Video-Based Coaching: An Efficient Learning and Teaching Modality for Pediatric Surgery and Pediatric Urology Training Program

Introduction

Teaching surgical procedures to trainees has been a subject of debate for many years.

Traditionally, surgical trainees acquired deliberate practice in the operating room (OR), with progressive independence throughout training.^1,2

However, as resident operative experience becomes increasingly limited by duty hour restrictions, above all in the COVID era,^3,4 the implementation of fellowships, and productivity, quality, and safety pressures on attendings, and concerns about the competence of new graduates have arisen.^5,6

The use of video-based coaching would fill these gaps in their operative education.

The use of huge hard disks for the storage of the videos of all minimally invasive surgery (MIS), endourological, and robotic procedures in all the operative theaters has evolved a lot in the past few years, allowing zooming and visualization of the surgical anatomy clearly. ⁷

The development of integrated multimedia ORs has made possible to record surgical procedures in MIS and open surgery. This modality of video storage allows the trainees to study surgical procedures based on video analysis.

The digital recorder gives indeed students a direct and immediate feedback for their performance from the various practical procedures, and it may aid in the transition from theory to practice. ⁸

The study of surgical procedures by video would be superior to classical learning by reading textbooks. We adopt this teaching modality using video coaching in our pediatric surgery and urology training program in the past 2 years.

The aim of this study is to compare two learning methods of surgical procedures, operative textbooks and video-based coaching, in a group of 10 pediatric surgery trainees.

Materials and Methods

We selected five surgical procedures to study: three MIS procedures, Nissen fundoplication, partial nephrectomy, and cholecystectomy; and two robotic procedures, Lich–Gregoir reimplantation for vesicoureteral reflux (VUR) and Henderson–Hynes pyeloplasty for ureteropelvic junction obstruction (UPJO).

OR video recordings ⁹ were transcribed with patient and surgeon identifiers removed.

We selected 10 residents from our pediatric surgery training program, with a similar level of surgical education, who have never personally witnessed the execution of one of the following procedures. These trainees were all part of the same graduate school and, specifically, 6 of them attended the first year of school and 4 of them the second year.

These trainees were divided, in a randomized manner, into two groups of 5 each, Group 1 (G1) and Group 2 (G2), consisting of 3 first-year and 2 second-year trainees. G1 studied the five procedures analyzing videos and G2 studied the same procedure classically reading a selected textbook on pediatric surgery detailing the surgical techniques.

Both groups had an equal period of 2 weeks to study the five techniques. The trainees were asked not to consult any additional source of learning during this period, such as internet, other textbooks different from those given to G2, or any other type of multimedia files different from those given to G1.

Tutors prepared a questionnaire of 100 multianswered questions that was submitted to both groups, divided into 20 questions for each surgical technique. The questionnaire was focused on minimally invasive procedures and, specifically, on trocar's access modalities, trocar's positioning, choice of devices, use of needles, and surgical steps. Furthermore, some questions were supported by some images and asked to identify an exact moment of the procedure.

After 2 weeks, an examination session was organized and the trainees had 2 hours to answer to all the questions. The questionnaires were corrected by the tutors and the answers were reviewed together with the trainees. The tutors were unaware of the groups the questionnaire belonged to during the correction of the questionnaires.

At the end of the test, we gave to trainees an evaluation questionnaire of the study method, with questions aimed to obtain feedback about their study experience. In this we considered the hours they spent studying each single procedure and their grade of satisfaction by the study method they carried out.

Results

Statistical analysis was carried out using an unpaired t-Student's test that has shown a level of statistical significant >95% with a P = .0265 for the average scores, P = .0010 for the average time of the study, and P = .0094 for the rate study session.

Analyzing the 10 questionnaires, G1 (video group) obtained a median result of 82 correct answers (74–97), whereas G2 (textbook group) obtained a median result of 64.2 correct answers (53–79) (Table 1).

Furthermore, the different score between the two groups is mostly observed in case of answers concerning complex procedures such as partial nephrectomy (P = .0453), Lich–Gregoir reimplantation for VUR (P = .0012), and Henderson–Hynes pyeloplasty for UPJO (P = .0014).

In case of more common procedures such as cholecystectomy (P = .3080) and fundoplication (P = .3786), the result was almost similar with no statistical significance (Table 2). Considering the total number of questions submitted to the trainees of G1, 14 questions did not have any answer, compared with 17 questions for G2. Only 1 trainee from G2 scored <60 (score 52), resulting an insufficient knowledge about the techniques that were studied. Analyzing statistically the results of two groups, the results of G1 were statistically significantly better than those of G2 (P = .0265).

Analyzing the evaluation questionnaires of the study methods, we found that the average study time for each procedure was 1.4 hours for G1 and 3.7 hours for G2. Furthermore, it was also found that the rate of the study session was 8.6 for G1 and 6.5 for G2 (Table 1).

Discussion

Teaching modalities in surgery and urology training programs changed completely in the past 10 years, thanks to the worldwide use of MIS, endourology, and robotic surgery.

However, analyzing the international literature, there are scanty reports comparing the old classic method to learn surgical techniques using textbooks and the new video modalities.

As proved in a study carried out by Hu et al., objective evaluation demonstrates that video-based coaching may be particularly useful for teaching higher level concepts, such as decision making, and for individualizing instructions and feedbacks to each resident. ¹⁰

Ozer et al. had shown how web-based video packages are helpful, definitive, easily accessible, and affordable that enable students with different pace of learning to reach information simultaneously in equal conditions and increase the learning curve in crowded group lectures during cadaver laboratories. ¹¹

The acquisition of surgical skills has a fundamental role in the training of a surgical resident. In a review by Forbes et al., emerged in nursing education, the use of video training seems to be a promising, relevant, and increasingly used instructional strategy that could enhance the quality of clinical skills education. ¹²

It is also useful to evaluate the average study time of the trainees, through the evaluation questionnaire that was submitted to them at the end of the study. It was found that, with video-based coaching, just 1 hour of study was enough to understand 50% of a surgical procedure. Differently, the average time taken by trainees who studied from the textbook to understand 50% of a surgical procedure was ∼3/4 hours of study for each technique. These data confirm the idea that studying a surgical procedure by video is a faster and more effective method than using a textbook.

Furthermore, trainees were more inclined to start learning from video than to use a textbook, with a greater degree of appreciation, developing more curiosity and interest in the subject, considering it as a fundamental aspect before being able to start the live learning.

From an evaluation carried out after the study, it emerged that 4 out of 5 trainees from G1 saw it as an opportunity to recover a lost teaching in the OR. Furthermore, having the possibility of stopping the video, going back and zooming in, the trainees could focus their attention better on every anatomical detail and on the various surgical steps, which is not possible to do during an operation where the tutor needs to be concentrated mainly on the surgical procedure and there is often no time to explain what is being done.

However, video recording has its limitations. First of all, a limitation of the study is represented by surgical judgment. Moreover, it allows to focus exclusively on the technical aspects of a procedure but does not allow to acquire fundamental skills such as the accuracy of the surgical technique, forward planning, exposure, and the use of assistants who are acquired only with practical activity and are basic elements in the education of a surgeon. However, video recording could play an important role in the self-assessment of a procedure carried out by a resident supervised by a tutor. In a randomized trial conducted by Soucisse et al., some residents were filmed performing a side-to-side anastomosis on cadaveric dog bowel, after which, they did a video playback coaching and debriefing session with a tutor, during which constructive feedback was given. All participants were filmed making a second intestinal anastomosis. These residents were found to be much more skilled in performing a new anastomosis than the control group who did not undergo a video coaching session. ¹³

Video coaching may be more effective in MIS, where the learning curve is longer and steeper than in open surgery. This practice may also allow to shorten the learning curve period and improve the training education of young pediatric surgeons. Moreover, video coaching might be useful when the young surgeon has his firsthand-on experience with minimally invasive procedures.

In conclusion, video-based coaching to learn surgical techniques is a novel, feasible, and excellent modality for supplementing intraoperative learning for pediatric surgery trainees. Objective evaluation using a multianswered questionnaire demonstrates that video-based coaching is statistically better than textbook classic education. Video-based coaching was also more appreciated from trainees and required less learning time. We suggest to adopt this teaching modality in every surgical training program above all to teach MIS and robotic surgery.