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Original Investigation |

Learning Curves of Virtual Mastoidectomy in Distributed and Massed Practice

Steven Arild Wuyts Andersen, MD1; Lars Konge, MD, PhD2; Per Cayé-Thomasen, MD, DMSc1; Mads Sølvsten Sørensen, MD, DMSc1
[+] Author Affiliations
1Department of Otorhinolaryngology–Head & Neck Surgery, Rigshospitalet, Copenhagen, Denmark
2Center for Clinical Education, Capital Region of Denmark, Copenhagen
JAMA Otolaryngol Head Neck Surg. 2015;141(10):913-918. doi:10.1001/jamaoto.2015.1563.
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Importance  Repeated and deliberate practice is crucial in surgical skills training, and virtual reality (VR) simulation can provide self-directed training of basic surgical skills to meet the individual needs of the trainee. Assessment of the learning curves of surgical procedures is pivotal in understanding skills acquisition and best-practice implementation and organization of training.

Objective  To explore the learning curves of VR simulation training of mastoidectomy and the effects of different practice sequences with the aim of proposing the optimal organization of training.

Design, Setting, and Participants  A prospective trial with a 2 × 2 design was conducted at an academic teaching hospital. Participants included 43 novice medical students. Of these, 21 students completed time-distributed practice from October 14 to November 29, 2013, and a separate group of 19 students completed massed practice on May 16, 17, or 18, 2014. Data analysis was performed from June 6, 2014, to March 3, 2015.

Interventions  Participants performed 12 repeated virtual mastoidectomies using a temporal bone surgical simulator in either a distributed (practice blocks spaced in time) or massed (all practice in 1 day) training program with randomization for simulator-integrated tutoring during the first 5 sessions.

Main Outcomes and Measures  Performance was assessed using a modified Welling Scale for final product analysis by 2 blinded senior otologists.

Results  Compared with the 19 students in the massed practice group, the 21 students in the distributed practice group were older (mean age, 25.1 years), more often male (15 [62%]), and had slightly higher mean gaming frequency (2.3 on a 1-5 Likert scale). Learning curves were established and distributed practice was found to be superior to massed practice, reported as mean end score (95% CI) of 15.7 (14.4-17.0) in distributed practice vs 13.0 (11.9-14.1) with massed practice (P = .002). Simulator-integrated tutoring accelerated the initial performance, with mean score for tutored sessions of 14.6 (13.9-15.2) vs 13.4 (12.8-14.0) for corresponding nontutored sessions (P < .01) but at the cost of a drop in performance once tutoring ceased. The performance drop was less with distributed practice, suggesting a protective effect when acquired skills were consolidated over time. The mean performance of the nontutored participants in the distributed practice group plateaued on a score of 16.0 (15.3-16.7) at approximately the ninth repetition, but the individual learning curves were highly variable.

Conclusions and Relevance  Novices can acquire basic mastoidectomy competencies with self-directed VR simulation training. Training should be organized with distributed practice, and simulator-integrated tutoring can be useful to accelerate the initial learning curve. Practice should be deliberate and toward a standard set level of proficiency that remains to be defined rather than toward the mean learning curve plateau.

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Figure 1.
Flowchart

Participants completed 12 identical sessions of virtual reality mastoidectomy training as either time-distributed practice (every other session spaced by ≥3 days) or massed practice (all sessions in 1 day).

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Figure 2.
An Example of Mastoidectomy Final Product Progression

Final product mastoidectomy performance from sessions 1, 6, and 12 for a nontutored participant in the distributed practice group.

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Figure 3.
Learning Curves of Virtual Reality Mastoidectomy

Final product performance learning curves (smoothed). Distributed practice (A) and massed practice (B) with and without initial simulator-integrated tutoring (sessions 1-5).

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