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Original Investigation |

Retention of Mastoidectomy Skills After Virtual Reality Simulation Training

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 and Neck Surgery, Rigshospitalet, Copenhagen, Denmark
2Copenhagen Academy for Medical Education and Simulation, Centre for HR, The Capital Region of Denmark, Copenhagen, Denmark
JAMA Otolaryngol Head Neck Surg. 2016;142(7):635-640. doi:10.1001/jamaoto.2016.0454.
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Importance  The ultimate goal of surgical training is consolidated skills with a consistently high performance. However, surgical skills are heterogeneously retained and depend on a variety of factors, including the task, cognitive demands, and organization of practice. Virtual reality (VR) simulation is increasingly being used in surgical skills training, including temporal bone surgery, but there is a gap in knowledge on the retention of mastoidectomy skills after VR simulation training.

Objectives  To determine the retention of mastoidectomy skills after VR simulation training with distributed and massed practice and to investigate participants’ cognitive load during retention procedures.

Design, Setting, and Participants  A prospective 3-month follow-up study of a VR simulation trial was conducted from February 6 to September 19, 2014, at an academic teaching hospital among 36 medical students: 19 from a cohort trained with distributed practice and 17 from a cohort trained with massed practice.

Interventions  Participants performed 2 virtual mastoidectomies in a VR simulator a mean of 3.2 months (range, 2.4-5.0 months) after completing initial training with 12 repeated procedures. Practice blocks were spaced apart in time (distributed), or all procedures were performed in 1 day (massed).

Main Outcomes and Measures  Performance of the virtual mastoidectomy as assessed by 2 masked senior otologists using a modified Welling scale, as well as cognitive load as estimated by reaction time to perform a secondary task.

Results  Among 36 participants, mastoidectomy final-product skills were largely retained at 3 months (mean change in score, 0.1 points; P = .89) regardless of practice schedule, but the group trained with massed practice took more time to complete the task. The performance of the massed practice group increased significantly from the first to the second retention procedure (mean change, 1.8 points; P = .001), reflecting that skills were less consolidated. For both groups, increases in reaction times in the secondary task (distributed practice group: mean pretraining relative reaction time, 1.42 [95% CI, 1.37-1.47]; mean end of training relative reaction time, 1.24 [95% CI, 1.16-1.32]; and mean retention relative reaction time, 1.36 [95% CI, 1.30-1.42]; massed practice group: mean pretraining relative reaction time, 1.34 [95% CI, 1.28-1.40]; mean end of training relative reaction time, 1.31 [95% CI, 1.21-1.42]; and mean retention relative reaction time, 1.39 [95% CI, 1.31-1.46]) indicated that cognitive load during the virtual procedures had returned to the pretraining level.

Conclusions and Relevance  Mastoidectomy skills acquired under time-distributed practice conditions were retained better than skills acquired under massed practice conditions. Complex psychomotor skills should be regularly reinforced to consolidate both motor and cognitive aspects. Virtual reality simulation training provides the opportunity for such repeated training and should be integrated into training curricula.

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Figure 1.
Study Flowchart

In the initial study (blue), participants completed 12 repeated mastoidectomy procedures on a virtual reality simulator either with distributed practice (sessions spaced in time) or as massed practice (all sessions completed in a single day). In this study (orange), participants were invited back for follow-up testing of their virtual mastoidectomy skills.

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Figure 2.
Final-Product Performance

Mean final-product performance of the distributed and massed practice groups in the last 2 sessions of training and in the retention sessions. Bars indicate 95% CIs. Dotted lines indicate that 3 months have passed between measurements.

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Figure 3.
Secondary Task Performance

Relative reaction time on the secondary task of the distributed and massed practice groups in the last 2 sessions of training and in the retention sessions. Bars indicate 95% CIs. Dotted lines indicate that 3 months have passed between measurements.

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