PNB 4D09 - Thesis Final - Kaitlyn Gonsalves - April 13 Submission

Running head: LEARNING METHODS IN ORTHOPAEDIC RESIDENCY EDUCATION

INVESTIGATING LEARNING METHODS FOR SURGICAL PROCEDURES IN

ORTHOPAEDIC RESIDENCY EDUCATION

BY

KAITLYN GONSALVES

A Thesis

Submitted to the Department of Psychology, Neuroscience & Behaviour

In Partial Fulfillment of the Requirements

for the Honours Bachelor of Science Degree

McMaster University

April 2016

LEARNING METHODS IN ORTHOPAEDIC RESIDENCY EDUCATION

ii

Descriptive Note

HONOURS BACHELOR OF SCIENCE (2016).

MCMASTER UNIVERSITY

Hamilton, Ontario.

TITLE: Investigating learning methods for surgical procedures in orthopaedic residency

education

Author: Kaitlyn Gonsalves

Supervisor: Dr. Ranil Sonnadara

Number of pages: vii, 50


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Abstract

Surgical residents often use different forms of studying to understand complex material.

Common forms of studying include writing or typing notes, reviewing a textbook, verbalizing or

explaining information to another individual, watching videos, or listening to podcasts to learn

complex material. Surgical residents are required to learn and perform a wide range of complex

surgical procedures. Recent changes in the healthcare system and the transition to competency-

based medical education (CBME) have resulted in medical educators seeking alternative

teaching methods as a supplement to direct operating room (OR) observation. Our study

compared textbook reading to a computer-based instructional video (CBVI) tool on surgical

procedures to examine the effectiveness of video-based learning tools. We studied two

procedures, ankle fracture and shoulder arthroplasty. Orthopaedic residents were split into two

groups, where each group received a baseline quiz. Residents independently studied either the

reading materials or the CBVI for a procedure, where order effects and mode of presentation

were controlled for in the design of the methodology. Both groups wrote an identical knowledge-

based quiz following the study period. One month after studying the procedures, residents

received an online retention test based on content from both procedures. A repeated measures

Analysis of Variance (ANOVA) was used to analyze the scores from the baseline, knowledge,

and retention quizzes. There was no significant difference between the quiz scores for

participants who studied via textbook or video modes for a procedure. By examining the

effectiveness of video-based learning tools for surgical procedures, it is our hope that CBVI tools

support the need for alternative teaching methods, which can be incorporated into modern

competency-based medical education for the 21st century.


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Acknowledgements

I would like to thank all the individuals in the Sonnadara lab and in the MultiSensory

Perception Lab, especially my fellow thesis students, for their guidance and support throughout

this long journey. To my family and close friends, thank you for your unwavering support and

patience while I worked away on my thesis throughout this past year, thank you for the

motivation to keep me going, and thank you for being a light through all my struggles. A special

thank you to Dr. Ranil Sonnadara, Dr. David Shore, Natalie Wagner, and Brendan Stanley for

being pillars of support. Thank you for your expertise, your kindness, and your wisdom

throughout this journey. I am infinitely thankful and grateful. They have all undoubtedly

encouraged and supported me through this project. Thank you for guiding me through this tough

year, without you, I wouldn’t be where I am today.


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TABLE OF CONTENTS

DESCRIPTIVE NOTE………………………………………………………………………..…ii ABSTRACT……………………………………………………………………………..………iii ACKNOWLEDGMENTS……………………………………………………………………....iv INTRODUCTION…………………………………………………………………….…………8

The traditional medical education curriculum…………………………………………….9

Problems with the traditional model highlight a need for reform………………………..11

Competency-based medical education curriculum (CBME)………………….…………14

Psychological foundations for learning and video-based learning………..……………..18

Using video instruction as an alternate teaching method within CBME curriculum…....21

METHODS……………………………………………………………..………………….……25

Participants……………………………………………………………..……………...…25

Procedure ……………………………………………………………..…………………26

RESULTS………………………………………………………..……………………………...29

DISCUSSION………………………………………………………..…………………….……39

Limitations………………………………………………………..………………..…….43

CONCLUSION………………………………………………………….……………..….……46

REFERENCES………………………………………………..………………………………...47


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Table Caption

Table 1. Methodology of data collection……………………………………………………..…28

Table 2. Day 2 demographics and descriptive statistics…………………………………………30

Table 3. Day 1 demographics and descriptive statistics…………………………………………32

Table 4. ANOVA analysis: within-subject factors and between-subject factors……..…………33

Table 5. ANOVA analysis: descriptive statistics…………………..……………………………34

Table 6. ANOVA analysis: tests of within-subjects effects……..………………………………38

Table 7. Descriptive statistics on demographic questionnaire from previous experience…...….40


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Figure Caption

Figure 1. Ankle Fracture Procedure showing the scores across time………………..………….35

Figure 2. Shoulder Arthroplasty Procedure showing the scores across time………..…………..36

Figure 3. Scores for ankle fracture and shoulder arthroplasty procedure ……......………...…...37


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Introduction

In medicine, there are often numerous long hours of studying material, reviewing case

studies, preparing for evaluations, and clinical procedures, which creates a demanding

environment for the medical student. On the path to becoming a medical practitioner, there is

about a 10-year timeline consisting of numerous hours of studying, practicing clinical skills, and

completing evaluations. After a minimum of three years of university, students start medical

school, and will spend three to four years learning knowledge, skills, and professional attitudes,

while applying these skills in the clinical setting as part of a health care team. Within Canada and

the United States, students graduate from medical school with a Doctor of Medicine (MD), and

begin their post-graduate work as residents who train in a specific speciality (for example,

paediatrics, family medicine, orthopaedics). Residents will do a variety of clinical rotations in

various hospitals and health care facilities under supervision of their residency program. Surgical

residents spend approximately three to seven (or more) years working in the hospital learning the

different specialities and focusing on the speciality of their choice (Hodges, 2010). They spend

extraordinarily long hours in the hospital setting taking care of patients, interpreting test results,

and reviewing case studies, in addition to learning clinical skills and understanding how to

perform surgeries in the operating room (OR) (Sonnadara et al., 2014). The traditional medical

education curriculum has prepared medical students for over a hundred years (Irby, Cooke, &

O'Brien, 2010), yet the current curriculum does not provide a flexible approach to teaching

modern physicians. There is a need for more flexible and effective approaches to prepare future

medical practitioners for modern medicine.


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The traditional medical education curriculum

Prior to 1910, medical education lacked a rigorous and standardized approach. Students were

taught by unqualified faculty members who were local doctors teaching to supplement their

income (Irby, Cooke, & O'Brien, 2010). Faculty members gave passive lectures, which did not

include opportunities to apply the knowledge to patient care and there was limited interaction

with patients (Irby, Cooke, & O'Brien, 2010). Abraham Flexner set the standard for the medical

school curriculum in the 1900s since it is primarily based on his recommendations from

Flexner’s classic 1910 report on educating physicians (Irby, Cooke, & O'Brien, 2010). He

created recommendations for medical education to be scientifically grounded within a university

atmosphere and a teaching hospital (Irby, Cooke, & O'Brien, 2010). Flexner’s 1910

recommendations transformed medical education to a more rigorous scientific standard for North

American medical schools. This revolutionary change is well known as a ‘Flexner revolution’

and it stood as the first extensive and large-scale reform in American and Canadian medical

schools in the 1920s (Hodges, 2010; Irby, Cooke, & O'Brien, 2010). Flexner’s recommendations

in the 1900s set the standard for the traditional medical education curriculum.

The traditional medical education curriculum is known as the time-spent model of medical

education curriculum, as the underlying assumption is that students will become competent

medical practitioners by being immersed in the clinical setting within a fixed interval of time

(Hodges, 2010). The rigid timelines that make up the traditional medical education curriculum is

the same model used for postgraduate surgical residency programs (Irby, Cooke, & O'Brien,

2010). The postgraduate surgical education curriculum used for residency programs requires

residents to spend a fixed time period in a clinical setting during the program (Hodges, 2010;

Sonnadara et al., 2014). During a fixed interval of time, residents are expected to work on patient


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cases, attend formal teaching in classroom settings and classroom-based learning activities,

observe and practice surgeries, as well as master clinical skills, all while learning under the

supervision of experienced clinical staff members (Irby, Cooke, & O'Brien, 2010; Sonnadara et

al., 2014). This supervision relies on the master-apprentice approach, where senior residents,

attending physicians, and senior physicians (for example, the “masters”) teach and train junior

residents (the “apprentice”) in the hospital (Dawson & Kaufman, 1998). The master-apprentice

approach has shown to be inefficient as residents have to train for years to be exposed to a full

range of surgical procedures (Dawson & Kaufman, 1998). The time-spent model has shown to be

resistant to change over time, as there have been few modifications over the past 100 years

(Hodges, 2010). Notable modifications to the model include early clinical exposure and the

addition of problem-based learning (Hodges, 2010). The common assumption is that the fixed

length of time for a residency program is sufficient for a resident trainee to develop competency

(where they must successfully showcase the appropriate abilities for a task) (Hodges, 2010). This

is not always the case. There is a lack of evidence surrounding the link between length of time

spent in a training program and developing competence (Hodges, 2010; Sonnadara et al., 2014).

The sole factor determining graduation is the length of time spent in the residency training

program; although other assessments take place during the program, it usually does not interfere

with one’s progress in the program (Hodges, 2010). Under extreme circumstances, if a resident is

clinically incompetent and fails multiple assessments, they will not be able to graduate from the

residency program.

Currently, the traditional medical education curriculum offers many concerns, as it is

outdated and it is grounded in rigid program guidelines making the curriculum inflexible (Irby,

Cooke, & O'Brien, 2010).


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Problems with the traditional model highlight a need for reform

The traditional medical education curriculum or time-spent model offers numerous problems

and concerns regarding the competency of trainees in the program. The following will discuss

current concerns and issues within the traditional curriculum.

Surgical residents and surgical residency program directors have both expressed concerns

regarding the level of preparedness of residents to practice independently upon graduation (Bell

et al., 2009). In a study by Bell et al. (2009) graduating general surgery residents reported an

average experience of completing nine essential surgeries approximately 20 times during their

residency. Approximately 121 essential surgical procedures were chosen by residency program

directors as essential for residents to practicing general surgery, yet only nine surgeries were

reported by graduating residents. It is clear the operative experience of surgical residents was not

at the level of basic competency, yet the program directors believe residents should be able to

perform these essential procedures independently upon graduation (Bell et al., 2009). The

traditional curriculum does a poor job of ensuring that surgical residents are fit for independent

practice, as residents have less experience in completing independent surgeries (Bell, Banker,

Rhodes, Biester, & Lewis, 2007). Additionally, it is possible that attending surgeons are making

decisions on behalf of the residents, in comparison to letting residents independently make their

own decisions (Bell et al., 2007), therefore the current model does a poor job of ensuring

residents are competent in these areas and inadequately prepares residents for independent

surgical practice beyond graduation.

The traditional curriculum has a number of internal limitations within its current structure.

Currently, residents are working shorter weeks in teaching hospitals due to a reduction in their

work hours; a previous maximum of 100 hours per week is currently reduced to 80 hours per


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week (Bell et al., 2007; Whang, Mello, Ashley & Zinner, 2003). A reduction in work hours

limits the amount of exposure to valuable teaching time in the hospital (Sonnadara et al., 2014;

Reznick & MacRae, 2006). Residents learn through a variety of methods, such as: viewing and

performing surgeries in the operating room (OR), and working on clinical cases under the

supervision of their senior supervisor. The time-spent model uses a fixed interval of time and

assumes overall competency in the speciality upon graduation, yet the current structure limits the

amount of time residents can learn through valuable methods, such as viewing and performing

surgeries, as well as learning under the supervision of their supervisor. Residents have a limited

amount of time to learn new surgeries in the OR during their work week, resulting in residents

reporting less exposure to view and perform surgeries, while program directors often require

more exposure to procedures to demonstrate competence (Bell et al., 2009; Sonnadara et al.,

2014). In addition, there is a high demand for surgeries in the OR to become more efficient.

Here, efficiency in the OR negatively impacts residents as they do not have sufficient time to

directly view and practice performing surgeries on a human patient (Sonnadara et al., 2014;

Reznick & MacRae, 2006; Van Eaton et al., 2011). A limited amount of direct OR observations

forces residents to practice clinical skills through stimulation, due to an increased need for

patient safety, and less time working in real clinical situations with human patients. Residents

should gain more exposure to direct OR surgeries, as it is assumed they have developed

competency through actually performing enough clinical cases during the time spent in the

residency program (Sonnadara et al., 2014; Reznick & MacRae, 2006). The fixed period of time

for a residency program has not shown to help individuals develop competency. In addition,

evaluating a resident’s competence with clear outcomes has never been clearly defined within

the traditional curriculum (Long, 2000). Successful completion of residency programs is widely


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based upon the time spent on clinical rotations, without taking into account the abilities acquired,

and disregarding competency (Carraccio, Wolfsthal, Englander, Ferentz & Martin, 2002). Thus,

without clear and defined outcomes that can be assessed, there are no valid or reliable measures

for assessing competency in residents (Hodges, 2010). Residents are expected to master clinical

procedures, while their supervisors have less time to focus on teaching residents important

clinical skills and surgical procedures, due to an increasing demand for clinical supervisors’ time

with additional administrative work (Irby, Cooke, & O'Brien, 2010; Ruiz, Mintzer, & Leipzig,

2006). Overall, a reduction in resident working hours, less exposure to surgeries, and clinical

staff who have limited time to teach residents, results in fewer opportunities for residents to learn

and presents serious obstacles for traditional or time-spent residency programs to overcome

(Irby, Cooke, & O'Brien, 2010; Sonnadara et al., 2014).

Residents must seek alternative strategies to develop competence in performing surgeries,

as today’s patients have more advanced and complex clinical cases, and there is a greater

emphasis on optimal performance with minimal errors (Reznick & MacRae, 2006). There must

be alternative methods that provide surgical residents with adequate experience to learn and

perform surgical procedures, in order to ensure they become competent surgeons. A potential

solution proposed to extend the length of residency programs (Sonnadara et al., 2014). It is

thought the additional time would allow residents to gain enough exposure to surgical procedures

and experience adequate teaching time. Yet, the length of residency programs is already long and

extending the time-spent residency program does not address the problematic issues within its

flawed and inflexible structure (Irby, Cooke, & O'Brien, 2010). The time-spent curriculum does

not provide flexibility for the trainee to learn at their own pace and the curriculum does not

prioritize a learner-centered approach. Individualized learning provides greater flexibility to


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center teaching around the trainee, by providing an individualized and learner-centered approach,

the trainee gains a more beneficial learning experience that can benefit them long-term—yet this

is currently not the case with the time-spent model (Irby, Cooke, & O'Brien, 2010).

Lastly, the time-spent model does not incorporate modern and innovative practices in

teaching and learning. Through decades of research, theories in teaching and learning have

evolved tremendously to become more established. We have collectively gained a better

understanding of how we can learn material for the long-term retention, and we can work

towards using best practices for teaching and learning clinical knowledge to improve patient-

based care. New, effective, and innovative ways to teach students to learn have not been

incorporated into the traditional medical education curriculum. The current issues arising from

the traditional model highlight the need for a medical education reform to a more flexible design

that includes effective learning methods.

To account for problems with the traditional medical education curriculum, we can find

solutions by using modern, flexible, and outcome-based approaches to training residents, such as

the competency-based medical education curriculum (CBME) (Sonnadara et al., 2014). In the

past 20 years there has been a shift towards transforming the traditional curriculum into a more

modern competency-based approach (Frank & Danoff, 2007).

Competency-based medical education curriculum (CBME)

There has been a movement to reform medical education in Canada and the United

States. Medical education is shifting towards a CBME curriculum for residency programs.

CBME can be defined in a variety of ways, and Frank et al. (2010) produced a definition

based on analyzing 173 definitions of competency-based education and identifying common


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themes among them (Sonnadara et al., 2014). CBME can be defined as a medical education

approach based on graduate outcome abilities and competencies that have been derived from

society and patient needs (Frank et al., 2010). CBME promotes a flexible style of teaching that is

centered around the learner and accountability, with less focus on the time spent in the program

(Frank et al., 2010).

Competency-based frameworks in medicine have aided in transforming the time-spent

model into a modern competency-based education (Iobst et al., 2010). In the 1990s, groundwork

was laid for the Canadian Medical Education Directions for Specialists or “CanMEDS” initiative

that was started by the Royal College of Physicians and Surgeons of Canada. It quickly became

one of the most important and influential competency-based medical education frameworks in

medicine (Frank & Danoff, 2007; Sonnadara et al., 2014). The CanMEDS initiative analyzed the

demands of modern medical practitioners: who need to be able to meet the diverse needs of

patients, their communities, and their societies they interact with to provide the best health care

(Frank & Danoff, 2007). From an analysis of patient and societal needs, the CanMEDS initiative

defined key outcome-based competencies, and grouped the competencies together into seven

clear roles of a physician to meet society’s needs (Frank & Danoff, 2007; Sonnadara et al.,

2014). The CanMEDS initiative developed an influential competency-based framework (Frank

& Danoff, 2007).

The competency-based approach aims to prepare residents for clinical practice by

focusing on successful completion of specific graduate outcome abilities and competencies

(Iobst et al., 2010). Residents can demonstrate successful abilities and competency through

outcome-based assessments (Frank & Danoff, 2007; Sonnadara et al., 2014). Residents must be

able to demonstrate they are competent on all aspects of their residency training (Iobst et al.,


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2010). The older CanMEDS 2005 framework has been revised to include changes such as

providing simple and clear language, and minimizing overlap between roles. The revisions are

included in the CanMEDS 2015 framework. The CanMEDS 2015 framework provides seven key

roles of a physician: medical expert, communicator, collaborator, leader, health advocate,

scholar, and professional (Frank, Snell, & Sherbino, 2015). Each of these roles has a set of

specific competencies related to the role (Frank & Danoff, 2007). Each of the competencies

within each role should be taught and assessed by residency programs. Residents should be able

to demonstrate these competencies upon graduation from the residency program (Sonnadara et

al., 2014). The Royal College of Physicians and Surgeons of Canada have incorporated the

CanMEDS initiatives as an essential part of Canadian medical residency education (Frank &

Danoff, 2007).

Establishing a competency-based framework can provide medical educators with the

tools to shift towards adopting a competency-based model for medical education and surgical

residency programs. A model of CBME provides a wide range of benefits for residents in

training. The CBME for residency programs focuses on accomplishing competencies based upon

abilities and de-emphasizes the time spent in the residency program (Iobst et al., 2010). With

recent changes to the healthcare system and previous issues from the traditional model,

implementing CBME will provide greater accountability for residents and clinical staff by

ensuring residents are able to successfully complete outcome-based competencies through

frequent assessments. Frequent assessments provide residents with more opportunities to learn,

as residents must demonstrate competency on assessments and tests to successfully move

forward within the residency program, thus providing supervisors with more confidence in the

residents’ capabilities (Sonnadara et al., 2014). It is key to assess and evaluate residents’ abilities


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in providing direct patient care, as it is one of their main responsibilities as a resident (Iobst et

al., 2010). Thus, the CBME framework for residency programs is centered around individualized

learning and focused on a learner-centered approach (Irby, Cooke, & O'Brien, 2010).

As CBME provides a more flexible framework with a learner-centered approach, it can

incorporate instructional methods that use the most effective strategies for residents to

understand concepts and learn clinical skills. The CBME framework offers greater flexibility for

residents to learn the curriculum, as residents can move through the program at a quicker or

slower pace, depending on how long it takes them to acquire the necessary skills to demonstrate

competency on assessments (Holmboe et al., 2010). Residents will acquire competency for skills

at different rates, as competency is based on individual progress (Carraccio et al., 2002).

Frequently practicing important skills and performing them can help residents to develop

competency, so it is important for residents to successfully complete frequent assessments and

gain feedback on their performance. The CBME model emphasizes continuous, complete, and

detailed assessments incorporated with frequent feedback to assess the resident throughout the

program (Holmboe et al., 2010). In comparison to the traditional curriculum, the CBME

curriculum will benefit residents who have gaps in specific areas of clinical knowledge, skills,

and professional attitudes. By providing continuous feedback and frequent assessments, residents

will be able to see the gaps in their knowledge, well in advance of major assessments. Thus,

residents and clinical staff members can work towards an action plan for help residents gain

competency in areas of weakness (Holmboe et al., 2010). The described benefits of the CBME

framework provide solutions to the current problems within the traditional time-spent

curriculum.


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The CBME framework can provide flexible and learner-centered solutions to the

problems with the traditional model, such as limited work hours, reduced direct OR teaching

time, and limited time of clinical staff to reach residents. The CBME model will allow for a

flexible learning environment where residents will be able to learn at their own pace (Irby,

Cooke, & O'Brien, 2010). Since the competency-based model of medical education offers a

flexible approach centered around the learner, we should look to using innovative and alternate

methods of learning that are efficient, including methods that offer the best retention for learning

complex clinical skills and procedures. Understanding the foundations of how learning works is

crucial to seeking alternative methods for residents to learn complex surgeries and important

skills. In the context of alternative methods for teaching and learning, we must first understand

teaching and learning in the field of health education.

Psychological foundations for learning and video-based learning

Medical education should be informed by research based theories that understand how

students learn, and use effective instructional teaching methods guided by evidence-based

principles (Mayer, 2010). Learning is often described as a change in the learner’s knowledge due

to experience (Mayer, 2008; Mayer, 2009; Mayer, 2011). Learning in medical education involves

multimedia learning, which is the combination of learning from words and pictures (Mayer,

2010). A well-established theory based on learning from words and pictures is known as the

cognitive theory of multimedia learning (Mayer, 2005; Mayer 2009). This theory is based on key

cognitive science principles, which emphasize that we have two different information processing

systems: auditory-verbal channel and visual-pictorial channel; both hold a limited amount of

information (Mayer, 2010). The cognitive theory of multimedia learning proposes three memory


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systems: a sensory memory that holds an exact copy of the presentation, working memory that

holds a few items at a given time, and long-term memory that holds knowledge for longer

periods of time (Mayer, 2010). Both the sensory and long-term memories have an unlimited

capacity, yet working memory has a limited amount of information that it can hold (Mayer,

2010). The capacities of the memory systems come into play when information is being

processed. Spoken words and pictures are processed separately as they enter the sensory

memory, and move into working memory (Mayer, 2010). It is within working memory that the

two channels (verbal and pictorial) are combined to create a holistic interpretation, which is

integrated with previous knowledge from long-term memory (Mayer, 2010). Learning takes

place through active cognitive processes, such as selecting, organizing, and integrating words

and pictures within each channel, respectively (Mayer, 2010). Processing information through

two different channels (which process stimuli-specific information) helps to reduce cognitive

load and makes it easier to integrate stimuli-specific information leading to understanding

complex material (Mayer, 2010).

By understanding how the learner processes information, we can shape medical education

to include teaching methods that align with how we process complex multimedia information.

Successful teaching methods initiate a change within the learner’s knowledge allowing for

learning to occur (Mayer, 2010). In order to initiate a change in the learner, there must be a clear

objective stating what is being taught, what level of expertise must the learner achieve, and how

will the learner be assessed (Mayer, 2010). Without these clear objectives, it is difficult for the

learner to understand the content, level of expertise expected, and what is expected of them in

assessment—these are clear issues within the traditional time-spent curriculum. With clear

objectives, one can design instructional materials that aid the learner in processing complex


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information. Well-designed instructional materials and teaching methods should include three

main goals: use only necessary content and minimize inessential information to avoid extraneous

(or unnecessary) processing, a level of complexity where the learner has enough cognitive

capacity to process information, and the learner has motivation to understand the given content

(Mayer, 2010).

Mayer (2010) discussed the underlying principles that govern the accomplishment of

these goals. Firstly, to reduce extraneous processing: instructors can eliminate unnecessary

material, highlight critical concepts, and place words near their respective image. Secondly, to

manage complexity: instructors should teach the key concepts in advance, separate lessons into

multiple parts, and use words in verbal form. Thirdly, to manage motivation: instructors should

present both pictures and words together, use conversation-style to present words and use a

human voice (compared to a machine-generated voice) (Mayer, 2010). These principles help to

guide multimedia learning to be an effective form of learning that coincides with how humans

process complex information. Mayer (2010) has described in-depth the importance of well-

designed teaching methods and instructional materials. Well-designed teaching methods and

instructional materials will benefit novice and experienced trainees, as with practice, they can

develop expertise and combine concepts into more complex ideas with ease (Van Merriënboer &

Sweller, 2010). Using well-designed multimedia instructional tools can benefit learners to

understand complex concepts, such as surgical procedures.

Using video instruction as an alternate teaching method within CBME curriculum

Well-designed multimedia instruction provides the learner with a video or pictures, and

spoken or printed instructions—these factors reflect real life actions and situations. In addition,


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video instruction enhances learning to go far beyond verbal explanation or printed text

(Greenhalgh, 2001). Using multimedia and video instruction provides a level of clarity that can

explain complex material in a more interactive manner using video and text, as compared to

passively reading the same content in printed text. The field of computer technology, multimedia

learning, and video instruction support various ways of learning content, which provides

versatility and flexibility when teaching content (Ruiz et al., 2006). Video instruction can allow

the learner to fast forward through the video, skip parts, and re-watch parts of the video to review

if they needed clarification. These options can be used to different extents by learners as they

progress at their own pace. Residents can use these options to help them learn a variety of

concepts. Advantages of multimedia learning include greater accessibility to content as learners

can adjust the pace and the time necessary to understand the material (Ruiz et al., 2006). Clinical

faculty and learners both agree that multimedia learning can enhance teaching and learning (Ruiz

et al., 2006). In addition, multimedia content can also include assessments throughout a video or

presentation to evaluate if the student has understood the material (Ruiz et al., 2006) and it can

provide a check-in regarding what they have learned. Multimedia learning provides solutions to

the previously stated issues with the traditional time-spent medical education curriculum, such as

the reduced resident work hours and limited teaching time from clinical staff. Multimedia

learning provides a flexible approach that can be incorporated into the CBME curriculum.

Learning using computer technology provides a convenient, flexible and personalized learning

experience for students to absorb material at their own pace (Greenhalgh, 2001). In addition,

multimedia content can be updated to match and reflect changing attitudes, new research

findings, and additional skills. Multimedia is a convenient, flexible, and efficient learning


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experience for residents, allowing residents anywhere in the world to review the same material

while still gaining a personalized learning experience.

Multimedia, computer and internet technologies, and computer-based video instruction

(CBVI) have been widely used in the context of medical education (Larvin, 2009). Learning via

computer and internet technologies has made medical e-learning an important priority in the UK

Department of Health. The UK Academy of Medical Royal Colleges have created e-learning

programs for various health care services (Larvin, 2009). The UK Academy also recommended

collaborating on e-learning ideas and sharing e-learning resources across health care professions

(Larvin, 2009). In addition, the UK Academy also recommended online assessments that are

directly related to expected learning outcomes and common competencies, in hopes of making

online assessments more reliable than one-time examinations (Larvin, 2009). Using technology

for learning or e-learning creates a huge potential for educating residents in surgical training,

compared to any other medical specialities (Larvin, 2009).

Multimedia learning benefits medical students learning surgical techniques. In a study by

Dubrowski & Xeroulis (2005), with 21 medical students, the authors investigated self-directed

learning skills by giving students a CBVI tool of the procedure (which was optional and they

were encouraged to use it for learning) but it was not necessary to use the CBVI to complete the

task. The students had to complete a 1-hour session on how to close wounds with suturing

instruments and knot tying techniques. The CBVI contained two versions of the video: 1)

presentation video involved slow speed and narration from an expert surgeon discussing proper

use of tools, tips on good techniques to use, common errors, and the overall performance of the

wound closure with suturing and knot tying techniques, 2) presentation involved a real-time

video with narration by an expert surgeon. Results indicated that medical students viewed


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sections of the slow presentation more, in comparison to the real-time video. The slow video was

used extensively during the practice sessions (Dubrowski & Xeroulis, 2005). Both videos were

shown to be useful as medical students learned surgical techniques, yet the slow presentation

highlighted section that were more beneficial to new learners, while the real-time presentation

would benefit experts (Dubrowski & Xeroulis, 2005). The study by Dubrowski and Xeroulis

(2005) highlights the added advantage of using CBVI, as compared to learning without using

CBVI. With the additional use of CBVI, the entire video or sections of the video can be re-

watched and re-played while the learner practices the task.

In an academic environment, individuals who used CBVI or video-based tools learned

more efficiently and exhibited better retention, as compared to more traditional teaching

strategies (Larvin, 2009). The Royal College of Surgeons of England valued e-learning to the

extent of revising their Surgical Education and Training Programme (STEP) in 2001 and

including an e-learning component (Larvin, 2009). Computer-based video instruction should not

replace traditional methods, but it should complement current teaching methods in the CBME

curriculum (Ruiz et al., 2006). Multimedia and video-based instruction provides the material in a

flexible format where one can learn from any place with access to the video. Multimedia

instruction provides an added advantage for surgical residents who work multiple shifts and a

considerable number of hours in a day. As the time with clinical supervisors is limited and the

work hours in a week are reduced, alternate methods for learning complex material must be

sought, such as using computer-based video instruction and e-learning for complex concepts,

especially when a considerable amount of studying must be done off duty (Larvin, 2009).

Instructional video-based learning offers experiences similar to real life practice, which

contrasts the act of passively reading textbook material. Residents have studied textbook content


24

for numerous years on their path to becoming a medical practitioner. Yet, studying complex

material from a textbook takes much longer than watching a multimedia video. It is possible

using video-based instruction could provide an alternative and effective learning method for

residents, especially given the time constraints with the traditional curriculum.

Based on the need for alternative methods for teaching residents complex surgical

procedures, we will compare two study methods for residents, instructional videos of surgical

procedures with voiceover instructions and traditional textbook readings to determine which

method provides better knowledge retention. We can use retention tests to assess how well the

learner retains information over time, based on information that was previously presented to

them (Mayer, 2010). The purpose for this study is to investigate the most effective method for

studying complete and complex surgical procedures, by comparing if textbook material or video-

based material is more successful.


25

Methods

We will use four surgical procedures in this study: Anterior Cruciate Ligament (ACL)

repair, shoulder arthroplasty, elbow arthroscopy, and ankle fracture. Participants will study the

procedures through different resources, either studying a procedure using textbook material, or

studying a procedure using the 10 to 20 minute surgical video with instructional voiceover from

a staff surgeon.

Participants

The participants were 18 orthopaedic surgical residents across all post-graduate years

(PGY) 1 through 5 from the McMaster Orthopaedic Program. From the 18 orthopaedic residents,

all were male, while the mean PGY was 2.88 years (SD 1.32 years). The residents were recruited

with support from the program director and program coordinator of the McMaster Orthopaedic

Program. On Day 1 of data collection, the 18 residents who showed up were randomly assigned

into two groups: Group A and Group B. Group A and B were separated from each other to

ensure participants completed the study individually. Two participants were excluded from the

data. One participant left halfway through the study period, and another participant only

completed one procedure on each data collection day, instead of the required two surgeries due

to being late on both days. For these reasons, the two participants were excluded from the results.

Both individuals were previously assigned to Group A. After excluding the two participants from

the results, Group A had 8 residents and Group B had 10 residents. There were two days of data

collection: Day 1 and Day 2.


26

Procedure

All participants completed a consent and demographic questionnaire. All participants had

10 minutes to complete a baseline quiz on ankle fracture and shoulder arthroplasty procedures, in

order to gauge their previous knowledge prior to completing the study. On Day 1 of data

collection, all participants studied two procedures: ankle fracture and shoulder arthroplasty.

Group A learned ankle fracture by reading the text material, while Group B learned ankle

fracture by watching the video with voice instruction. All participants had 15 minutes for the

study period. Immediately after the study period, participants had 5 minutes to complete a short-

answer knowledge based quiz to test if they gained any knowledge from the material. Next,

Group A learned shoulder arthroplasty by watching the video with voice instruction, while

Group B learned shoulder arthroplasty by reading the text material. All participants had 20

minutes for the study period, and they had 5 minutes to complete a short-answer knowledge

based quiz.

On Day 2 of data collection, all participants studied the final two procedures: elbow

arthroscopy and ACL repair. All participants had 10 minutes to complete a baseline quiz on

elbow arthroscopy and ACL repair procedures, in order to gauge their previous knowledge prior

to completing the study. Group A learned elbow arthroscopy by watching the video with voice

instruction and completing a quiz, while Group B learned elbow arthroscopy by reading the text

material and completing a quiz. The study periods for elbow arthroscopy and ACL repair were

both 15 minutes with 5 minutes to complete the knowledge quiz. Next, Group A learned ACL

repair by reading the text material and completing a quiz, while Group B learned ACL repair by

watching the video with voice instruction and completing a quiz. On each data collection day,

both Group A and Group B had one hour to complete the two baseline quizzes, study two


27

procedures and complete the procedure-specific knowledge quizzes. By the end of data

collection Day 2, both groups have learned four surgical procedures in total, and each group

would have only learned a procedure either by text or video material. The methodology is best

described visually, as seen in Table 1.

One-month post-data collection, an online retention test was administered to all

participants via the McMaster LimeSurvey platform. The goal of the retention test was to see if

participants retained the knowledge they previously studied on the two data collection days

encompassing all four procedures. The retention quiz included six to seven questions per

procedure. The participants received a personalized invitation via an e-mail with a link to the

closed survey. Participants had approximately five days to complete it. Participants received

reminder e-mails approximately 12 hours before the midnight deadline. All factors have been

taken into consideration and they have been controlled for in the development of the

methodology to ensure they do not influence the results.

The text reading material, including questions and answers for baseline, knowledge, and

the retention quizzes were created by the senior orthopaedic staff surgeon and orthopaedic

resident on this project. Each procedure specific quiz had approximately six or seven questions.

The quizzes were all in the form of short answer as to be fair to both groups who studied using

either textbook or video material. If the quizzes were multiple choice, participants who studied a

surgery via textbook material might be able to recognize the written correct answer. Recognizing

words you were previously exposed to leads to recognition memory and the repetition effect,

which would be far greater for words that were studied and later tested (Goldinger, 1996;

Hintzman, Block, & Inskeep, 1972). Thus, if the quizzes were multiple choice, participants who

studied via textbook material would gain an unfair advantage leading to skewed results.


28

Table 1. Methodology of data collection

Data Collection

Group 1 (A) Time Allocated Group 2 (B) Time Allocated

Day 1 (February 3rd

2016)

Baseline Quiz 10 mins Baseline Quiz 10 mins

Ankle Fracture (text)

Study - 15 mins Ankle Fracture (12 min video)

Study - 15 mins

Quiz - 5 mins Quiz - 5 mins

Shoulder Arthroplasty

(18 min video)

Study - 20 mins Shoulder Arthroplasty (text)

Study - 20 mins

Quiz - 5 mins Quiz - 5 mins

Day 2 (February 17th

2016)

Baseline Quiz 10 mins Baseline Quiz 10 mins

Elbow Arthroscopy (12 min video)

Study – 15 mins Elbow Arthroscopy (text)

Study – 15 mins

Quiz – 5 mins Quiz – 5 mins

ACL Repair (text)

Study – 15 mins ACL Repair (14 min video)

Study – 15 mins

Quiz – 5 mins Quiz – 5 mins

Day 3 Retention test

(March 8th–12th 2016)

LimeSurvey Quiz: Procedure 1 Procedure 2 Procedure 3 Procedure 4

LimeSurvey Quiz: Procedure 1 Procedure 2 Procedure 3 Procedure 4


29

Results

Since one group studied a procedure via text, and the other group studied the same

procedure via video, we investigated if there are differences in the information retained by the

study method. We compared baseline quiz scores, knowledge quiz scores immediately after

learning, and retention quiz scores one month later, across both groups and all procedures. We

will use this as a link to understand which method of studying (text or video) was the most

effective for long-term retention, which we hope will benefit surgical residents when learning

complete surgeries.

Data from Day 2 of data collection was excluded from data analysis, as a random

assortment of participants returned for the second part of the study, resulting in an imbalance

between groups on Day 2. As Group A had two participants, and Group B had seven

participants, it created an imbalance, resulting in insufficient data to run further analysis (see

Table 2 for descriptive statistics).

The research question considers if computer-based video instruction (CBVI) is an

effective tool for teaching complete and complex surgeries in surgical residency programs. To

assess the primary research question, data were analyzed using a repeated measures Analysis of

Variance (ANOVA) design. It was chosen to compare which of the two study methods is more

effective over time, as all residents participated in learning both surgical procedures. The

dependent measures were the quiz scores for the baseline, knowledge, and retention quizzes. The

within-subject factors were: time point (with three levels: baseline, immediate knowledge test,

and one month later for the retention test), and procedure (with two levels: ankle fracture and

shoulder arthroplasty). The only between-subjects factor was group (with two levels: group A

and group B). This aided in understanding the differences among groups receiving either


30

Table 2. Day 2 demographics and descriptive statistics

Group A Group B Number of participants 2 7 Mean PGY (years) 2.5 2.71 SD of PGY (years) 2.12 1.50 Median PGY (years) 2.5 3 Gender All male All male


31

textbook or video material for a procedure. Statistical significance at p<0.05 was considered

significant. The statistical software used was SPSS IBM version 23.

Demographics on Day 1 from both groups indicated that Group A had 8 participants with

a mean PGY of 3.1 years (SD of PGY was 1.36 years), and a median PGY of 4 years. Group B

had 10 participants with a mean PGY of 2.8 years (SD of PGY was 1.32 years), and a median

PGY of 3 years (see Table 3). Refer to Table 2 for descriptive statistics from Day 2 participants.

The ANOVA looked at the scores of participants who completed the baseline,

knowledge, and retention quizzes for ankle fracture and shoulder arthroplasty procedures. There

was a total of n = 11 participants (see Table 4). The descriptive statistics including the mean and

standard deviation of the quiz scores for ankle fracture and shoulder arthroplasty procedures can

be found in Table 5 (to see a graphic representation, see Figure 1 and 2). Across three time points

for both surgeries, participants had statistically significant changes in their scores showing a

main effect of time F(2,18) = 10.30, p = 0.001 (see Figure 3). All other factors were not significant

and outliers have been removed (see Table 6).


32

Table 3. Day 1 demographics and descriptive statistics

Group A Group B Number of participants 8 10 Mean PGY (years) 3.1 2.8 SD of PGY (years) 1.36 1.32 Median PGY (years) 4 3 Gender All male All male


33

Table 4. ANOVA analysis: within-subject factors and between-subject factors

Within-subject factors Dependent variable Between-subject factor Procedure Time Group A Group B

1 – Ankle Fracture 1 Ankle fracture baseline quiz score

N = 4 N = 7

2 Ankle fracture knowledge quiz score

3 Ankle fracture retention quiz score

2 – Shoulder Arthroplasty

1 Shoulder arthroplasty baseline quiz score

2 Shoulder arthroplasty knowledge quiz score

3 Shoulder arthroplasty retention quiz score


34

Table 5. ANOVA analysis: descriptive statistics

Dependent variable Group: A or B

Mean Standard deviation

N

Ankle fracture baseline quiz score

A 46.88% 21.35% 4 B 42.86% 6.68% 7

Ankle fracture knowledge quiz score

A 67.50% 22.17% 4 B 80.00% 17.32% 7

Ankle fracture retention quiz score

A 62.07% 6.56% 4 B 46.88% 26.93% 7

Shoulder arthroplasty baseline quiz score

A 56.25% 12.50% 4 B 39.29% 9.27% 7

Shoulder arthroplasty knowledge quiz score

A 67.86% 21.43% 4 B 71.43% 27.36% 7

Shoulder arthroplasty retention quiz score

A 67.71% 13.68% 4 B 63.20% 24.52% 7


35

Figure 1. Ankle Fracture Procedure showing the scores across time. Participant scores were collapsed within Group A and within Group B.

47%

68%62%43%

80%

47%

0%10%20%30%40%50%60%70%80%90%

100%

Baseline Quiz Knowledge Quiz Retention Quiz

Qui

z Sc

ore

Time

Ankle Fracture Procedure

Group A (text)

Group B (video)


36

Figure 2. Shoulder Arthroplasty Procedure showing the scores across time. Participant scores were collapsed within Group A and within Group B.

56%68% 68%

39%

71%63%

0%10%20%30%40%50%60%70%80%90%

100%


Qui

z Sc

ore

Time

Shoulder Arthroplasty Procedure

Group A (video)Group B (text)


37

Figure 3. Scores for ankle fracture and shoulder arthroplasty procedure are collapsed together across group, which highlights the main effect of time.

46%

72%

60%

0%10%20%30%40%50%60%70%80%90%

100%


QU

IZ S

CO

RE

TIME

Ankle Fracture and Shoulder Arthroplasty Quiz Scores


38

Table 6. ANOVA analysis: tests of within-subjects effects

Measure Degrees of freedom and F value Significance, p value Time F(2,18) = 10.30 0.001 Procedure F(1,9) = 0.54 0.48 Procedure*Group F(1,9) = 0.18 0.67 Time*Group F(2,18) = 1.77 0.20 Procedure*Time F(2,18) = 1.36 0.28 Procedure*Time*Group F(2,18) = 0.95 0.41

Note. Only the main effect of time was significant, all other factors were not significant.


39

Discussion

Results show that across time, participants have statistically different scores, this

indicates the textbook material and video material influenced their scores across the three time

points. There was a non-significant difference across the 3-way interaction of time, group, and

procedure. This indicates that textbook material and CBVI show similar learning outcomes. The

main effect of time being significant from the ANOVA highlight that across time, participants

had significant differences between their scores on the baseline, knowledge, and retention test

across procedures (refer to Figure 3). This indicates that participants did better on the knowledge

quizzes after reviewing either the textbook or video material; yet one study mode was not

superior to the other, as they were roughly equal in providing the learner with knowledge to

complete the quizzes.

Prior experience and PGY were taken into account through the demographic

questionnaire at the beginning of the study, and on the retention test. The demographic

questionnaire asked about prior experience: how many times they have completed any of the four

surgeries, and how many times have they watched (and not completed) any of the surgeries. The

retention test questionnaire asked participants if they had completed or witnessed any of four

surgeries during the 4-week period between the last study period and the retention test. This

information provided valuable insight into the previous knowledge and experiences of the

residents that they bring with them as they complete this study and prior to completing the

retention test. Descriptive statistics on the demographic questionnaire and participants’ previous

experience can be found in Table 7 and it is discussed below.

Regarding the demographic questionnaire, participants who completed or witnessed a

procedure in the range of 20-50 times, did relatively better on the respective procedure and


40

Table 7. Descriptive statistics on demographic questionnaire from previous experience

Measure

How many times have you actively participated in the following:

How many times have you witnessed (and not actively participated) in the following:

ACL Repair


Ankle Fracture Repair

Elbow Arthroscopy

ACL Repair


Ankle Fracture Repair

Elbow Arthroscopy

Mean 10.94 5.5 19.53 0.93 17.81 7.19 23.06 0.81

SD of mean 8.94 5.98 17.60 1.831 19.12 8.09 22.16 1.72

Median 10 4 10 0 8.5 5 11 0

Note. Participants entered in numbers 0–50 to quantify their previous experience for a procedure.


41

scored in the range of 70-80% on the respective procedure’s knowledge and retention test

(example: a participant in PGY 4 had viewed the ankle fracture procedure approximately 50

times, scored 50% on the ankle fracture baseline quiz, scored 90% on the knowledge quiz, and

71% on the retention test after studying the ankle fracture video). Residents who have viewed

more procedures tend to be in PGY 4 or 5, which is towards the end of their residency and they

have much more experience than first or second year residents. Their vast amount of experience

in completing and viewing specific surgeries over the years attributed to their higher scores on

the quizzes for the respective surgeries.

Regarding the retention test, approximately 11 participants completed the retention test at

the time of analysis, yet of the 11 participants, only five of them had completed or witnessed one

or more of the surgeries during the four-week period. It is thought that these five participants

would score better on the retention test, considering they completed or witnessed these surgeries

during the four-week period between the last study period and the retention test. About 3 of the 5

participants scored 70% and above on the retention test related to the surgeries they had

completed or witnessed. The other two participants did somewhat worse (they scored 57% and

14% respectively) on the retention test related to the surgeries they had completed or witnessed.

It is possible that our retention test answer key was specific to the teachings from one or two

orthopaedic staff surgeons, so it was not inclusive to all possible alternate answers from other

staff surgeons. The way that residents learn from experienced staff surgeons can differ, as it

depends on the staff surgeon whom is supervising the resident, so residents may have learned the

same surgery in slightly different ways. This can contribute to their different answers on the

baseline, knowledge, and retention quizzes, and thus affected their scores on our dependent

measure.


42

Participants in both Group A and Group B had variable scores after watching the video of

a procedure compared with the textbook material—sometimes they scored much better and

sometimes they scored much worse. In some cases, the video of the procedure helped the

participant to score better on the knowledge quiz, yet it did not improve their score on the

retention test a month later. One participant on Day 2, stated “watching the video of the ACL

repair was so much easier.” However, this participant scored 70% on the baseline quiz for ankle

fracture, 73% on the knowledge quiz, and 29% on the retention test. Through anecdotal

conversations with participants, they seemed to enjoy and prefer the video of the procedure, yet

they did not always improve on the respective knowledge and retention quizzes. Participants

could enjoy multimedia and CBVI tools due to the convenience of replaying or stopping the

video, yet it could also be less engaging, as they could prefer other forms of learning, such as

live lectures, which should be further explored (Schreiber, Fukuta, & Gordon, 2010).

In other cases, participants who watched the video of the procedure did relatively the

same as their baseline, or worse. These instances where participants did worse on the knowledge

and retention test could be explained by a few environmental and individual factors. Both data

collection days were an hour earlier than the residents’ scheduled grand rounds, and participants

could have been tired from an earlier on-call night (in one case). As well, there was no real

motivation or drive for residents to participate in a research study as there were no direct benefits

or compensation for their participation. This can be seen through participation on the retention

test approximately two weeks after the deadline and analysis had to accommodate the late

responses. These factors could all have negatively attributed to participants score on the quizzes.


43

Limitations

Limitations of the study include a variety of factors, such as participant recruitment, and

marking the data from the quizzes. The study was completed in three phases that needed all

participants to return to all three phases. Recruiting participants to come in on time (as it was

early in the morning) and to return on subsequent days of the study was a challenge. Only half

the participants came back on Day 2 to study the final two procedures, greatly limiting the

amount of full data sets we would have for analysis. As well, participants were randomly

assigned to Group A or Group B, and they had to stay within their groups to receive the proper

study mode for the given procedure. The groups on Day 2 were imbalanced, as only two

participants came back from Group A, and seven participants came back from Group B.

Recruiting participants for the retention test was another challenge, as only eight participants

completed the retention test by the original deadline. Two weeks after the deadline,

approximately seven participants completed the retention test. The majority of participants who

completed the retention test did not complete data collection on Day 2, thus we did not have a

full data set to compare their pre- and post-answers. Participants who did not return to complete

all three phases of the study affected data analysis and it greatly contributed to the exclusion of

Day 2 from the results. Our strong relationship with the orthopaedic program director aided us

greatly in recruiting participants, yet it still remained a challenge to get the same residents to

come out to all three data collection days to create complete participant data sets across all three

phases. To resolve this, it would be crucial to advertise the study as three phases, where

attendance at all three phases are required to participate, and include a compensation in monetary

value or gift prize to be won at the end of the study.


44

A considerable barrier was individually marking the baseline, knowledge, and retention

quizzes. The researcher marked all short answer quizzes for Day 1, Day 2, and the retention test.

The answers from participants compared to the answer key highlighted only partial matches, and

it was discovered that participants answered quite differently than the correct answer we were

looking for on the answer key. This was a huge barrier in accessing correct scores for each quiz,

as each alternate answer for each question on every quiz had to be double-checked by an

orthopaedic staff surgeon. All alternate answers for each question on every quiz had to be

recorded, and verified to be either correct or incorrect. This barrier directly affected the scores on

the dependent variable, as personal judgment had to be used regarding each incorrect or correct

response. It is possible some answers could have been marked incorrectly, due to using personal

judgment and advice from the orthopaedic staff surgeon. This could be relieved through two or

three individuals simultaneously marking all the quizzes in one session, and one of them would

be the orthopaedic staff surgeon or resident on the project to advise on possible alternate

answers.

Future research and directions from this project could take on many forms. A secondary

study from this research could compare textbook material and video material in combination,

compared to text material only, and video material only. Other suggestions could be to compare

how residents perform on live versions of these surgeries, and residents could be assessed in real-

time using competency-based assessments from a staff surgeon. Since residents practice

procedures in the OR during their time spent in residency, it would be worthwhile to investigate

how residents in PGY 1 through 5 perform during live surgeries, while an orthopaedic staff

surgeon assesses their competency using valid and reliable assessment tools, such as filling out a

checklist and assessment during the live procedure. It would be interesting to see if


45

implementing feedback and not implementing any feedback from the staff surgeon plays a role in

how residents perform during live procedures. A future study could compare the scores on the

assessment tools to further understand how residents learn while in the OR, and information

from this study can be compared to studying CBVI tools and textbook material for the same

procedures.


46

Conclusion

Although this project cannot definitively state that video materials are superior to text

materials for studying complete and complex surgical procedures; surgical residents can continue

to use traditional text material and articles for reference, and supplement their learning with

additional instructional videos that can provide an engaging learning experience similar to

completing the surgery live. The videos created for this project can be used by the residents in

the McMaster Orthopaedic program to supplement their learning when they are not in the OR or

in the hospital. The reading materials and videos can be available to them no matter where they

are, especially for when they cannot be in the OR.

Medical education has taken huge strides in the past few decades. The addition of

ongoing research investigating best practices, optimal learning methods, and techniques for

teaching surgical procedures to residents indicate that modern medicine is becoming more

flexible to encompass the best practices for learning. The Royal College of Physicians and

Surgeons of Canada and medical educators need continue to learn from one another to

implement competency-based frameworks throughout all medical education programs and work

together to provide the best possible learning environments for future medical practitioners.


47

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