t h e s u r g e o n 9 ( 2 0 1 1 ) S 2 6 eS 2 7

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The Surgeon, Journal of the Royal Colleges

of Surgeons of Edinburgh and Ireland
www.thesurgeon.net

Review

The role of proximate feedback in skills training

Stavan Parmar, Conor P. Delaney*

Division of Colorectal Surgery, Case Western Reserve University, Cleveland, Ohio, USA

article info abstract

Article history: Skills training has been an increasingly important focus of surgical training and is ideally
Received 22 October 2010 performed prior to reaching the operating room. Although our understanding of the role is
Accepted 3 November 2010 increasing, and there are more publications describing endpoints with simulation and
different training models, the optimal training methodology remains unclear. In this paper
we discuss our experience with simulation and a variety of training models, primarily for
Keywords: teaching laparoscopic colorectal resection. Feedback during training is likely important,
Skills training and the more proximate that feedback, the better its effectiveness. Optimal skills’ training
Proximate feedback likely depends on a combination of having the optimal curriculum, in conjunction with an
Role appropriate training model.
ª 2010 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and
Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.

Skills training has been an increasingly important focus of
surgical training and is ideally performed prior to reaching the
operating room. There has been relatively little research on the
role of feedback during training. Risucci and colleagues dis-
cussed practice only with verbal instruction but no feedback
and compared this to students who received video and verbal
training with immediate feedback. They found that there were
fewer errors in the group that received instruction with feed-
back. Other authors have suggested that force feedback, or
haptic feedback, during knot-tying training also improves
adequacy of task completion. At Case Western Reserve
University, we have established an Institute for Surgery and
Innovation. This institute has 3 primary goals: 1) research;
2) product development and innovation; 3) surgical skills
training. Over the last 5 years, many local and regional, national
and international surgeons and trainees have attended courses
here. Resident basic skills training courses have utilized
a variety of different training models: 1) Box and plastic models
have been used for teaching of basic skills such as knot-tying; 2)
Simulators have been used for teaching basic endoscopic, and
laparoscopic skills; 3) Tissue-based training models have been
used to teach procedures such as opening and closing an
abdominal wall incision, and also complete procedures such
as colectomy, gastrectomy, and hepatectomy. Postgraduate
surgical courses have been specialty-dependent and have
ranged from advanced minimally-invasive colorectal courses to
minimally-invasive thoracic courses, urology, and other
subspecialties.
Much of the work we have done with training has been
related to laparoscopic colorectal surgery. We have studied the
learning curve for colon surgery and, based on an analysis of 900
cases, we found that the learning curve was approximately
50e60 cases. In fact, a learning curve probably depends very
much on the endpoint that is chosen to determine proficiency.
One can easily understand how the first ten or twenty cases
performed by a surgeon will be spent simply learning the order
of each step of the procedure. True proficiency will only be
attained by performing a larger number of procedures and this

* Corresponding author.
E-mail addresses: conor.delaney@uhhospitals.org, ICOSET@rcsi.ie (C.P. Delaney).
1479-666X/$ e see front matter ª 2010 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of
Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.surge.2010.11.006
 t h e s u r g e o n 9 ( 2 0 1 1 ) S 2 6 eS 2 7
explains the more gradual sloped second phase to the curve. If
we can help surgeons accelerate their learning of the steps of the
procedure and their understanding of the procedure, hopefully
we can get them onto the more advanced prolonged phase of the
curve without having to spend time learning the more basic
steps which might be learned in a non-clinical training model.
We have found porcine models to be useful for teaching
both laparoscopic and open procedures. In fact, recently, we
developed a model of open porcine colectomy which we feel is
important as residents see less and less open surgery. Thus,
open surgery is becoming a more important part of their
training outside the operating room. In conjunction with this,
we have reported a new objective ratings system to assess
outcome of the trainee’s experience with these models. In fact,
we have used similar techniques to assess performance and
proficiency in trainees performing laparoscopic colorectal
surgery in clinical practice.
However, when we discuss training for any procedure, it is
unclear what the best training model may be. For many
procedures we have options with skills lab, box and model
training, animal or cadaver labs, tutorials and courses, oper-
ative experience with mini-fellowships, or artificial models
with or without haptic feedback. In practice we have
combined many of these teaching models into standardized
courses which we now use for colorectal, abdominal hernia,
thoracic, urologic, and pediatric surgery (www.isi-case.org).
Attendees receive didactic training during lectures. They then
practice the procedures on simulators with human anatomy,
before going to a porcine operating room where they practice
the procedures again in live models. On the subsequent day,
attendees see several live cases as part of a mini-fellowship.
The advent of laparoscopy has meant that full virtual reality
simulation has become a possibility for training. We had the
opportunity to be involved in the development of one of these
virtual reality simulated training models which allows all of
the steps of a laparoscopic sigmoid colectomy to be performed.
Some of the simulation models have haptic feedback and
others do not. However, all of them allow the trainee to
perform each of the steps of the procedure. Early data with this
training model show that it has excellent construct and face
validity. This simulator clearly distinguished between resi-
dents, trainee surgeons, and experts when evaluating
endpoints such as inferior mesenteric artery exposure, right
and left instrument movement, rectal mobilization, and steps
for the anastomosis. Interestingly, there was also a significant
difference in movement of the left instrument between
S27
residents and experts. This closely relates to what we feel is
one of the important steps of training to do a laparoscopic
colectomy, namely that exposure of the tissues to be dissected
by the operating surgeon’s non-dominant hand as a very
important part of performing an efficient laparoscopic
procedure.
Recent psychological studies suggest that avoiding disap-
pointment is a powerful motivator for training. Proximate
feedback may improve performance, and also may make the
trainee’s expectations of their performance on a procedure
less optimistic than if they did not expect proximate feedback.
Kettle and colleagues showed that when trainees expected
feedback, they were less likely to give themselves a high score
on their performance of a training technique. If they were told
that this feedback would not given until 1 or 2 weeks later,
they were more likely to score themselves higher. This rein-
forces the concept that proximate feedback is an important
part of the trainee’s perception of the learning process.
In conclusion, the best skills’ training likely depends on
a combination of having the optimal curriculum, in conjunction
with an appropriate training model. Which training model is
used depends on the trainee’s prior experience and the subject
matter being taught. A trainee with minimal experience in
colorectal surgery may get a lot of benefit from a plastic hybrid
virtual reality skills trainer; an experienced surgeon in clinical
practice of general surgery who has open surgical experience
and performs laparoscopic cholecystectomies in his practice is
less likely to get benefit from a hybrid VR simulator. For these
surgeons, either a live porcine model with bleeding, or a cadaver
model may be the optimal means for training. For both groups,
however, a high fidelity full VR simulator may be useful as they
can practice the procedure a number of times before using the
procedure in the clinical setting.
With all of these training models, there is great need to
develop standardized metrics of assessment of performance
in operative procedures, both in the training lab and, perhaps
even more importantly, in clinical practice. All of these
training methodologies provide opportunity for feedback.
Whether this is proximate or terminal, feedback is likely to
help accelerate the learning of the trainee for the procedure
being taught.
Conflict of interest
None declared.