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Simulator Training to Automaticity Leads to Improved Skill Transfer Compared With Traditional Proficiency-Based Training: A Randomized Controlled Trial

Stefanidis, Dimitrios MD, PhD*,†; Scerbo, Mark W. PhD; Montero, Paul N. MD; Acker, Christina E. BA*; Smith, Warren D. PhD§

doi: 10.1097/SLA.0b013e318220ef31
Randomized Clinical Trials

Objective: We hypothesized that novices will perform better in the operating room after simulator training to automaticity compared with traditional proficiency based training (current standard training paradigm).

Background: Simulator-acquired skill translates to the operating room, but the skill transfer is incomplete. Secondary task metrics reflect the ability of trainees to multitask (automaticity) and may improve performance assessment on simulators and skill transfer by indicating when learning is complete.

Methods: Novices (N = 30) were enrolled in an IRB-approved, blinded, randomized, controlled trial. Participants were randomized into an intervention (n = 20) and a control (n = 10) group. The intervention group practiced on the FLS suturing task until they achieved expert levels of time and errors (proficiency), were tested on a live porcine fundoplication model, continued simulator training until they achieved expert levels on a visual spatial secondary task (automaticity) and were retested on the operating room (OR) model. The control group participated only during testing sessions. Performance scores were compared within and between groups during testing sessions.

Results: Intervention group participants achieved proficiency after 54 ± 14 and automaticity after additional 109 ± 57 repetitions. Participants achieved better scores in the OR after automaticity training [345 (range, 0–537)] compared with after proficiency-based training [220 (range, 0–452; P < 0.001].

Conclusions: Simulator training to automaticity takes more time but is superior to proficiency-based training, as it leads to improved skill acquisition and transfer. Secondary task metrics that reflect trainee automaticity should be implemented during simulator training to improve learning and skill transfer.

In this study, we compared simulator training to secondary task endpoints (automaticity) with traditional proficiency-based training and found that automaticity training leads to superior skill acquisition of novice learners and improved transfer of simulator-acquired skill to the operating room.

*Carolinas Simulation Center, Carolinas Medical Center, Charlotte, NC

Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Medical Center, Charlotte, NC

Department of Psychology, Old Dominion University, Norfolk, VA

§Department of Electrical and Electronic Engineering, California State University, Sacramento, CA.

Reprints: Dimitrios Stefanidis, MD, PhD, FACS, Carolinas Simulation Center, Division of Gastrointestinal and Minimally Invasive Surgery, Department of General Surgery, Carolinas Medical Center, Surgical Speciality Center, Suite 300, 1025 Morehead Medical Drive, Charlotte, NC 28204. E-mail:

Presented at the 2010 Surgical Education Week, San Antonio, TX

Disclosure: Supported by a CESERT grant from the Association for Surgical Education.

© 2012 Lippincott Williams & Wilkins, Inc.