Sébastien Bathalon, M.D. Dominique Dorion, M.D., M.Sc. Marcel Martin, M.D. Cognitive Task Analysis, Kinesiology and Mental Imagery: Challenging Surgical.

Sébastien Bathalon, M.D.Dominique Dorion, M.D., M.Sc.Marcel Martin, M.D.

Cognitive Task Analysis, Kinesiology and Mental Imagery: Challenging

Surgical Attrition

Introduction

See one.Do one.

Teach one.*

* Halsted WS. The training of the surgeon. * Halsted WS. The training of the surgeon. Bull Johns Hopkins Hosp,Bull Johns Hopkins Hosp, 1904  1904 

The problem…Pressures to change the classical teaching

system– Pathologies– Explosion of the surgical armamentarium– Medico-legal issues

• efficacy• efficiency• safety• cost

– Requirement for standardization by accreditation bodies (ACGME. AB)

– Attrition of knowledge

…the solutions

•Simulation lab•Cognitive task analysis•Kinesiology•Mental imagery

…the solutions

•Simulation lab

•Cognitive task analysis•Kinesiology•Mental imagery

«Cognitive task analysis is a formal way of deconstructing a procedure into its simpler parts»

Cognitive task analysis

2- laryngeal stabilization2- laryngeal stabilization

3- incision3- incision

1- anatomical landmark 1- anatomical landmark identificationidentification

4- blunt dissection4- blunt dissection

5- stab incision of CT 5- stab incision of CT membranemembrane

6- opening of CT space6- opening of CT space

7- insertion of canula7- insertion of canula 8- inflation of tracheotomy tube 8- inflation of tracheotomy tube

…the solutions

•Simulation lab•Cognitive task analysis

•Kinesiology•Mental imagery

- The study of movements–Applied to surgery, it leads to including aspects of biomechanics (ergonomics), task and movement analysis and correction.

Kinesiology

…the solutions

•Simulation lab•Cognitive task analysis•Kinesiology

•Mental imagery

«Symbolic repetition of a physical action without the muscular counterpart»

Richardson A, Mental Imagery, 1969Richardson A, Mental Imagery, 1969

Mental imagery

HypothesisThe use ofThe use of - - cognitive task analysis cognitive task analysis

- - kinesiology kinesiology - - mental imagerymental imagery

in the teaching of in the teaching of rarely performedrarely performed emergency emergency procedures like cricothyrotomyprocedures like cricothyrotomy

will improve its will improve its acquisitionacquisition and and long-term long-term retentionretention compared to standard teaching compared to standard teaching

Method• 44 first-year medical students

• Teaching session – 45-minute timed teaching session– Surgical anatomy– Short lecture on the handling of

surgical instruments– Practice on rubber neck model

Method•Randomized in three groups

–Kinesiology alone (KG)–Kinesiology+mental practice (KG+MI)

–Control group ATLS

MethodSTEPS 16 marksTIME 7 marksFLUIDITY 2 marks TOTAL 25 marks

∗ Evaluation at 2 weeks; 6 months and 12 months (2 years is planned)

Results

2 weeks

KG + MI 20,3 +/- 1,5 *

(n=15)

KG 19,3 +/- 2.9

(n=13)

ATLS 18,2 +/- 2,5 *

(n=16)

6 months

19,7 +/- 2,4 *

(n=14)

19,4 +/- 3,4

(n=13)

16,6 +/- 4,8 *

(n=15)

12 months

21,5 +/- 1,8 * # (n=15)

19,5 +/- 1,9 # ‡ (n=13)

16,5 +/- 2,9 * ‡ (n=16)

Conclusions• Educating residents is evolving faster

and faster…

• Cognitive task analysis, kinesiology and mental imagery are new approaches that improve the teaching of rarely performed surgical skills.

• Applications for these new tools are yet to

be explored and will require more work.

Conclusions• More specifically regarding mental

imagery, – How should it be taught?– Who should we teach it to?– Can it be used to select residents?

• Lots of work is yet to be done…

Thanks

Dr Marcel MartinNicolas FontaineIsabelle and Marie-Eve

Résultats (acquisition 2

semaines)Étapes (16) Temps (7) Fluidité (2) Total (25)

KG +RM1

(n=15)14,8 +/- 0,9*

3,9 +/- 0,9 1,6 +/- 0,6*

20,3 +/- 1,5*

KG2

(n=13)14,5 +/- 1,3 3,2 +/- 1,8 1,5 +/-

0,7*19,3 +/- 2,9

Contrôle (ATLS)(n=16)

13,2 +/- 1,8 4,0 +/- 1,4 1,0 +/- 0,7 18,2 +/- 2,5

Potential applications of imaginary practice

• Early stages of learning a basic skill• Diminishing the learning curve for a new

procedure• Transferring skills from an established

technique• Hindering the decay of skills• Pre-op preparation for a complex

procedure

Hall, American Journal of Surgery, 2002

Mental imagery techniques

• External imagery– The person views himself from the

perspective of an external observer (much like in home movies).

• Internal imagery– approximation of the real life

phenomenology– the person actually imagines being inside

his/her body– experiencing those sensations which might

be expected in the actual situation.

MAHONEY and al. Cognit. Ther; 1977

Yerkes-Dodson ruleLearning potential vs stress

ExpertsNicolas FontaineAlain ProstJacques LaffiteAnnie PelletierSylvie BernierEric LucasMélanie Turgeon

Résultats (total)GROUPE

2 sem 6 mois 12 mois

KG+RM 20,3 +/- 1,5*(n=15)

19,7 +/- 2,4*(n=14)

21,5 +/- 1,8* #(n=15)

KG 19,3 +/- 2,9(n=13)

19,4 +/- 3,4(n=13)

19,5 +/- 1,9*(n=13)

ATLS 18,2 +/- 2,5(n=16)

16,6 +/- 4.8(n=15)

16,5 +/- 3,0(n=16)

Ali Ali et alet al, American J of Surgery, 2002, American J of Surgery, 2002

" J'ai pris les grands moyens avec un entraînement sur glace et hors glace. J'ai également fait beaucoup de visualisation…  »

José Théodore