- Email: [email protected]
Bridging the Gap: Theory-Based Design of a Microsurgical Skills Course for Ophthalmology Residents
ORIGINAL REPORTS
Bridging the Gap: Theory-Based Design of a Microsurgical Skills Course for Ophthalmology Residents Antigoni Koukkoulli, MD,* Aman Chandra, BSc,* Hithen Sheth, FRCOphth,* Narciss Okhravi, PhD,* Seema Verma, MD,* Paul Sullivan, MD,* and Daniel G. Ezra, MD*,†,‡,§ Department of Education, Moorfields Eye Hospital, London, United Kingdom; †National Institute for Health Research, Biomedical Research Centre for Ophthalmology, Moorfields Eye Hospital and UCL Institute of Ophthalmology, Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom; ‡Adnexal Department, Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom; and §Department of Cell Biology, UCL Institute of Ophthalmology, London, United Kingdom *
OBJECTIVE: Although theory-based schemes for course
design are widely used in educational settings, making use of cognitive theory in the design of surgical skills courses in ophthalmology is rare. The primary aim of this study is to describe the application of instructional design, an established theory-based approach in course design, to the development of a surgical skills course for ophthalmology residents. The secondary aim of this study is to assess the educational effect of this theory-based course. DESIGN: A 1-day skills course was designed according to Gagné's events of instruction model, which was employed as a template for the instructional sequence of learning steps. Skills acquisition following the implementation of the model was measured with precourse and postcourse assessments. SETTING: Moorfields Eye Hospital organized the 1-day
annual intermediate surgical skills course, which was hosted at the Royal College of Ophthalmologists’ microsurgical skills laboratory. PARTICIPANTS: A total of 20 ophthalmology residents of
Moorfields Eye Hospital participated in the study. RESULTS: A 1-day surgical skills course was formulated
according to the instructional design principles outlined. The 4 objectives of the course (corneal suturing, corneal
Funding: This study was funded by the Department of Health through the award by the National Institute for Health Research to Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology for a Specialist Biomedical Research Centre for Ophthalmology. The views expressed in this publication are those of the authors and not necessarily those of the Department of Health. Correspondence: Inquiries to Antigoni Koukkoulli, MD, FRCOphth, Moorfields Eye Hospital NHS Trust, City Road, London EC1V 2PD, UK; fax: (208) 202-5383; e-mail: [email protected]
gluing, intravitreal injections, and eyelid suturing) were addressed in a parallel fashion as to allow for multiple objectives to be processed simultaneously, in the context of the instructional design sequence. Assessments demonstrated significant improvement in skills acquisition for the 4 course objectives. CONCLUSIONS: Instructional design is a valuable tool for planning effective surgical training courses as it is portable, allowing its application to a wide variety of outcomes and settings, and its terminology is simple and understandable to those working in clinical education. ( J Surg 72:585-591. C J 2015 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: microsurgical skillourse, instructional course
design theory COMPETENCIES: Patient Care, Medical Knowledge, Professionalism, Practice-Based Learning and Improvement
INTRODUCTION One of the most fundamental changes in surgical training over the past decade has been the move away from an apprenticeship model of teaching toward a more systematic approach. Integral to this shift has been the implementation of teaching strategies to provide for the development of skills and experience in a graduated process toward reality. This involves trainees acquiring skills in a simulated patient environment before or in parallel with exposure to patients.1 This transition has been established for some time in undergraduate medical training and is now being embraced by postgraduate surgical training.2,3 Simulated surgical teaching techniques including surgical skills courses,
Journal of Surgical Education & 2015 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2014.12.015
585
multimedia demonstrations, and virtual reality training techniques have been widely used in other surgical specialities.4 In ophthalmic surgical training, there has been a recent emergence of a variety of surgical training modalities to allow residents to improve their skills.5 Microsurgical skills courses in ophthalmology have played a central role in skills development, and the effectiveness of these courses is now widely accepted.6 Teaching complex motor skills in a formal environment can be challenging. Modern educational theory suggests that there is a psychomotor domain of learning consisting of a hierarchy of internal cognitive processes, which include an awareness of the task, sensory stimulation, and guided responses.7 To enhance the effectiveness of teaching, it is argued that these processes must be addressed by an instructional approach.8 One such model for linking internal cognitive processes to a teaching template is “instructional design theory,” which refers to the use of frameworks for developing teaching methods that enhance the effectiveness and efficiency of learning.9 Several different instructional design models exist, and perhaps one of the most widely used is that developed by Gagné who described 9 instructional events that detail the conditions necessary for learning to occur. This is known as the “events of instruction” model.9,10 Moorfields Eye Hospital runs a 1-day surgical skills course for ophthalmology residents. The primary aim of this study is to describe the application of Gagné’s instructional design model to the process of construction and development of a surgical skills course for ophthalmology residents based on our experience at Moorfields. The secondary aim of this study is to assess the effectiveness of this theory-based course using precourse and postcourse assessments.
MATERIALS AND METHODS Setting Moorfields Eye Hospital organizes a 1-day annual intermediate surgical skills course, consisting of microsurgical and oculoplastics components, for 20 residents, which is
hosted at the Royal College of Ophthalmologists’ microsurgical skills laboratory. No ethical approval was required for the study. Objectives The first step in the design process is to be clear about the objectives of the teaching exercise and then organize instructional events appropriate to that outcome. The course objectives were determined by content experts (P. S., N.O., and S.V.) in the context of the curriculum for higher surgical training by the Royal College of Ophthalmologists (Table 1).11 Instructional Design Model: Gagné’s Events of Instruction Gagné’s “events of instruction” model was employed as a template for the instructional sequence of learning steps. Gagné proposed 9 events of instruction to be sequentially applied to be compatible with cognitive learning processes.9 These events as applied to motor skill acquisition have been summarized in Table 2. Event 1: Gaining Attention—Introducing Stimulus Change The purpose of this initial step is to focus learners on the tasks ahead. Techniques for gaining attention include the presentation of dramatic or difficult cases. Stimulus change also relates to the choice of media used for the duration of the course. Event 2: Informing Learner of Objective(s)—Provide a Demonstration of the Performance to be Expected The objectives must be clarified from the outset to inform the learner what is expected to be achieved by the end of the course. This instructional step will help to prime the learner to organize the teaching material in the context of the expected objective.
TABLE 1. The Course Objectives as Determined by the Course Experts Task Corneal suturing
Oculoplastic suturing in the form of reconstitution of the eyelid margin Vitreous tap and intravitreal injection Corneal gluing
586
Description of Task All ophthalmologists are expected to be competent in corneal suturing, as it is a skill required for globe repair following trauma, and in dealing with leaking wounds in cataract surgery. It is performed under the microscope using 10-0 nylon suture in interrupted or continuous fashion. Trainees are expected to be able to repair eyelid lacerations involving the lid margin. It is repaired in sequential anatomical layers using a 6-0 vicryl suture, either with the aid of loops or unaided. Endophthalmitis is an ocular emergency that requires urgent treatment in the form of intravitreal injection of antibiotics, preceded by vitreous sampling. Corneal gluing is indicated for small corneal perforations, corneal melts, or leaks. Cyanoacrylate glue is used, and the procedure is performed under the slit lamp in clinic. Journal of Surgical Education Volume 72/Number 4 July/August 2015
TABLE 2. Gagné’s 9 Events of Instruction as Applied to Motor Skill Learning9 Instructional Event 1. 2. 3. 4. 5. 6. 7. 8. 9.
Gaining attention Informing learner of objective Stimulating recall of prior learning Presenting the stimulus material Providing learning guidance Eliciting the performance Providing feedback Assessing performance Enhancing retention and transfer
Motor Skill Introducing stimulus change Provide a demonstration of the performance to be expected. Stimulate recall of part skills already attained Provide external stimulus for performance including tools and instruments. Provide practice with feedback on performance achievement Ask for execution of the performance Provide feedback on degree of accuracy and timing of the performance Learner executes performance of total skill Learner continues to practice.
Event 3: Stimulating Recall of Prior Learning— Stimulate Recall of Part Skills Stimulating recall of prior knowledge is well recognized as a powerful teaching tool to enhance the retention and effectiveness of learning and is known as “schema activation.” The process of building on prior knowledge is a cognitive strategy employed in teaching and known as the “advance organizer” concept.12 In the context of motor skills teaching, the learner is stimulated to recall part skills that they have previously encountered.
Event 4: Presenting the Stimulus Material—Provide External Stimulus for Performance Including Tools or Instruments This event lies at the heart of the design process and is concerned with conveying the new skills to be acquired to the learner. An important part of this process is the presentation of the necessary instruments required to perform the task, and the focus on instruments helps learners to contextualize the task.
Event 5: Providing Learning Guidance—Provide Practice With Feedback on Performance Achievement The learners are shown the correct performance of the task. The teacher shows the steps required to complete the task and the learners follow along as the different steps are presented. Students will have the opportunity to ask questions on what they are doing to reinforce the process.
Event 6: Eliciting the Performance—Ask for Execution of the Performance The learner is given the opportunity to practice the total motor skills that they have learned for the first time. The previous event demonstrates the correct execution of the task, and this is now an opportunity to practice. The emphasis is on learning rather than on testing. This step offers the learner the opportunity to explore their understanding of the task and the opportunity to repeat it assists retention.
Event 7: Providing Feedback—Provide Feedback on Degree of Accuracy and Timing of the Performance Feedback is provided to confirm correctness and accuracy of the task. Practice without feedback is of less value to learners as they have no opportunity for redress. Feedback should not be limited to determining whether the performance is correct or incorrect, but rather should be a tailored individual feedback to address specific weaknesses. Event 8: Assessing Performance—Learner Executes Performance of Total Skill On completing practice of the task and having been given appropriate feedback, the learner is asked to reproduce the skill in its entirety without prompting. Performance assessment is concerned with exhibiting complete demonstration of the required outcome. The learner is expected to demonstrate, without assistance, the required task defined in the course objectives. The task is then formally assessed. Event 9: Enhancing Retention and Transfer—Learner Continues to Practice Learning is most valuable when the skills can be placed in a number of different environments and contexts. An essential element of skills acquisition is the transfer of those skills from the learning context to different environments. Assessment of Skills Acquisition All 4 course objectives were assessed prior and after the course. Assessment of corneal suturing was completed but described in detail in a separate publication.6 The results demonstrated that competence in corneal suturing, as measured by a validated motion-tracking system, significantly improved after the 1-day course. Oculoplastic suturing was assessed using a specialized “Royal College of Ophthalmologists surgical skills board.” Candidates were asked to close a wound with 1 interrupted suture. A detailed previously validated 5-score Likert rating scale, the Objective Structured Assessment of Technical Skill, was employed. For corneal gluing and intravitreal injection skills, objective marking schemes were devised in accordance with competency requirements set out by the Royal College of Ophthalmologists. Pig eyes were presented
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to each candidate in a Marty head. They were asked to firstly administer an intravitreal injection to the eye as they would in a clinic. This was described as a clean case, with no requirement for a vitreous biopsy. Candidates were allocated 1 or 0 marks for each completed component with a maximum of 10 points. Subsequently, a stab incision was created to the cornea of the pig eye. Candidates were then asked to apply corneal glue to this wound. Candidates were again marked between 0 and 10. All residents were offered the same equipment in a standardized environment. Of the authors, 2 (A.C. and H.S.) examined the candidates 4 weeks before the microsurgical skills course in 2 sessions. Postcourse assessments were all made in 1 session. Data were analyzed using the Statistical Package for Social Sciences, version 15.0 (SPSS, Chicago, IL). Intergroup comparisons before and after the course were analyzed using the paired t test.
RESULTS A 1-day surgical skills course was designed according to the instructional design principles outlined. The 4 objectives of the course (corneal suturing, corneal gluing, intravitreal injections, and eyelid suturing) were addressed in a parallel fashion to allow for multiple objectives to be processed simultaneously. A table representing the matching scheme for the instructional events enshrined in the course components is given in Table 3. Course Components 9:00-9:30 Basic Techniques (Lecture) Attention is gained using a variety of video techniques, and throughout this lecture, a video camera with zoom lens is attached through a projector so as the learner can comfortably see the instruments and demonstrations of knot tying. In addition, they were given lengths of ropes to practice
with, providing the learners with multimodal and multimedia tactile and visual interactions. A list of objectives was also given, and the students were shown video examples of the types of task that they are to carry out. This lecture also describes the instruments expected to be used in detail. The course participants are at an intermediate level in their residencies and will all have attended a compulsory basic microsurgical skills course at the start of their training and would be familiar with reef-knot–tying principles. Residents are demonstrated some of these previously encountered knot-tying techniques and further additional ones such as slip knots and mattress sutures. 9:30-10:00 Corneal Section (Lecture) Schematic illustrations, computer animations, and video footage concentrating on extracapsular cataract extraction (ECCE) and phacoemulsification wound construction and suturing techniques are shown. Both continuous and interrupted suturing techniques for closing ECCE wounds are demonstrated. 10:00-10:30 Vitreous Tap and Intravitreal Injections (Lecture) This lecture focuses on the practical aspects of vitreous and anterior chamber taps as well as intravitreal injections. Residents are again shown a video demonstrating the execution of the entire task. 10:30-11:00 Coffee 11:00-13:00 Practical Session I: Suture Practice This is the first practical session. The residents are split into 2 groups of 10, as the wet laboratory has a maximum capacity of 10 operating microscopes. Each group switches over after 1 hour. Wet Laboratory: 1 Hour. Residents are provided with fresh porcine eyes mounted in a plastic Marty head. A
TABLE 3. Course Components Match Instructional Steps for all 4 Objectives Time -
Instructional Events for a Given Objective Course Component Basic techniques Corneal section Vitreous taps Practical I Repairing open globes Repairing lid lacerations Practical II After the course Microsurgical suturing assessment Wet laboratory use DVD of knot-tying examples
Microsurgical Suturing
Corneal Gluing
Lid Suturing
Intravitreal Injection
1, 2, 3, and 4 4
1, 2, 3, and 4 4
1 and 2
1 and 2 3 and 4 5, 6, 7, and 8
5, 6, and 7 5, 6, 7, and 8 6 and 7
8
3 and 4 5, 6, 7, and 8
8 and 9
9
9
9
Gagné’s 9 instructional events: 1, gain student’s attention; 2, informing learners of objectives; 3, stimulate recall of prior learning; 4, presenting the skill; 5, providing learning guidance; 6, eliciting performance; 7, provide feedback; 8, assessing performance; and 9, enhancing retention. 588
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teacher first demonstrates a simple reef knot and slip knot using 10-0 nylon. Residents are then expected to make linear corneal incisions or ECCE incisions and begin practicing their knot tying. In total, 3 teachers with extensive microsurgical experience observe residents and provide active feedback throughout the process. In addition, 3 senior residents were available to enhance the availability of feedback. A formal assessment is made at this point of an intravitreal injection and corneal gluing which is marked by an assessor. Feedback on the strengths and weaknesses of each technique is provided. Skills Laboratory: 1 Hour. Residents are provided with Royal College of Surgeons skills set and a variety of sutures and instruments. An instructor will again demonstrate basic knottying techniques using oculoplastics instruments and larger 5-0 and 6-0 sutures. A video camera with macro lens is attached to a projector to allow all of the residents to observe the teaching in detail. Residents are again expected to practice these knottying techniques, and 3 experienced teachers will again provide roaming feedback while they are practicing. 13:00-14:00 Lunch 14:00-14:30 Repairing Open Globes The principles of repairing traumatic corneal and scleral perforations and lacerations are discussed. This lecture covers aspects of draping, eyelid control, peritomy, and suturing strategies for commonly encountered wound locations and morphologies. 14:30-15:00 Repairing Lid Lacerations The principles for repairing full-thickness eyelid lacerations are discussed. Surgical anatomy of the eyelid margin and sequential suturing techniques are provided in detail.
eyelid margin reconstitution and were then expected to practice the process with roaming feedback. At the end of this session, residents were expected to place 1 gray-line suture to secure the eyelid, and this was marked by an expert assessor. Feedback on the strengths and weaknesses of the technique as well as instrument handling was provided. After the Course Residents were expected to make an appointment with the course organizer (P.S.) and view the suturing video, at which time a formal assessment was made with detailed feedback. To encourage residents to continue to practice, a media resource of all video and computer animation footage demonstrating model suturing techniques, vitreous tap, intravitreal injections, and instrument handling were placed on a DVD for the learner to study in their own time. The hospital wet laboratory facility was made available to all course participants as a resource for ongoing practice. Objective Assessment of Skills Acquisition Of 20 residents, 16 were recruited for objective assessments of skills acquisition. In addition to significant improvement in microsurgical suturing skills in the form of corneal suturing, which has already been demonstrated and discussed in a separate publication, there has also been a significant improvement in corneal gluing (p o 0.0001), intravitreal injection (p o 0.0001), and skin suturing (p o 0.0001). The marked improvement in the data spread of these assessment scores is demonstrated as box and whisker plots in Figures 1-3.
CONCLUSIONS Instructional design theories are based on psychological learning models that describe how learners perceive stimuli,
15:00-17:00 Practical Session II: Upper Eyelid Wedge Resection or Intravitreal Injections and Stellate Lacerations This is the second practical session, and residents are again split into 2 groups of 10, and the 2 groups switch over after 1 hour. Wet Laboratory: 1 Hour. Residents are expected to repair more complex corneal lacerations. Residents then continue to practice, with 3 teachers and 3 senior residents providing feedback to the 10 residents in the wet laboratory. At the end of this session, the residents are expected to perform an assessment exercise consisting of a single corneal reef-knot suture using 10-0 nylon without any prompting. This exercise is recorded as a video file, and a copy of each student’s exercise is given to them to take home for assessment at a later date. Skills Laboratory: 1 Hour. Residents were shown how to complete a full-thickness pentagon wedge excision including
FIGURE 1. Data spread of precourse and postcourse assessment scores for intravitreal injections.
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FIGURE 2. Data spread of precourse and postcourse assessment scores for corneal gluing.
store memory, retrieve information, and perform other processing tasks. Although these internal processes are not fully understood, the role of instructional design is to formulate external events in the teaching process that mirror and support these essential internal processes; in other words, instructional design provides a framework for teachers to organize their teaching to mirror the internal learning process of their students.9 Gagné’s 9 events of instruction model draws on both behaviorist and cognitive learning theories and offers a framework for instructional design that has been used for decades. Surgeons are usually good at teaching surgical techniques, but some of the cognitive aspects of the learning process are often not addressed. These processes are emphasized in Gagné’s model. The essential components of Gagné’s model are as follows: schema activation, presenting the skill, providing practice with feedback, providing learner guidance, and facilitating long-term practice. Although this study has described a 1-day skills course, the format is not intended to be proscriptive, and we emphasize the objective-based adaptability of instructional design theory. The outlined course design has also demonstrated that with appropriate planning, instructional design can be adapted so that it can be used to address multiple objectives in parallel throughout the course. This study has demonstrated this adaptability and shown that an instructional design–based course provides a significant improvement in skills acquisition for all of the motor skills objectives set out before the course. The need for training organizations to develop their own skills courses has also been emphasized by training regulatory bodies throughout the world. The Royal College of Ophthalmologists in the United Kingdom has made attendance at such a course a compulsory requirement before the commencement of intraocular surgery.13 In the United States, the Accreditation Council for Graduate Medical Education has made the presence of a surgical skills 590
laboratory a compulsory requirement for retaining resident program accreditation and some residency programs have integrated wet laboratory experience in the residency curriculum.14,15 A recent review highlighting potential barriers to the local implementation of national Accreditation Council for Graduate Medical Education guidelines includes lack of resources and “competency fatigue”—institutional apathy toward implementing competency-based learning and assessment. Suggested solutions include the need to end passive learning sessions, which should become more interactive and “linked to external benchmarks,” and a more efficient and cost-effective educational effort.16 Instructional design–based courses could help to overcome these barriers by providing a validated framework for learning and a practical approach to teaching design to achieve defined objectives. Using existing educational models such as this can enhance the efficiency and make it more effective in terms of cost and time. Despite the mandatory requirement for microsurgical skills courses, there is a lack of published data on how skills courses should be structured to promote skills acquisition.13,14 Some detailed work describing important practical aspects of wet laboratory organization is available but only limited material focusing on curriculum content and structure.17 A valuable and detailed contribution to guiding skills course implementation has been the Iowa wet laboratory curriculum, describing a 10-week wet laboratory curriculum, which was partly based on education theory including reflective learning and task repetition.15 However, this curriculum model takes place over several weeks and has a complex structure making it expensive, relatively inflexible, and difficult to apply to different sets of objectives. The next natural step is also to tap into the cognitive processes of the expert tutor. Gagné’s instructional model is
FIGURE 3. Data spread of precourse and postcourse OSATS scores for skin suturing. OSATS, Objective Structured Assessment of Technical Skill.
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an educational tool used to meet the internal cognitive demands of the learner, but what about the cognitive processes of the educator. The surgical educator does not only have to teach the steps and sequence of the procedural skill but also the underlying cognitive decisions that accompany this. Clark et al.18 have published extensively on this and more specifically on the concept of cognitive task analysis (CAT). They have shown that an expert often fails to articulate why certain steps in a procedure are necessary because the procedure has become automated and no longer accessible to the conscious mind. CAT is a relatively new educational tool by which the automated elements of performing a procedure can be captured and therefore both the overt observable behavior and the covert function behind it are taught effectively from experts to novices. CAT has been used successfully by the army, corporations, and more recently in training residents in procedural skills.19 The instructional design methodology outlined has been demonstrated to significantly improve surgical skills in the context of our course.6 Gagné’s model has been selected as it has wide support and currency among the educational establishment. Gagné’s approach to instructional design may be a valuable tool in resident training as it is portable, allowing its application to a wide variety of outcomes and settings, and its terminology is simple and understandable to those working in clinical education.
6. Ezra DG, Aggarwal R, Michaelides M, et al. Skills
acquisition and assessment after a microsurgical skills course for ophthalmology residents. Ophthalmology. 2009;116(2):257-262. 7. Bloom BS. Taxonomy of Educational Objectives: the
Classification of Educational Goals, Vol 2. Longmans; 1964.
London:
8. Kovacs G. Procedural skills in medicine: linking theory
to practice. J Emerg Med. 1997;15(3):387-391. 9. Okey J. Procedures of lesson design. In: Briggs LJ,
Gustafson KL, Tillman ME, eds. Instructional Design: Principles and Applications, 2nd ed. Englewood Cliffs, NJ: Educational Technology Publications; 1991. 10. Gagné RM, Briggs LJ, Wager WW. Principles of
Instructional Design, 4th ed. Fort Worth: Harcourt Brace Jovanovich College Publishers; 1992. 11. Royal College of Ophthalmologists. Available at: 〈http://
curriculum.rcophth.ac.uk/〉; 15.08.2014.
2003
Accessed
12. Ausubel D. The use of advance organizers in the
learning and retention of meaningful verbal material. J Educ Psychol. 1960;51(1):267-272. 13. Royal College of Ophthalmologists. Microsurgical skills
course. Available at: 〈http://www.rcophth.ac.uk/about/ skillscentre/bms〉; Accessed 15.08.2014.
REFERENCES 1. Wong JA, Matsumoto ED. Primer: cognitive motor
learning for teaching surgical skill—how are surgical skills taught and assessed? Nat Clin Pract Urol. 2008;5(1):47-54. 2. General Medical Council. Tomorrow’s doctors: recom-
mendations on undergraduate medical education issued by the education committee of the general medical council in pursuance of section 5 of the medical Act 1983. Available at: 〈http://www.gmc-uk. org/Tomorrows_Doctors_1993.pdf_25397206. pdf〉; 1993 Accessed 15.08.2014. 3. Accreditation Council for Graduate Medical Educ-
14. Accreditation Council for Graduate Medical Educ-
ation. RRC news for ophthalmology. (Winter 2005). Available at: 〈http://www.acgme.org/acWeb site/RRC_240_News/240n_winter05.pdf〉; Accessed 15.08.2014. 15. Lee AG, Greenlee E, Oetting TA, et al. The Iowa
ophthalmology wet laboratory curriculum for teaching and assessing cataract surgical competency. Ophthalmology. 2007;114(7):e21-e26. 16. Lee AG, Oetting T, Beaver HA, Carter K. The
ACGME Outcome Project in ophthalmology: practical recommendations for overcoming the barriers to local implementation of the national mandate. Surv Ophthalmol. 2009;54(4):507-517.
ation (ACGME) Outcome Project. Common program requirements: general competencies. Available at: 〈http://www.acgme.org/outcome/comp/GeneralCom petenciesStandards21307.pdf〉; 2009 Accessed 15.08.2014.
17. Henderson BA, Grimes KJ, Fintelmann RE, Oetting TA.
4. Kneebone RL, Nestel D, Vincent C, Darzi A. Com-
18. Clark RE, Estes F. Cognitive task analysis. Int J Educ
plexity, risk and simulation in learning procedural skills. Med Educ. 2007;41(8):808-814. 5. Henderson BA, Ali R. Teaching and assessing com-
petence in cataract surgery. Curr Opin Ophthalmol. 2007;18(1):27-31.
Stepwise approach to establishing an ophthalmology wet laboratory. J Cataract Refract Surg. 2009;35(6):1121-1128. Res. 1998;25(5):403-417. 19. Velmahos G, Toutouzas K, Sillin L, et al. Cognitive
task analysis for teaching technical skills in an inanimate surgical surgical skills laboratory. Am J Surg. 2004;187(5):114-119.
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Bridging the Gap: Theory-Based Design of a Microsurgical Skills Course for Ophthalmology Residents Antigoni Koukkoulli, MD,* Aman Chandra, BSc,* Hithen Sheth, FRCOphth,* Narciss Okhravi, PhD,* Seema Verma, MD,* Paul Sullivan, MD,* and Daniel G. Ezra, MD*,†,‡,§ Department of Education, Moorfields Eye Hospital, London, United Kingdom; †National Institute for Health Research, Biomedical Research Centre for Ophthalmology, Moorfields Eye Hospital and UCL Institute of Ophthalmology, Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom; ‡Adnexal Department, Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom; and §Department of Cell Biology, UCL Institute of Ophthalmology, London, United Kingdom *
OBJECTIVE: Although theory-based schemes for course
design are widely used in educational settings, making use of cognitive theory in the design of surgical skills courses in ophthalmology is rare. The primary aim of this study is to describe the application of instructional design, an established theory-based approach in course design, to the development of a surgical skills course for ophthalmology residents. The secondary aim of this study is to assess the educational effect of this theory-based course. DESIGN: A 1-day skills course was designed according to Gagné's events of instruction model, which was employed as a template for the instructional sequence of learning steps. Skills acquisition following the implementation of the model was measured with precourse and postcourse assessments. SETTING: Moorfields Eye Hospital organized the 1-day
annual intermediate surgical skills course, which was hosted at the Royal College of Ophthalmologists’ microsurgical skills laboratory. PARTICIPANTS: A total of 20 ophthalmology residents of
Moorfields Eye Hospital participated in the study. RESULTS: A 1-day surgical skills course was formulated
according to the instructional design principles outlined. The 4 objectives of the course (corneal suturing, corneal
Funding: This study was funded by the Department of Health through the award by the National Institute for Health Research to Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology for a Specialist Biomedical Research Centre for Ophthalmology. The views expressed in this publication are those of the authors and not necessarily those of the Department of Health. Correspondence: Inquiries to Antigoni Koukkoulli, MD, FRCOphth, Moorfields Eye Hospital NHS Trust, City Road, London EC1V 2PD, UK; fax: (208) 202-5383; e-mail: [email protected]
gluing, intravitreal injections, and eyelid suturing) were addressed in a parallel fashion as to allow for multiple objectives to be processed simultaneously, in the context of the instructional design sequence. Assessments demonstrated significant improvement in skills acquisition for the 4 course objectives. CONCLUSIONS: Instructional design is a valuable tool for planning effective surgical training courses as it is portable, allowing its application to a wide variety of outcomes and settings, and its terminology is simple and understandable to those working in clinical education. ( J Surg 72:585-591. C J 2015 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: microsurgical skillourse, instructional course
design theory COMPETENCIES: Patient Care, Medical Knowledge, Professionalism, Practice-Based Learning and Improvement
INTRODUCTION One of the most fundamental changes in surgical training over the past decade has been the move away from an apprenticeship model of teaching toward a more systematic approach. Integral to this shift has been the implementation of teaching strategies to provide for the development of skills and experience in a graduated process toward reality. This involves trainees acquiring skills in a simulated patient environment before or in parallel with exposure to patients.1 This transition has been established for some time in undergraduate medical training and is now being embraced by postgraduate surgical training.2,3 Simulated surgical teaching techniques including surgical skills courses,
Journal of Surgical Education & 2015 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2014.12.015
585
multimedia demonstrations, and virtual reality training techniques have been widely used in other surgical specialities.4 In ophthalmic surgical training, there has been a recent emergence of a variety of surgical training modalities to allow residents to improve their skills.5 Microsurgical skills courses in ophthalmology have played a central role in skills development, and the effectiveness of these courses is now widely accepted.6 Teaching complex motor skills in a formal environment can be challenging. Modern educational theory suggests that there is a psychomotor domain of learning consisting of a hierarchy of internal cognitive processes, which include an awareness of the task, sensory stimulation, and guided responses.7 To enhance the effectiveness of teaching, it is argued that these processes must be addressed by an instructional approach.8 One such model for linking internal cognitive processes to a teaching template is “instructional design theory,” which refers to the use of frameworks for developing teaching methods that enhance the effectiveness and efficiency of learning.9 Several different instructional design models exist, and perhaps one of the most widely used is that developed by Gagné who described 9 instructional events that detail the conditions necessary for learning to occur. This is known as the “events of instruction” model.9,10 Moorfields Eye Hospital runs a 1-day surgical skills course for ophthalmology residents. The primary aim of this study is to describe the application of Gagné’s instructional design model to the process of construction and development of a surgical skills course for ophthalmology residents based on our experience at Moorfields. The secondary aim of this study is to assess the effectiveness of this theory-based course using precourse and postcourse assessments.
MATERIALS AND METHODS Setting Moorfields Eye Hospital organizes a 1-day annual intermediate surgical skills course, consisting of microsurgical and oculoplastics components, for 20 residents, which is
hosted at the Royal College of Ophthalmologists’ microsurgical skills laboratory. No ethical approval was required for the study. Objectives The first step in the design process is to be clear about the objectives of the teaching exercise and then organize instructional events appropriate to that outcome. The course objectives were determined by content experts (P. S., N.O., and S.V.) in the context of the curriculum for higher surgical training by the Royal College of Ophthalmologists (Table 1).11 Instructional Design Model: Gagné’s Events of Instruction Gagné’s “events of instruction” model was employed as a template for the instructional sequence of learning steps. Gagné proposed 9 events of instruction to be sequentially applied to be compatible with cognitive learning processes.9 These events as applied to motor skill acquisition have been summarized in Table 2. Event 1: Gaining Attention—Introducing Stimulus Change The purpose of this initial step is to focus learners on the tasks ahead. Techniques for gaining attention include the presentation of dramatic or difficult cases. Stimulus change also relates to the choice of media used for the duration of the course. Event 2: Informing Learner of Objective(s)—Provide a Demonstration of the Performance to be Expected The objectives must be clarified from the outset to inform the learner what is expected to be achieved by the end of the course. This instructional step will help to prime the learner to organize the teaching material in the context of the expected objective.
TABLE 1. The Course Objectives as Determined by the Course Experts Task Corneal suturing
Oculoplastic suturing in the form of reconstitution of the eyelid margin Vitreous tap and intravitreal injection Corneal gluing
586
Description of Task All ophthalmologists are expected to be competent in corneal suturing, as it is a skill required for globe repair following trauma, and in dealing with leaking wounds in cataract surgery. It is performed under the microscope using 10-0 nylon suture in interrupted or continuous fashion. Trainees are expected to be able to repair eyelid lacerations involving the lid margin. It is repaired in sequential anatomical layers using a 6-0 vicryl suture, either with the aid of loops or unaided. Endophthalmitis is an ocular emergency that requires urgent treatment in the form of intravitreal injection of antibiotics, preceded by vitreous sampling. Corneal gluing is indicated for small corneal perforations, corneal melts, or leaks. Cyanoacrylate glue is used, and the procedure is performed under the slit lamp in clinic. Journal of Surgical Education Volume 72/Number 4 July/August 2015
TABLE 2. Gagné’s 9 Events of Instruction as Applied to Motor Skill Learning9 Instructional Event 1. 2. 3. 4. 5. 6. 7. 8. 9.
Gaining attention Informing learner of objective Stimulating recall of prior learning Presenting the stimulus material Providing learning guidance Eliciting the performance Providing feedback Assessing performance Enhancing retention and transfer
Motor Skill Introducing stimulus change Provide a demonstration of the performance to be expected. Stimulate recall of part skills already attained Provide external stimulus for performance including tools and instruments. Provide practice with feedback on performance achievement Ask for execution of the performance Provide feedback on degree of accuracy and timing of the performance Learner executes performance of total skill Learner continues to practice.
Event 3: Stimulating Recall of Prior Learning— Stimulate Recall of Part Skills Stimulating recall of prior knowledge is well recognized as a powerful teaching tool to enhance the retention and effectiveness of learning and is known as “schema activation.” The process of building on prior knowledge is a cognitive strategy employed in teaching and known as the “advance organizer” concept.12 In the context of motor skills teaching, the learner is stimulated to recall part skills that they have previously encountered.
Event 4: Presenting the Stimulus Material—Provide External Stimulus for Performance Including Tools or Instruments This event lies at the heart of the design process and is concerned with conveying the new skills to be acquired to the learner. An important part of this process is the presentation of the necessary instruments required to perform the task, and the focus on instruments helps learners to contextualize the task.
Event 5: Providing Learning Guidance—Provide Practice With Feedback on Performance Achievement The learners are shown the correct performance of the task. The teacher shows the steps required to complete the task and the learners follow along as the different steps are presented. Students will have the opportunity to ask questions on what they are doing to reinforce the process.
Event 6: Eliciting the Performance—Ask for Execution of the Performance The learner is given the opportunity to practice the total motor skills that they have learned for the first time. The previous event demonstrates the correct execution of the task, and this is now an opportunity to practice. The emphasis is on learning rather than on testing. This step offers the learner the opportunity to explore their understanding of the task and the opportunity to repeat it assists retention.
Event 7: Providing Feedback—Provide Feedback on Degree of Accuracy and Timing of the Performance Feedback is provided to confirm correctness and accuracy of the task. Practice without feedback is of less value to learners as they have no opportunity for redress. Feedback should not be limited to determining whether the performance is correct or incorrect, but rather should be a tailored individual feedback to address specific weaknesses. Event 8: Assessing Performance—Learner Executes Performance of Total Skill On completing practice of the task and having been given appropriate feedback, the learner is asked to reproduce the skill in its entirety without prompting. Performance assessment is concerned with exhibiting complete demonstration of the required outcome. The learner is expected to demonstrate, without assistance, the required task defined in the course objectives. The task is then formally assessed. Event 9: Enhancing Retention and Transfer—Learner Continues to Practice Learning is most valuable when the skills can be placed in a number of different environments and contexts. An essential element of skills acquisition is the transfer of those skills from the learning context to different environments. Assessment of Skills Acquisition All 4 course objectives were assessed prior and after the course. Assessment of corneal suturing was completed but described in detail in a separate publication.6 The results demonstrated that competence in corneal suturing, as measured by a validated motion-tracking system, significantly improved after the 1-day course. Oculoplastic suturing was assessed using a specialized “Royal College of Ophthalmologists surgical skills board.” Candidates were asked to close a wound with 1 interrupted suture. A detailed previously validated 5-score Likert rating scale, the Objective Structured Assessment of Technical Skill, was employed. For corneal gluing and intravitreal injection skills, objective marking schemes were devised in accordance with competency requirements set out by the Royal College of Ophthalmologists. Pig eyes were presented
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to each candidate in a Marty head. They were asked to firstly administer an intravitreal injection to the eye as they would in a clinic. This was described as a clean case, with no requirement for a vitreous biopsy. Candidates were allocated 1 or 0 marks for each completed component with a maximum of 10 points. Subsequently, a stab incision was created to the cornea of the pig eye. Candidates were then asked to apply corneal glue to this wound. Candidates were again marked between 0 and 10. All residents were offered the same equipment in a standardized environment. Of the authors, 2 (A.C. and H.S.) examined the candidates 4 weeks before the microsurgical skills course in 2 sessions. Postcourse assessments were all made in 1 session. Data were analyzed using the Statistical Package for Social Sciences, version 15.0 (SPSS, Chicago, IL). Intergroup comparisons before and after the course were analyzed using the paired t test.
RESULTS A 1-day surgical skills course was designed according to the instructional design principles outlined. The 4 objectives of the course (corneal suturing, corneal gluing, intravitreal injections, and eyelid suturing) were addressed in a parallel fashion to allow for multiple objectives to be processed simultaneously. A table representing the matching scheme for the instructional events enshrined in the course components is given in Table 3. Course Components 9:00-9:30 Basic Techniques (Lecture) Attention is gained using a variety of video techniques, and throughout this lecture, a video camera with zoom lens is attached through a projector so as the learner can comfortably see the instruments and demonstrations of knot tying. In addition, they were given lengths of ropes to practice
with, providing the learners with multimodal and multimedia tactile and visual interactions. A list of objectives was also given, and the students were shown video examples of the types of task that they are to carry out. This lecture also describes the instruments expected to be used in detail. The course participants are at an intermediate level in their residencies and will all have attended a compulsory basic microsurgical skills course at the start of their training and would be familiar with reef-knot–tying principles. Residents are demonstrated some of these previously encountered knot-tying techniques and further additional ones such as slip knots and mattress sutures. 9:30-10:00 Corneal Section (Lecture) Schematic illustrations, computer animations, and video footage concentrating on extracapsular cataract extraction (ECCE) and phacoemulsification wound construction and suturing techniques are shown. Both continuous and interrupted suturing techniques for closing ECCE wounds are demonstrated. 10:00-10:30 Vitreous Tap and Intravitreal Injections (Lecture) This lecture focuses on the practical aspects of vitreous and anterior chamber taps as well as intravitreal injections. Residents are again shown a video demonstrating the execution of the entire task. 10:30-11:00 Coffee 11:00-13:00 Practical Session I: Suture Practice This is the first practical session. The residents are split into 2 groups of 10, as the wet laboratory has a maximum capacity of 10 operating microscopes. Each group switches over after 1 hour. Wet Laboratory: 1 Hour. Residents are provided with fresh porcine eyes mounted in a plastic Marty head. A
TABLE 3. Course Components Match Instructional Steps for all 4 Objectives Time -
Instructional Events for a Given Objective Course Component Basic techniques Corneal section Vitreous taps Practical I Repairing open globes Repairing lid lacerations Practical II After the course Microsurgical suturing assessment Wet laboratory use DVD of knot-tying examples
Microsurgical Suturing
Corneal Gluing
Lid Suturing
Intravitreal Injection
1, 2, 3, and 4 4
1, 2, 3, and 4 4
1 and 2
1 and 2 3 and 4 5, 6, 7, and 8
5, 6, and 7 5, 6, 7, and 8 6 and 7
8
3 and 4 5, 6, 7, and 8
8 and 9
9
9
9
Gagné’s 9 instructional events: 1, gain student’s attention; 2, informing learners of objectives; 3, stimulate recall of prior learning; 4, presenting the skill; 5, providing learning guidance; 6, eliciting performance; 7, provide feedback; 8, assessing performance; and 9, enhancing retention. 588
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teacher first demonstrates a simple reef knot and slip knot using 10-0 nylon. Residents are then expected to make linear corneal incisions or ECCE incisions and begin practicing their knot tying. In total, 3 teachers with extensive microsurgical experience observe residents and provide active feedback throughout the process. In addition, 3 senior residents were available to enhance the availability of feedback. A formal assessment is made at this point of an intravitreal injection and corneal gluing which is marked by an assessor. Feedback on the strengths and weaknesses of each technique is provided. Skills Laboratory: 1 Hour. Residents are provided with Royal College of Surgeons skills set and a variety of sutures and instruments. An instructor will again demonstrate basic knottying techniques using oculoplastics instruments and larger 5-0 and 6-0 sutures. A video camera with macro lens is attached to a projector to allow all of the residents to observe the teaching in detail. Residents are again expected to practice these knottying techniques, and 3 experienced teachers will again provide roaming feedback while they are practicing. 13:00-14:00 Lunch 14:00-14:30 Repairing Open Globes The principles of repairing traumatic corneal and scleral perforations and lacerations are discussed. This lecture covers aspects of draping, eyelid control, peritomy, and suturing strategies for commonly encountered wound locations and morphologies. 14:30-15:00 Repairing Lid Lacerations The principles for repairing full-thickness eyelid lacerations are discussed. Surgical anatomy of the eyelid margin and sequential suturing techniques are provided in detail.
eyelid margin reconstitution and were then expected to practice the process with roaming feedback. At the end of this session, residents were expected to place 1 gray-line suture to secure the eyelid, and this was marked by an expert assessor. Feedback on the strengths and weaknesses of the technique as well as instrument handling was provided. After the Course Residents were expected to make an appointment with the course organizer (P.S.) and view the suturing video, at which time a formal assessment was made with detailed feedback. To encourage residents to continue to practice, a media resource of all video and computer animation footage demonstrating model suturing techniques, vitreous tap, intravitreal injections, and instrument handling were placed on a DVD for the learner to study in their own time. The hospital wet laboratory facility was made available to all course participants as a resource for ongoing practice. Objective Assessment of Skills Acquisition Of 20 residents, 16 were recruited for objective assessments of skills acquisition. In addition to significant improvement in microsurgical suturing skills in the form of corneal suturing, which has already been demonstrated and discussed in a separate publication, there has also been a significant improvement in corneal gluing (p o 0.0001), intravitreal injection (p o 0.0001), and skin suturing (p o 0.0001). The marked improvement in the data spread of these assessment scores is demonstrated as box and whisker plots in Figures 1-3.
CONCLUSIONS Instructional design theories are based on psychological learning models that describe how learners perceive stimuli,
15:00-17:00 Practical Session II: Upper Eyelid Wedge Resection or Intravitreal Injections and Stellate Lacerations This is the second practical session, and residents are again split into 2 groups of 10, and the 2 groups switch over after 1 hour. Wet Laboratory: 1 Hour. Residents are expected to repair more complex corneal lacerations. Residents then continue to practice, with 3 teachers and 3 senior residents providing feedback to the 10 residents in the wet laboratory. At the end of this session, the residents are expected to perform an assessment exercise consisting of a single corneal reef-knot suture using 10-0 nylon without any prompting. This exercise is recorded as a video file, and a copy of each student’s exercise is given to them to take home for assessment at a later date. Skills Laboratory: 1 Hour. Residents were shown how to complete a full-thickness pentagon wedge excision including
FIGURE 1. Data spread of precourse and postcourse assessment scores for intravitreal injections.
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FIGURE 2. Data spread of precourse and postcourse assessment scores for corneal gluing.
store memory, retrieve information, and perform other processing tasks. Although these internal processes are not fully understood, the role of instructional design is to formulate external events in the teaching process that mirror and support these essential internal processes; in other words, instructional design provides a framework for teachers to organize their teaching to mirror the internal learning process of their students.9 Gagné’s 9 events of instruction model draws on both behaviorist and cognitive learning theories and offers a framework for instructional design that has been used for decades. Surgeons are usually good at teaching surgical techniques, but some of the cognitive aspects of the learning process are often not addressed. These processes are emphasized in Gagné’s model. The essential components of Gagné’s model are as follows: schema activation, presenting the skill, providing practice with feedback, providing learner guidance, and facilitating long-term practice. Although this study has described a 1-day skills course, the format is not intended to be proscriptive, and we emphasize the objective-based adaptability of instructional design theory. The outlined course design has also demonstrated that with appropriate planning, instructional design can be adapted so that it can be used to address multiple objectives in parallel throughout the course. This study has demonstrated this adaptability and shown that an instructional design–based course provides a significant improvement in skills acquisition for all of the motor skills objectives set out before the course. The need for training organizations to develop their own skills courses has also been emphasized by training regulatory bodies throughout the world. The Royal College of Ophthalmologists in the United Kingdom has made attendance at such a course a compulsory requirement before the commencement of intraocular surgery.13 In the United States, the Accreditation Council for Graduate Medical Education has made the presence of a surgical skills 590
laboratory a compulsory requirement for retaining resident program accreditation and some residency programs have integrated wet laboratory experience in the residency curriculum.14,15 A recent review highlighting potential barriers to the local implementation of national Accreditation Council for Graduate Medical Education guidelines includes lack of resources and “competency fatigue”—institutional apathy toward implementing competency-based learning and assessment. Suggested solutions include the need to end passive learning sessions, which should become more interactive and “linked to external benchmarks,” and a more efficient and cost-effective educational effort.16 Instructional design–based courses could help to overcome these barriers by providing a validated framework for learning and a practical approach to teaching design to achieve defined objectives. Using existing educational models such as this can enhance the efficiency and make it more effective in terms of cost and time. Despite the mandatory requirement for microsurgical skills courses, there is a lack of published data on how skills courses should be structured to promote skills acquisition.13,14 Some detailed work describing important practical aspects of wet laboratory organization is available but only limited material focusing on curriculum content and structure.17 A valuable and detailed contribution to guiding skills course implementation has been the Iowa wet laboratory curriculum, describing a 10-week wet laboratory curriculum, which was partly based on education theory including reflective learning and task repetition.15 However, this curriculum model takes place over several weeks and has a complex structure making it expensive, relatively inflexible, and difficult to apply to different sets of objectives. The next natural step is also to tap into the cognitive processes of the expert tutor. Gagné’s instructional model is
FIGURE 3. Data spread of precourse and postcourse OSATS scores for skin suturing. OSATS, Objective Structured Assessment of Technical Skill.
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an educational tool used to meet the internal cognitive demands of the learner, but what about the cognitive processes of the educator. The surgical educator does not only have to teach the steps and sequence of the procedural skill but also the underlying cognitive decisions that accompany this. Clark et al.18 have published extensively on this and more specifically on the concept of cognitive task analysis (CAT). They have shown that an expert often fails to articulate why certain steps in a procedure are necessary because the procedure has become automated and no longer accessible to the conscious mind. CAT is a relatively new educational tool by which the automated elements of performing a procedure can be captured and therefore both the overt observable behavior and the covert function behind it are taught effectively from experts to novices. CAT has been used successfully by the army, corporations, and more recently in training residents in procedural skills.19 The instructional design methodology outlined has been demonstrated to significantly improve surgical skills in the context of our course.6 Gagné’s model has been selected as it has wide support and currency among the educational establishment. Gagné’s approach to instructional design may be a valuable tool in resident training as it is portable, allowing its application to a wide variety of outcomes and settings, and its terminology is simple and understandable to those working in clinical education.
6. Ezra DG, Aggarwal R, Michaelides M, et al. Skills
acquisition and assessment after a microsurgical skills course for ophthalmology residents. Ophthalmology. 2009;116(2):257-262. 7. Bloom BS. Taxonomy of Educational Objectives: the
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Gustafson KL, Tillman ME, eds. Instructional Design: Principles and Applications, 2nd ed. Englewood Cliffs, NJ: Educational Technology Publications; 1991. 10. Gagné RM, Briggs LJ, Wager WW. Principles of
Instructional Design, 4th ed. Fort Worth: Harcourt Brace Jovanovich College Publishers; 1992. 11. Royal College of Ophthalmologists. Available at: 〈http://
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