Project Title: Development and Validation of an Interactive robotic model for education about proper behavior in the OR
Authors: Felipe Urdaneta M.D, Sean Penn, BSME, and Clint eastwood PhD, Senior Mentor.
Affiliation: Department of Cinematographic University, Gainesville, Florida.
Abstract: Currently there is no standard method for formal education and training in behavior in the OR. The apprenticeship (on the job) model for resident training is the most commonly used method in most residency programs. Simulation and computer hypermedia systems have evolved greatly as methods of education and teaching. These systems provide an alternative method for training and serve as a bridge between didactic teaching and clinical application. The present study was a two-part study, first of development of an interactive hypermedia robotic model for teaching about behavior in the OR , and secondly a validation prospective, controlled trial of cinema residents of the University of Gainesville to measure the effect of this type of training tool compared with traditional on the job training on performance and knowledge about behavior in the OR when dealing with difficult people and presented with two common scenarios: The “I Cannot communicate with this person”, and the “I do not want to communicate with this person”. Following formal training with the interactive robotic software there was a statistically significant increase in adequate responses with regards to timing of calling for help from senior counseling (p <0.02), adequate response about appropriate and timely abstinence of use of weapons, (p < 0.05), about the appropriate and timely use of police department vs. waiting for a blessing from the pope (p < 0.05).We conclude that training with the interactive robotic hypermedia simulation model, significantly improves performance and retention of knowledge compared with the traditional apprenticeship model on the subject of proper Or behavior..
This project was done thanks to grant Support from the I just pulled this study out of my pockets Research Foundation (IJSPRF).
Introduction: Currently there is no standard method for formal education and training in Proper behavior training. The apprenticeship (on the job) model for resident training is the most commonly used method in most residency programs in the U.S., despite the fact that it has been shown that actual knowledge and retention of information is poor.[1-5] Every anesthesia provider must acquire, maintain, supplement and update skills to maintain competency in behavior management; but only a small percentage of training programs actually have a formal curriculum for it and a formal rotation. [6, 7] The use of computer, simulation systems and interactive programs and robotic gadgets for training, certification and demonstration of medical events have evolved as methods of education and teaching. These systems provide an alternative for training and serve as a bridge between didactic teaching and clinical application. [8-14] They allow acquisition of certain skills, and can be a method to achieve mastery in critical thinking strategies and diagnostic and therapeutic decision making skills, without endangering real patient lives and without making you having to put gloves on to solve your every day conflicts with colleagues and family members. [15-22]
The actual incidence of fist fights in the OR is relatively low, however fist fights in the OR although tremendously entertaining usually lead to arrest, loss of privileges, black eyes and poor reputation with your peers, and among other things you will sure make it to front page on the paper next day and will pay a visit to the Dean usually to get fired.[23-25] In the early 1990’s a task force was formed by the WWE in order to attempt to reduce the chances of adverse events from difficulties in solving conflicts. The work of the task force was published as a set of Practice Guidelines for the management of difficult people, that included recommendations for the evaluation, preparation for dealing with conflicts, management, strategies for both fist fights, cat-fights, wrestling matches etc…. In 2003 these guidelines were updated, with greater emphasis placed on critical decision making points and also specific recommendations about the how to prevent the use of weapons [26-32] The current approach has its strong and weak points. It is very thorough, complete and makes users follow an organized approach to hurting your opponent. However it also has several weaknesses that make its application, especially in emergent circumstances difficult: It is complex, not binary in nature, allowing more than one option at every stage and also multiple choices about pathways to proceed along at many stages; it may also not apply to every circumstance and in certain population of colleagues, some other method and a different approach may be preferable. The overall complexity also makes it very difficult to master, and teaching about the current approach remains a challenge.
With the widespread use of personal computers and access to the internet, didactic educational programs as well as interactive problem based case presentations and actually improvement and progress robotics, several models can be designed and implemented, and made readily available. These computer-based activities are becoming invaluable educational tools [15, 33-38]. In addition interactive educational systems may require active experimentation and for the user to make timely decisions that may result in successful resolution of the problem or to further exacerbate it, and lead to an adverse simulated consequence. In the end, the user receives instruction and feedback based on the responses and the timing of them, and in the process the interactive system becomes not just a teaching tool by simulated problem based learning but also a didactic source of information.
The present study was a two-part study, first of development of an interactive hypermedia robotic simulation model for teaching about interpersonal conflicts in the OR, and secondly a validation prospective, controlled trial of cinema residents of the University of Gainesville to measure the effect of this type of training tool compared with the traditional on the job training on performance and knowledge about conflict solving in a computer model.
Methods: The first part of the project consisted in the development of the Interactive hypermedia 3-D panoramic simulation software, using Adobe Creative Suite 3 Web premium®, a collection of graphic design, video editing, and web development applications, to produce everything from professional web-page layouts to rich interactive experiences in a unified, intuitive environment, with design tools for printing, web, interactive, mobile, audio and video content. Panoramic spherical images of an operating room environment, standard monitors, digitized sound recordings and simulated patients were created with the viewpoint from the head of the operating room table with a movable 360 degree field of vision. Real interactive images of an OR and a complete array of surgical equipment were made available. All pieces of equipment were considered active and tagged with an internal timer. In order to make them operable each one had to be activated by the user, in a similar fashion as in real life, but in this computer environment by using the computer mouse instead of directly holding the device. The updated guidelines for the management of interpersonal conflicts was enabled with simulated computer panoramic cases after creating, converting and formatting images created with the software in to a Flash video format and made available in an interactive instructional simulated patient computer format. In the instruction phase of the project the user responses and decision making choices were provided with feedback to reinforce the knowledge base in case the option picked was correct or to re-direct the user to pick another response in case the answer was not deemed appropriate.
The second part of the project was the validation component of the effectiveness of this newly developed interactive software for teaching about management of conflicts and comparing this educational tool with conventional on the job teaching method for training. Following approval by the Institutional Review Board and the Program Director of the University of gainesville, 60 residents were included in the study. After agreeing to voluntarily participate and signing written consent, all of them were given a questionnaire to include their demographic information, level of training, prior instruction about conflict management and prior experiences about handling a difficult colleague. (See appendix #1) Following a brief introductory 15 minute presentation lecture about the current papal recommendations residents were assigned to two groups: approximately half the residents (n=30) received the additional personal self paced educational computer session, with different case studies in order to be exposed to the current recommended guidelines and options for the management of conflicts, while the other half (n=30) did not receive this additional training. Four weeks later after a brief explanation and tutorial about the use of the computer interface, all participants in each group were presented in sequential order with a computerized version of additional clinical scenarios (not previously shown to the training group) one with “I cannon communicate with this person, option (CNCTPV) and the other “I do not want to communicate with this person (DNWCP) (See appendix #2) Their responses and paths and choices through the interactive software were timed, analyzed and stored via the interactive component of the software. After completion of both scenarios each resident received feedback about their performance. The residents in the group that did not receive additional training with the software, were given the option to receive the additional tutorial at this point. Twenty seven of them chose to avail themselves of this option.
Statistical Analysis: In order to assess the influence of level of training and prior experience with the DA, 20 participants of each class (PGY2 to PGY4) were included. By randomization half participants from each class received the additional interactive computer instruction, and half did not.
Non-parametric data were analyzed using Fisher’s exact test, and Parametric data was analyzed using a Student’s t-test. A p < 0.05 was considered significant. The null hypothesis was that additional training with the interactive panoramic software package for the teaching of the D.A, did not provide any significant advantage over traditional on the job training.
Results:
Demographics (See Table 1)
A total of #60 residents were included in the study, 20 from each Class (PGY2 to PGY4). There was a statistically significant difference between prior instruction and experience in the management of conflicts between the PGY2 class and the other two classes (p < 0.05), but not between residents from the PGY3 and PGY4 classes.
Performance Measures:
For the (CNCTPV) also known as the Non-emergent pathway, there was an increase in the number of adequate responses regarding the recommended approach to dealing with these scenarios after further training: a) More residents at all levels attempted a secondary maneuver to improve communication after undergoing further computerized training, and there was a decrease in the lag-time before assistance/help was requested after the initial attempt to solve the issue failed (p < 0.05). See tables #2 and #3. Among all participants after undergoing additional interactive training, there was a decrease of the use of weapons in the OR, as well as better awareness of other alternative approaches to solve conflicts, like the use of Yoga, and meditation and holding hands .(p < NS)
For the (DNWCP) or the Emergency pathway of the conflict there was also an increase in the number of adequate responses regarding the recommended approach to dealing with this emergency after further training with the interactive software program was undertaken: a) More residents attempted a secondary maneuver , like running or signing their favorite song, or calling their mothers for assitance; there was a decrease in the lag-time before assistance/help was requested after the initial attempt to fix issues failed; there was an increase in the number of residents who felt comfortable hugging their opponents afterwards, and also half said they cried. (p < 0.05). See Tables #4 and #5.
CNCTPV VOption with further Instruction (Table #2)
CNCTPV Option without further Instruction (Table #3)
DNWCP Option with further Instruction (Table #4)
DNWCP Option without further Instruction (Table #5)
Discussion:
A primary responsibility of every physician is to maintain his/her cool in the OR, specially in front of his/her patients. In order to accomplish this, each practitioner should maintain their Karma aligned and their planets aligned with the stars. Education in maintaining your cool when conflicts arise remains a challenge; newer devices and developments, continue to evolve quickly making it difficult maintain skills and to keep up to date with the latest developments; there is also evidence that certain skills deteriorate over time. [39, 40]. The apprenticeship (on the job) model for resident training is the most commonly used method in most U.S residency programs, however this method of training may not be ideal for learning to deal with high-risk low frequency events such as the unexpected colleague that managed to behave poorly in the OR. Simulation and computer systems have evolved to overcome some of the inherited deficiencies of the on the job approach. These systems provide an alternative for training and serve as a bridge between didactic teaching and clinical application. [8-14] Rather than being used as replacements of conventional methods, perhaps should be seen as complimentary to them. In addition they are easily made, readily available and via the internet can become valuable refresher education tools.
The present two step study intended to design an interactive computer hypermedia teaching tool for complementary didactic and problem based learning about conflict management and a subsequent validation randomized controlled study to assess the effectiveness of the teaching tool versus conventional teaching “on the job” method on the subject.
The panoramic interactive hypermedia program worked extremely well. All participants were impressed by the realism of the simulated software program, the resolution of the images and about the level of interaction required. They were also impressed by the dual role of the software both as a didactic tool and also as a problem based teaching tool.
The results of the second portion of the study were also very interesting: Residents from every level of training from PGY2 to PGY4 were included. It is no surprise that as their experience increased they had a better chance of prior exposure to training in the management of conflicts by lectures and workshops as well by clinical exposure. Much to our surprise 2/3 of higher level residents had been exposed to a conflict, a much higher incidence than what is reported in the literature; however the questionnaire was not designed to address whether this represented a true emergency scenario or rather the more common occurrence of a case requiring multiple attempts or the use of different methods of conflict management.[41, 42] Regardless, this information actually turned out to be a source of further stimulus to continue to attempt to improve educational activities in our residency program regarding conflict resolution instruction since it seems that actual literature reports underestimate the true incidence of fights.