key: cord-258475-hj7fverf
authors: Ahmad, Karam; Bhattacharyya, Rahul; Gupte, Chinmay
title: Using cognitive task analysis to train orthopaedic surgeons - Is it time to think differently?A systematic review
date: 2020-09-23
journal: Ann Med Surg (Lond)
DOI: 10.1016/j.amsu.2020.09.031
sha: 
doc_id: 258475
cord_uid: hj7fverf

BACKGROUND: Working time restraints; senior led care; and a reduction in ‘out of hours’ operating has resulted in less operating time for orthopaedic trainees in the United Kingdom. Therefore, there has been an attempt to overcome these challenges by implementing novel techniques. Cognitive Task Analysis (CTA) focuses on the mental steps required to complete complex procedures. It has been used in training athletes and in general surgery but is new to orthopaedic training. AIMS: To undertake a systematic review to analyse if CTA is beneficial to train novice surgeons in common orthopaedic and trauma procedures. MATERIALS AND METHODS: A systematic review was performed evaluating CTA in trauma and orthopaedic surgery on MEDLINE and EMBASE. Search terms used were: Cognitive task’, ‘mental rehearsal’ and ‘Orthop*‘. 33 studies were originally identified. Duplicate studies were excluded (11). Articles not relating to Orthopaedic surgery were excluded (15). The CTA research ranking scale was used to evaluate the impact of the studies included. RESULTS: 7 studies were identified as appropriate for inclusion. 264 participants. 178 M, 86F. All studies showed objective or subjective benefits from CTA in orthopaedic training when compared to traditional methods. The majority of the participants highlighted high subjective satisfaction with the use of the CTA tools and reported that they proved to be excellent adjuncts to the traditional apprenticeship model. CONCLUSION: CTA learning tools have demonstrated significant objective and subjective benefits in trauma and orthopaedic training. It is cost effective, easily accessible and allows repeated practice which is key in simulation training.

A SYSTEMATIC REVIEW. 3 4 Abstract: 5 6 Background: Working time restraints; senior led care; and a reduction in 'out of hours ' 7 operating has resulted in less operating time for orthopaedic trainees in the United Kingdom. 8

Therefore, there has been an attempt to overcome these challenges by implementing novel 9

techniques. Cognitive Task Analysis (CTA) focuses on the mental steps required to complete 10 complex procedures. It has been used in training athletes and in general surgery but is new to 11 orthopaedic training. were excluded (11) . Articles not relating to Orthopaedic surgery were excluded (15) . The 20 CTA research ranking scale was used to evaluate the impact of the studies included. repeated practice which is key in simulation training. 31

Despite changes to orthopaedic training it is well established that current trainees have 36 significantly less theatre training time as compared to their predecessors [1] . The shift from 37 time-based to competency-based training has worsened the current situation [1] . In an attempt 38 to counter both a reduction in theatre time for trainees and a rising demand for skilled 39 surgeons, the development of simulation as an adjunct to the apprenticeship system has aided 40 trainees to achieve their required training needs. 41 42 Simulation is 'a method or technique that is employed to produce an experience without 43 going through the real event' [2] . It occurs in a safe environment and has been shown to 44 The intervention group were taught using the CTA tool and the control group were given a 119 standard operative manual. The students were scored on MCQs and how effectively manual 120 steps were completed using finger swipes on the smartscreen. 121 122 Bhattacharyya et al [18] carried out a randomised control trial to evaluate the effectiveness of 123 CTA in knee arthroscopy. The cognitive task tool was developed and designed using the Scores were given for decision making, swipe interactions, and time taken to complete steps. 149

Percentage total scores were calculated. 150 151 Sugand et al [23] attempted to validate Touch Surgery TM for Intramedullary Femoral Nailing 152 (IFN). As per Sugand's previous study [22] , the procedure was divided into four modules. 153

Real-time objective performance data was obtained and stored from the participants primary 154

attempt. This was used to assess construct validity. A post-study questionnaire using the 155 Likert scale was used to assess face and content validity. The study on CTA and AA-THA by Logishetty at al [19] found cognitively trained 170 participants were on average 35% faster, made 69% fewer errors in instrument selection, and 171 required 92% fewer prompts. They also were more accurate with acetabular cup orientation. 172

Both studies by Sugand et al [22, 23] [20] rated content validity, quality of graphics, 182 ease of use, and usefulness to surgery preparation as very high. Bhattacharyya et al [17, 18] , 183 found that participants agreed the cognitive task analysis learning tool was a useful training 184 adjunct to learning in the operating room. Over 90% of participants found to tool easy to use 185 and enjoyed using it. Levin et al [21] found that 10/14 participants believed using CTA 186 improved baseline understanding, 9/14 believed learning was accelerated and 8/14 felt the 187 procedure was easier to learn as a result of this. 188

All participants in the AA-THA study by Logishetty et al [19] found the CTA tool useful to 189

understand key technical steps, decision making processes, highlighting errors, and easy to 190 use. 34/35 enjoyed using the tool. 191

When validating Touch Surgery™ for intramedullary femoral nailing, Sugand et al [23] 192 found that both junior and senior cohorts rated the face validity, quality of graphics, 193 willingness to use the app, usefulness for preoperative rehearsal as good or very good. 194

Experts also rated the content validity as good. The use of CTA within orthopaedic training is relatively novel. 6/6 studies show objective 198 benefits when using CTA (one study did not use objective assessment). They suggest CTA 199 enhances performance and efficiency in orthopaedic training. In the randomised controlled 200 trials by Bhattacharyya et al [17, 18] and Logishetty et al [19] Trainees can progress faster through the initial phase of the Sigmoid learning curve [24] . 211

This, a concept of mathematical psychology, follows the learner from unfamiliarity to 212 mastery of a skill. Initially progress is slow, however with intentional practice, traction is 213 gained, and one enters the stage of 'hypergrowth' (where learning is exponential) and then 214 subsequent mastery [24] . The aim of CTA is to propel the novice learner into hypergrowth 215 prior to getting sustained theatre experience, thereby improving efficiency of their operating 216 theatre training time. Furthermore, this enhances patient safety as trainees are more equipped 217 with knowledge on the technical skills and potential errors before they perform a procedure 218 for the first time on patients [17, 19] . 219 220 By undertaking CTA procedures, the trainee is enabled to progress through unconscious 221 incompetence, conscious incompetence and potentially reach the stage of conscious 222 competence. They, therefore, enter the learning process on patients at a higher point on the 223

Broadwell learning curve [25] . 224

Studies have estimated that 70% of vital steps can be missed out when taught by experts [13] . 2. All participants agreed the tool made the procedure easy to understand. The multimodality approach was beneficial and that it was beneficial to use the tool prior to operating. 10/11 participants agreed that the tool was easy to use and 9/11 enjoyed using the tool.

Yes Yes 9 Full-text articles assessed for eligibility (n = 7)

Full-text articles excluded, with reasons (n = 0)

Studies included in qualitative synthesis (n = 7)

Studies included in quantitative synthesis (meta-analysis) (n =7 ) 

No time to train the surgeons

Simulation in medical education

Training and simulation for patient safety

Demonstration of high-fidelity simulation team training for emergency medicine

Teaching surgical skills-changes in the wind

Surgical skills simulation in trauma and orthopaedic training

Arthroscopy Skills Development With a Surgical Simulator: A Comparative Study in Orthopaedic Surgery Residents

Improving residency training in arthroscopic knee surgery with use of a virtual-reality simulator. A randomized blinded study

Improving Resident Performance in Knee Arthroscopy: A Prospective Value Assessment of Simulators and Cadaveric Skills Laboratories

Testing basic competency in knee arthroscopy using a virtual reality simulator: exploring validity and reliability

Current and future use of surgical skills training laboratories in orthopaedic resident education: a national survey

Simulation in surgical training: Prospective cohort study of access, attitudes and experiences of surgical trainees in the UK and Ireland

Cognitive Task Analysis: Bringing Olympic Athlete Style Training to Surgical Education

Teaching and measuring surgical techniques: the technical evaluation of competence

Phases of meaningful learning

Patterns of regional brain activation associated with different forms of motor learning

Trauma simulation training: a randomized controlled trial -evaluating the effectiveness of the Imperial Femoral Intramedullary Nailing Cognitive Task Analysis (IFINCTA) tool

Knee Arthroscopy Simulation: A Randomized Controlled Trial Evaluating the Effectiveness of the Imperial Knee Arthroscopy Cognitive Task Analysis (IKACTA) Tool

A Multicenter Randomized Controlled Trial Evaluating the Effectiveness of Cognitive Training for Anterior Approach Total Hip Arthroplasty

A Mobile-Based Surgical Simulation Application: A Comparative Analysis of Efficacy Using a Carpal Tunnel Release Module

Pre-course cognitive training using a smartphone application in orthopaedic intern surgical skills "boot camps

Training effect of using Touch Surgery™ for intramedullary femoral nailing

Validating Touch Surgery™: A cognitive task simulation and rehearsal app for intramedullary femoral nailing

Throw your life a curve

Teaching for learning (XVI). The Gospel Guardian

Changes to training have resulted in less theatre time for Orthopaedic trainees

Cognitive Task Analysis (CTA) focuses on understanding technical steps and the cognitive decision making required for each phase of a procedure

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