Traditional teaching methods in surgery rely on clinical experience and supervisor feedback. The current advancement in technology has provided extra tools for teaching. Some of those tools are well known, and used, such as Power Point and projectors, whilst others have not been fully utilised yet, for example video-
recording. Video recording is used to enhance athletes’ performance (82). It has also been used in medical education. Guerlain et al. (83) developed a laparoscopic surgery perceptual judgement course using multiple video sections from various surgical procedures. Videos established the level of performance, which is far better than text in describing complex procedures which led NASA to sponsor a just-in- time step-by-step video guide to help astronauts performing emergency medical procedures (84). Dr. Bruce Jarrell, the chief surgeon from Maryland University summarised the advantages of video recording when he said ‘‘A picture is worth ten thousand words’’ (85).
Recent studies have focused more on the audio-visual role as a performance
feedback tool. Performance feedback is a vital component for successful training as discussed earlier (29, 46, 47, 49, 50, 53, 54). Olsen asked emergency medicine residents (51) to report their mistakes, especially the most frequently occurring, before reviewing their actual recorded performance. Viewing of their own videotape- presents trainees with objective evidence of their performance, helping them to improve their self-assessment ability (86). It also provides the student with the opportunity to discover their mistakes, and creates a self-improvement agenda which
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is more likely to be implemented than an external agenda forced on them by the trainer (64).
As a result video-review enhances training and reduces time to reach competency. Cauraugh et al. (87) videotaped surgical candidates performing a McVay hernia repair twice with a teaching period in between. They were randomised into a traditional teaching group and an experimental group. The experimental group reviewed their video recordings on a split screen with the videotape of an expert performing the same steps. This session was facilitated by an expert surgeon. The experimental group had a statistically significant improvement in instrument handling and surgical technique compared with the traditional teaching group. Mistakes were repeated in the traditional teaching group. The overall surgical time was significantly reduced with the experimental group. Using the sensory-motor integration theory they argued that the split screen facilitated the video-review sessions and exposed candidates to more spatial clues and ‘‘perceptual-based cognitions’’, improving their instrument handling and overall ‘‘procedural knowledge’’. It also provided the residents with an expert reference point by enabling them to compare their own performance to that of the expert (88). Early recognition of the importance of cognitive clues in the learning thinking process is inspiring in the light of the newly available evidence discussed earlier in this chapter (54).
These improvements in training are echoed through the literature in relation to both time spent on training and better outcomes. Scherer et al. (89) noticed no
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improvement after three months of verbal feedback following use of the Advanced Trauma Life Support (ATLS) protocol. This was evident despite being video recorded during resuscitation. However, an improvement in half of the desired behaviours occurred one month after reviewing of the team-members’ own-tapes. This improvement continued throughout the remaining study period. Goldman et al. (90, 91) showed surgical, technical and non-technical skills improvement in the video group including correcting exposure inadequacy, reducing indecisive
inflexible actions and reducing irrelevant motions. Brinbach et al. (92) videotaped twenty two trainee anaesthetists and randomised them into two groups: one reviewed their own videotapes, and the other received standard teaching. The video-review group achieved higher overall grades, and improved to a greater degree than the non- video-review group by the end of the rotation and were the only group to continue to improve after the mid-rotation evaluation. This study suggests some skills are
facilitated by video review, such as, aseptic technique and needle control.
Video-review seems to facilitate non-technical skill acquisition as well. Such an effect should lead to patient safety enhancement due to the previously described non- technical skills safety role in surgery. Santora et al’s (93) study of adherence to ATLS protocols showed improvement in surgical resident leadership skills in the later part of their study when the video reviews were introduced, and a reduction in failure to meet ATLS standards. Resident postgraduate training level did not influence their overall performance, suggesting the role of videotape review rather than the natural learning curve.
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In another study, resuscitation team leaders identified and improved missed systems examinations and poor communication after reviewing their own tapes (94).
Townsend et a1 (95) demonstrated a reduction in resuscitation times after introducing an educational video-review resuscitation programme especially for severely injured patients. The video-review group had significantly more unexpected survivors when compared to the Major Trauma Outcome Study database (96). Improving non-technical skills should translate into a better outcome as described previously. As a result such enhancement in resuscitation survival rate in the last study is not a really surprising result.
The Royal Melbourne Hospital study in Australia (94) provided the legal ground for carrying out video recording in practice. Covering the study under the hospital quality assurance activity umbrella protected it from any legal actions. Quality assurance legislation provided the study with the needed legal protection from the freedom of information act and coroner inquiry. As such, neither the patient nor relative signed approval, this was not seen as necessary as long as CCTV warning signs were displayed and no identifiable information was captured in the recordings (94, 97). Maryland trauma centre had no medico-legal issues within their 11 years video recording practice (97).
A trainee’s own video-review serves as a way of reflecting on their practice. Review sessions take place in a calm environment away from the action. This helps to isolate any associated emotions and facilitate reflection. This set up accords well with reflective theory (66). Schon argued that reflection-in-action and reflection-on-action
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are the two activities needed for professionals to learn from experience, as discussed earlier. If students fail to reflect on their practice they will simply gain no benefit from their training regardless of how intense it is. Rushed practice would increase the risk for medical errors and patient harm (64).
Despite the clear benefits from video-review, it has been challenging to introduce such a tool in everyday surgical education practice for two reasons. First, the focus of many surgical video assessment studies used blinded assessors armed with a rating scale. Those studies confirmed the value of video-based assessment rating scales in surgical skills assessment and reported positively on the feedback value of video review and the use of rating scales (98). However, they rightly argued against the use of this approach as it required excessive reviewer time for the assessor. This disadvantage is very hard to ignore in the case of using blinded video assessment but would be eliminated if videos were reviewed by trainees themselves in the way described in the new design to be presented in the next chapter.
Secondly, due to the historical technical difficulty in tape recording, video-review was challenging to implement and use routinely. This difficulty might be hard to imagine in the era of digital recordings. However, with improvements to video recording machines and reductions in size, recording is used easily today:
laparoscopic intra-abdominal operation recording is carried out with a simple press on the recording button of the laparoscopic stack. Further synchronised recording will become standard in the new digital theatres gradually being installed across the country. Furthermore, various recording and synchronising systems have become commercially available and implemented in various degrees in trusts all over the country. An example of such a systems includes the Scotia Medical Observation and
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Training System (SMOTS) (99) which is available in various trusts in the Northern Deanery and will be discussed in detail in later chapters.
In conclusion, a review of operations using video-recording offers the best tool to make the most of every training opportunities and shorten the time needed to reach competency. It improves technical and non-technical skills far more than the traditional teaching methods. This is vitally important in the current era of reduced training opportunities. Video-review of one’s own practice facilitates reflection and lifelong learning. Those two strengths along with raising awareness of one’s blind spots, provide the basis for improved professionalism. Having a holistic approach to clinical practice leads to improved professionalism and to achieving the aims of outcome-based curriculum (21). Professionalism is ranked the highest in clinical competency and guarantees better and safer practice (40).