baseline skill is necessary.14 This study suggests that video game experience is beneficial to a future career in endoscopic surgery as such experi-
Journal of Surgical Education • Volume 68/Number 5 • September/October 2011
Card 120.00
Cube Map
100.00
80.00
Mean 60.00
40.00
20.00
0.00
Gamers
Non-gamers
FIGURE 4. Scores for the 3 visuospatial tests (card rotation, cube comparison, and map planning) for gamers and nongamers.
ence may serve as a marker for requisite eye– hand coordination skills for laparoscopy. However, the predictive value of these findings is uncertain and additional research is required to define the role of video games in tailoring the training of specific trainee subgroup.
REFERENCES 1. Schueneman AL, Pickleman J, Hesslein R, et al. Neuro-
psychologic predictors of operative skill among general surgery residents. Surgery. 1984;96:288-295. 2. Cuschieri A, Francis N, Crosby J, et al. What do master
surgeons think of surgical competence and revalidation? Am J Surg. 2001;182:110-116. 3. Gibbons RD, Baker RJ, Skinner DB. Field articulation
testing: a predictor of technical skills in surgical residents. J Surg Res. 1986;41:53-57. 4. Hegarty M, Keehner M, Cohen C, et al. The role of spatial
cognition in medicine: Applications for selecting and training professionals. In: Allen G, ed. Applied Spatial Cognition. Mahwah, NJ: Lawrence Erlbaum Associates; 2007.
5. Gallagher AG, Cowie R, Crothers I, et al. PicSOr: An
objective test of perceptual skill that predicts laparoscopic technical skill in three initial studies of laparoscopic performance. Surg Endosc. 2003;7:1468-1471. 6. Westman VB, Ritter EM, Kjellin A, et al. Visuospatial
abilities correlate with performance of senior endoscopy specialist in simulated colonoscopy. J Gastrointest Surg. 2006;10:593-599. 7. Ritter E, McClusky D, Gallagher AG, et al. Perceptual,
visuospatial, and psychomotor abilities correlate with duration of training required on a virtual-reality flexible endoscopy simulator. Am J Surg. 2006;192:379-384. 8. McGreevy JM. The aviation paradigm and surgical edu-
cation. J Am Coll Surg. 2005;201:110-117. 9. Green CS, Bavelier D. Action video game modifies visual
selective attention. Nature. 2003;423:534-537. 10. Rosser JC, Lynch PJ, Cuddihy L, et al. The impact of
video games on training surgeons in the 21st century. Arch Surg. 2007;142:181-186.
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11. Tsai CL, Heinrichs WL. Acquisition of eye-hand coordi-
18. Lynch J, Aughwane P, Hammond TM. Video games and
nation skills for videoendoscopic surgery. Am Assoc Gynecol Laparosc 1994;1(4, Part 2):S37.
surgical ability: a literature review. J Surg Educ. 2010;67: 184-189.
12. Rosenberg BH, Landsittel D, Averch TD. Can video
19. Hislop SJ, Hsu JH, Narins CR, et al. Simulator assess-
games be used to predict or improve laparoscopic skills? J Endourol. 2005;19:372. 13. Harper JD, Kaiser S, Ebrahimi, et al. Prior video game
ment of innate endovascular aptitude versus empirically correct performance. J Vasc Surg. 2006;43:47-55. 20. Fleming N. Surgeons are better after playing Nintendo
exposure does not enhance robotic surgical performance. J Endourol. 2007;21:1207-1210.
Wii. Available at: http://www.telegraph.co.uk/science andtechnology/science/sciencenews/3322112/Surgeons-arebetter-after-playing-Nintendo-Wii.html. Accessed 2010.
14. Madan AK, Harper JL, Frantzides CT, et al. Nonsur-
21. Reilly M. A Wii warm-up hones surgical skills. New Sci.
gical skills do not predict baseline scores in inanimate box or virtual-reality trainers. Surg Endosc. 2008;22: 1686-1689. 15. Cowie R. Measurement and modelling of perceived slant
in surfaces represented by freely viewed line drawings. Perception. 1988;27:505-540. 16. Gallagher AG, Cowie R, Crothers I, et al. PicSOr: an
2008;197. 22. Li R, Polat U, Makous W, et al. Enhancing the contrast
sensitivity function through action video game training. Nat Neurosci. 2009;12:527-528. 23. DFC Intelligence. DFC Intelligence forecasts video game
market to reach $44 billion by 2011; September 26, 2006. Available at: http://www.dfcint.com/news/prsept262006. html. Accessed June 13, 2010.
objective test of perceptual skill that predicts laparoscopic technical skill in three initial studies of laparoscopic performance. Surg Endosc. 2003;7:1468-1471.
24. Land Warrior Training Initiative. Available at: http://
17. Ekstrom R, French J, Harman H. Manual for Kit of
25. Curet MJ. Commentary on “The impact of video games
Factor-Referenced Cognitive Tests. Princeton, NJ: Educational Testing Service; 1976.
on training surgeons in the 21st century.” Arch Surg. 2007;142:186.
420
www.siaa.asn.au/get/2395363515.pdf. Accessed 2010.
Journal of Surgical Education • Volume 68/Number 5 • September/October 2011
Video Gaming Enhances Psychomotor Skills But Not Visuospatial and Perceptual Abilities in Surgical Trainees A. M. Kennedy, MD,* E. M. Boyle, MD,* O. Traynor, FRCS,* T. Walsh, FRCS,† and A. D. K. Hill, FRCS* *Royal College of Surgeons in Ireland, Dublin, Ireland, and †James Connolly Memorial Hospital, Blanchardstown, Ireland INTRODUCTION: There is considerable interest in the iden-
tification and assessment of underlying aptitudes or innate abilities that could potentially predict excellence in the technical aspects of operating. However, before the assessment of innate abilities is introduced for high-stakes assessment (such as competitive selection into surgical training programs), it is essential to determine that these abilities are stable and unchanging and are not influenced by other factors, such as the use of video games. The aim of this study was to investigate whether experience playing video games will predict psychomotor performance on a laparoscopic simulator or scores on tests of visuospatial and perceptual abilities, and to examine the correlation, if any, between these innate abilities. METHODS: Institutional ethical approval was obtained. Thirty-
eight undergraduate medical students with no previous surgical experience were recruited. All participants completed a selfreported questionnaire that asked them to detail their video game experience. They then underwent assessment of their psychomotor, visuospatial, and perceptual abilities using previously validated tests. The results were analyzed using independent samples t tests to compare means and linear regression curves for subsequent analysis. RESULTS: Students who played video games for at least 7 hours per week demonstrated significantly better psychomotor skills than students who did not play video games regularly. However, there was no difference on measures of visuospatial and perceptual abilities. There was no correlation between psychomotor tests and visuospatial or perceptual tests. CONCLUSIONS: Regular video gaming correlates positively with psychomotor ability, but it does not seem to influence visuospatial or perceptual ability. This study suggests that video game experience might be beneficial to a future career in surCorrespondence: Inquiries to Anne-Marie Kennedy, MD, National Surgical Training Centre, Royal College of Surgeons in Ireland, 121 St. Stephens Green, Dublin 2, Ireland; fax: (353) 213-5641; e-mail: [email protected]
414
gery. It also suggests that relevant surgical skills may be gained usefully outside the operating room in activities that are not related to surgery. (J Surg 68:414-420. © 2011 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: innate ability, psychomotor ability, visuospa-
tial ability, perceptual ability, surgical training COMPETENCY: Medical Knowledge, Systems Based Practice,
Practice Based Learning and Improvement
INTRODUCTION There is considerable interest in the identification and assessment of the innate abilities of surgical trainees as these abilities have the potential to predict technical operative performance.1 Although technical skill is only one desirable competency for a surgeon, it is vital for successful surgical practice. Technical skill is thought to be influenced by innate or inborn psychomotor, visuospatial, and perceptual abilities.2 Technical skill may be likened to a motor skill where a good technique is the result of a specific combination of innate abilities in addition to practice that is applied to a particular task. Skill contrasts with ability, which is considered a set of innate attributes that determine potential for a given activity. It is believed that abilities are present at birth, are relatively unchanging through life, and are not generally affected by training or other possible intervention.3 Psychomotor ability is the ability to perform body motor movements with precision, coordination, or strength. Expert technical skill is considered a combination of both innate psychomotor ability and practice or experience. Visuospatial ability (the ability to generate, retain, retrieve, and transform wellstructured visual images) is thought to be essential in the interpretation of images, such as those generated by X-ray, computed tomography, magnetic resonance imaging, or ultrasound. When interpreting such images, medical personnel have to picture mentally and infer the patients’ three-dimensional
Journal of Surgical Education • © 2011 Association of Program Directors in Surgery Published by Elsevier Inc. All rights reserved.
1931-7204/$30.00 doi:10.1016/j.jsurg.2011.03.009
(3D) anatomy from a two-dimensional (2D) image.4 In the same way, the ability to interpret images has become even more important given the expansion of minimally invasive techniques in surgery. In addition to visuospatial ability, pictorial depth perception (the ability to use visual clues from a 2D image to perceive objects’ distances and layout in 3D space) is also considered important in laparoscopic surgery.5 Operating surgeons manipulate instruments in 3D space while viewing 2D images on a monitor, and they must deal also with challenges like the fulcrum effect, loss of binocular vision, and difficulties with depth perception and image quality. Overcoming the technical challenges associated with surgery in general and laparoscopic surgery in particular makes demands on the surgeon’s visuospatial, perceptual, and psychomotor abilities. It has been shown, for example, that differences in innate abilities can predict the rate of endoscopy skill acquisition.6,7 Therefore, the assessment of these abilities may be an appropriate part of the selection process for trainees for higher surgical training as the results of such assessments may indicate which candidates are best suited to a career in surgery.8 This is particularly relevant as surgery requires a lengthy training period. However, before the widespread introduction of innate ability testing to a selection process, it is essential to determine that these abilities are innate (ie, unchanging from birth) and are not influenced by surgical practice or experience. If this were the case, then those trainees who gained more operative experience might be at an unfair advantage. In addition, the impact of nonsurgical abilities and dexterities, such as video gaming ability on laparoscopic surgical skills, is not yet fully understood, which might be a confounding factor. Recent studies have provided evidence for the beneficial effects of video games on both visual attention and hand– eye coordination. Green and Bavelier9 assessed video gaming enhancement of visual attention and spatial distribution, both of which might be relevant to surgical practice. A positive correlation was found between video gaming and visual attention processing. In addition, Rosser et al10 demonstrated that surgeons who played video games in the past for more than 3 hours/week made 37% fewer errors, were 27% faster, and scored 42% better overall on a laparoscopic training course than surgeons who never played video games. It has been suggested that younger surgeons might acquire skills in laparoscopic surgery more rapidly than their elder colleagues, possibly because they have been exposed to video games at a young age and, thus, have had more experience with screen-mediated task execution.11 However, Rosenberg et al12 showed that although video game aptitude seems to predict the baseline level of laparoscopic skill in the novice surgeon, practicing video games did not improve laparoscopic skill significantly. However, other studies provide conflicting and contrary evidence for the positive benefits of video games. Harper et al13 concluded that game playing is correlated inversely with the ability to learn robotic suturing but that there is a positive relationship between the ability to learn robotic suturing and
musical or athletic ability. In addition, Madan et al14 considered that nonsurgical skills, including video game experience, did not predict baseline scores on a surgical simulator. To date, studies have focused on the effect of video gaming on hand eye coordination/psychomotor abilities. Proficiency at a motor skill is considered a combination of both innate psychomotor ability and practice; in other words, practice makes perfect. However, it is still uncertain if video gaming has an influence on other innate abilities, such as visuo-spatial or perceptual abilities. We therefore wished to test the following two hypotheses: (a) video game experience will predict psychomotor performance on a laparoscopic simulator and (b) video game experience will have no influence of tests of visuo-spatial and perceptual abilities (if they are indeed innate abilities).
MATERIALS AND METHODS Institutional ethics approval was granted for this study. In all, 38 undergraduate medical students from the Royal College of Surgeons in Ireland volunteered to participate in the study. No participating students had any previous operative surgical experience. All students gave their consent to participate in the study. All participants completed a self-reported questionnaire that asked them to detail their video-game participation. They were asked to categorize themselves according to the following criteria: (1) played video games for at least 7 hours per week in the 3 of the last 5 years or (2) do not/have not played video games. All participants were then tested on the following 3 tasks: 1. Psychomotor ability was measured by performance on the ProMIS laparoscopic surgical simulator (Haptica, Dublin, Ireland). The “Instrument Handling-Locating and Coordinating” module was used. In this module, the bimanual use of laparoscopic instruments is tested. Two real instruments (right and left hand) are used to touch targets and maintain a steady position in a virtual abdomen. Once inside the simulator, all instruments are tracked in 3D space, generating assessment metrics. These metrics comprise time taken, instrument path length, and instrument smoothness scores, which are recorded objectively and saved by the simulator. 2. Perceptual ability was measured with the Pictoral Surface Orientation (PicSOr) “cube and arrow” test.15 This computerbased test works by generating 2 objects: a target cube and a rotating probe that connects by its tip with the slanting upper surface of the cube. The aim of the task is to set the rotating arrow so that it appears to be at a 90° angle to the surface of the cube. This requires the subjects to reconstruct 3D objects from their 2D representations with minimal depth cues. This test has been validated previously as a predictor of endoscopic simulator performance.16 3. Visuospatial ability was measured with the cube comparison, card rotation, and map planning tests taken from the
Journal of Surgical Education • Volume 68/Number 5 • September/October 2011
415
25.00
20.00
Time 15.00
10.00
5.00
Gamers
Non-gamers
FIGURE 1. Boxplot shows scores for the “time” component of the psychomotor task for gamers and nongamers.
Kit of Factor-Referenced tests.17 These timed, paper-based tests require subjects to manipulate both 2D and 3D objects, and to navigate maps. As they are scored with negative marking, trainees are required to answer as quickly as possible without sacrificing accuracy. Statistical Analysis A statistical analysis was performed using SPSS version 15 (SPSS, Inc, Chicago, Illinois). Shapiro Wilk tests were used to determine normality. Independent samples t tests were used for the nominal variables. A linear regression analysis and a multivariate analysis of variance were used to assess significant relationships. Correlations were examined using the Pearson product–moment correlation coefficient. The significance level was set at 0.05.
RESULTS All participants completed all assessments and there were no missing data. The average age of the participants was 25.6 years (⫾2.8 years). In total, 16 of the 38 participants played video games (“gamers”) according to the criteria outlined in the methods section. No participants had any previous laparoscopic surgical or simulator experience. Psychomotor Results A significant difference was found between gamers and nongamers for the time score t27.75 ⫽ –2.14, p ⬍ 0.04 (Fig. 1). 416
There was also a significant difference between gamers and nongamers for the instrument path length score t25.04 ⫽ –2.35, p ⬍ 0.027 (Fig. 2). No significant difference was found between the groups for the instrument smoothness score t(31) ⫽ 1.12, p ⬍ 0.27 (Table 1). A linear regression model was used to explore these relationships. Regression modeling showed that video game experience did not explain significantly the variation in the time score F1,31 ⫽ 4.15, p ⫽ 0.05. Video game experience only explained 11.8% of the variation in the time. However, video game experience did explain significantly the variation in the instrument path length score F1,31 ⫽ 4.90, p ⬍ 0.03. A direct relationship was found between the video game experience and the path length score (those with video game experience had shorter path lengths, ie, performed better). Linear regression modeling showed that video game experience did not explain significantly the variation in the instrument smoothness score F1,31 ⫽ 1.24, p ⬍ 0.27. Video game experience explained only 3.9% of the variation in the instrument smoothness variable.
Perceptual and Visuospatial Results No significant differences were found between gamers and nongamers for the PicSOr score, card rotation, cube comparison, or map planning scores (Figs. 3 and 4, Table 1). No significant correlations were observed between the PicSOr score, card rotation, cube comparison, or map planning scores with time, path length, or economy of movement scores
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35.00
30.00
25.00
Path Length 20.00
15.00
10.00
5.00
Gamers
Non-gamers
FIGURE 2. Boxplot shows scores for the “path length” component of the psychomotor task for gamers and nongamers.
(ie, between the tests of visuospatial and perceptual ability and the test of psychomotor ability).
DISCUSSION The impact of video games on psychomotor abilities is a topic of much research, and there is good evidence of skills transfer between playing video games and performance on surgical simulators. It is likely that frequent and repetitive video game playing can improve psychomotor abilities. A recent review of the link between video games and surgical ability concluded that there is some evidence that training on video games over a short periods can improve laparoscopic ability.18 Hislop et al19 determined that playing video games, which involves looking at objects on a screen that are altered by unwatched hand movements, improves time scores on an endo-
vascular simulator. Fleming20 reported that Dr Kanav Kohel and Dr Marshall Smith demonstrated that surgical residents who practiced on the Nintendo Wii (Nintendo of America, Inc., Redmond, Washington) video game before performing a simulated case scored nearly 50% higher on tool control and overall performance than other trainees. In fact, Reilly21 reported that Kohel and Smith are now working on developing a new, Wii-based software package that will serve as a relatively low-cost training solution for trainee surgeons in developing countries. In this study, video gamers significantly outperformed nongamers on 2 metrics recorded by the ProMIS simulator—time and instrument path length. However, it is important to note that this is a correlational study; cause or effect cannot be concluded definitively. Some students may possess superior psychomotor abilities that increase their interest in pursuits involv-
TABLE 1. Scores for the Psychomotor, Perceptual, and Visuospatial Tests for Gamers and Nongamers
Psychomotor Time, min Path length, mm Economy Perceptual PicSOr Visuospatial Card rotation test Cube comparison test Map planning test
Gamer Mean (SD)
Nongamer Mean (SD)
p Value
10.25 (2.52) 11.5 (3.38) 2203.87 (599.67)
12.87 (4.41) 15.98 (7.20) 2566.72 (1133.13)
0.040 0.027 0.273
0.87 (0.12)
0.170
0.92 (0.10) 111.63 (21.04) 22.06 (8.91) 26.4 (5.62)
103.36 (32.72) 18.64 (10.26) 24.18 (5.79)
0.380 0.290 0.180
SD, standard deviation. Journal of Surgical Education • Volume 68/Number 5 • September/October 2011
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PicSor
1.25
1.00
Mean
0.75
0.50
0.25
0.00
Gamers
Non-gamers
FIGURE 3. Scores for the perceptual test (PicSor) for gamers and nongamers.
ing manual dexterity, such as video games. Other students may simply enjoy playing video games and are, therefore, more likely to practice frequently, thus improving their motor skills. In addition, there may be other confounding variables, including interests in pursuits such as sports or music. Although an increasing number of studies are exploring the relationship between video game experience and psychomotor abilities, there has been little work on the influence of video games on visuospatial and perceptual abilities. Theoretically, there should be no influence as visuospatial and perceptual abilities are considered innate and, therefore, unaffected by influences such as video game use. This theory is in keeping with the findings in our study. We found that there was no significant difference in baseline visuospatial and perceptual abilities between gamers and nongamers. This finding indicates that as expected, visuospatial and perceptual abilities are resistant to the influence of experience and practice on video games. However, Li et al22 demonstrated unsuspected plastic potentiality in the adult visual system. They showed that playing video games resulted in enhanced contrast sensitivity (the ability to detect small increments in shades of gray on a uniform background). Green and Bavelier9 showed also that video game playing enhances visual attention capacity and spatial distribution. It is important to consider that the tests we used, although they were validated tools, tested only some components of innate abilities. For example, the Kit of Factor Referenced Tests can assess 23 different abilities, including elements such as memory, fluency, 418
and reasoning. However, not all these components may be relevant to surgical performance. Therefore, it might be advisable to perform a similar study with more participants to investigate this point even more or to examine different aspects of innate abilities. Video games have become a routine part of many people’s recreational time, particularly for teenagers and young adults. It is predicted that the worldwide video game industry will grow from $29 billion in 2005 to $44 billion in 2011.23 Therefore, it is logical to explore the positive benefits for teaching of video games, given their broad and persistent populist appeal. Indeed, the United States military are already using video games such as Delta Force 2 (NovaLogic Inc, Calabasas, California) as part of their training strategies.24 The results of these studies should stimulate a debate on how to include video game play as an adjunct to laparoscopic skills training,10 and the surgical community could therefore consider using video games as another educational tool in curricula tailor-made for individual surgical trainees. Perhaps trainees with superior skills for video games could use games as part of their training program, whereas those with little or no video game skill could use other training modalities.25 However, before attempting the individualization of laparoscopic training, a thorough initial assessment and determination of baseline skill is necessary.14 This study suggests that video game experience is beneficial to a future career in endoscopic surgery as such experi-
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Card 120.00
Cube Map
100.00
80.00
Mean 60.00
40.00
20.00
0.00
Gamers
Non-gamers
FIGURE 4. Scores for the 3 visuospatial tests (card rotation, cube comparison, and map planning) for gamers and nongamers.
ence may serve as a marker for requisite eye– hand coordination skills for laparoscopy. However, the predictive value of these findings is uncertain and additional research is required to define the role of video games in tailoring the training of specific trainee subgroup.
REFERENCES 1. Schueneman AL, Pickleman J, Hesslein R, et al. Neuro-
psychologic predictors of operative skill among general surgery residents. Surgery. 1984;96:288-295. 2. Cuschieri A, Francis N, Crosby J, et al. What do master
surgeons think of surgical competence and revalidation? Am J Surg. 2001;182:110-116. 3. Gibbons RD, Baker RJ, Skinner DB. Field articulation
testing: a predictor of technical skills in surgical residents. J Surg Res. 1986;41:53-57. 4. Hegarty M, Keehner M, Cohen C, et al. The role of spatial
cognition in medicine: Applications for selecting and training professionals. In: Allen G, ed. Applied Spatial Cognition. Mahwah, NJ: Lawrence Erlbaum Associates; 2007.
5. Gallagher AG, Cowie R, Crothers I, et al. PicSOr: An
objective test of perceptual skill that predicts laparoscopic technical skill in three initial studies of laparoscopic performance. Surg Endosc. 2003;7:1468-1471. 6. Westman VB, Ritter EM, Kjellin A, et al. Visuospatial
abilities correlate with performance of senior endoscopy specialist in simulated colonoscopy. J Gastrointest Surg. 2006;10:593-599. 7. Ritter E, McClusky D, Gallagher AG, et al. Perceptual,
visuospatial, and psychomotor abilities correlate with duration of training required on a virtual-reality flexible endoscopy simulator. Am J Surg. 2006;192:379-384. 8. McGreevy JM. The aviation paradigm and surgical edu-
cation. J Am Coll Surg. 2005;201:110-117. 9. Green CS, Bavelier D. Action video game modifies visual
selective attention. Nature. 2003;423:534-537. 10. Rosser JC, Lynch PJ, Cuddihy L, et al. The impact of
video games on training surgeons in the 21st century. Arch Surg. 2007;142:181-186.
Journal of Surgical Education • Volume 68/Number 5 • September/October 2011
419
11. Tsai CL, Heinrichs WL. Acquisition of eye-hand coordi-
18. Lynch J, Aughwane P, Hammond TM. Video games and
nation skills for videoendoscopic surgery. Am Assoc Gynecol Laparosc 1994;1(4, Part 2):S37.
surgical ability: a literature review. J Surg Educ. 2010;67: 184-189.
12. Rosenberg BH, Landsittel D, Averch TD. Can video
19. Hislop SJ, Hsu JH, Narins CR, et al. Simulator assess-
games be used to predict or improve laparoscopic skills? J Endourol. 2005;19:372. 13. Harper JD, Kaiser S, Ebrahimi, et al. Prior video game
ment of innate endovascular aptitude versus empirically correct performance. J Vasc Surg. 2006;43:47-55. 20. Fleming N. Surgeons are better after playing Nintendo
exposure does not enhance robotic surgical performance. J Endourol. 2007;21:1207-1210.
Wii. Available at: http://www.telegraph.co.uk/science andtechnology/science/sciencenews/3322112/Surgeons-arebetter-after-playing-Nintendo-Wii.html. Accessed 2010.
14. Madan AK, Harper JL, Frantzides CT, et al. Nonsur-
21. Reilly M. A Wii warm-up hones surgical skills. New Sci.
gical skills do not predict baseline scores in inanimate box or virtual-reality trainers. Surg Endosc. 2008;22: 1686-1689. 15. Cowie R. Measurement and modelling of perceived slant
in surfaces represented by freely viewed line drawings. Perception. 1988;27:505-540. 16. Gallagher AG, Cowie R, Crothers I, et al. PicSOr: an
2008;197. 22. Li R, Polat U, Makous W, et al. Enhancing the contrast
sensitivity function through action video game training. Nat Neurosci. 2009;12:527-528. 23. DFC Intelligence. DFC Intelligence forecasts video game
market to reach $44 billion by 2011; September 26, 2006. Available at: http://www.dfcint.com/news/prsept262006. html. Accessed June 13, 2010.
objective test of perceptual skill that predicts laparoscopic technical skill in three initial studies of laparoscopic performance. Surg Endosc. 2003;7:1468-1471.
24. Land Warrior Training Initiative. Available at: http://
17. Ekstrom R, French J, Harman H. Manual for Kit of
25. Curet MJ. Commentary on “The impact of video games
Factor-Referenced Cognitive Tests. Princeton, NJ: Educational Testing Service; 1976.
on training surgeons in the 21st century.” Arch Surg. 2007;142:186.
420
www.siaa.asn.au/get/2395363515.pdf. Accessed 2010.
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