Continuous versus step by step training for learning surgical anatomy on an open inguinal hernia model

Background: Segmentation of surgical procedures may facilitate learning. The step-by-step framework segments surgical procedures in a standardized manner based on anatomy. The effects of the framework are compared to a continuous approach, on learning anatomy on an inguinal hernia model by pre-novices. Methods: Students from 10 high schools located in or near Rochester, Minnesota, were randomized into continuous and step-by-step groups. They trained using step-by-step versus continuous videodemonstrations of an open inguinal hernia repair on a simulation model. Anatomical knowledge and cognitive load were assessed. Results: In total, 220 students participated (156 female; mean age 15 years). In the selection that watched the video-demonstration, the step-by-step group answered 1.9 questions correctly, and the continuous group 2.4, p=0.010. The cognitive load did not differ between the groups. Conclusions: In pre-novices, anatomy knowledge transfer might be better using continuous rather than step-by-step video-demonstrations. Research Article Continuous versus step by step training for learning surgical anatomy on an open inguinal hernia model Tahmina Nazari1*, Muhammad H Zeb2, Mary EW Dankbaar3,4, Johan F Lange1,5, Jeroen JG van Merriënboer6, Theo Wiggers7 and David R Farley2 1Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands 2Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA 3The Institute of Medical Education Research Rotterdam (iMERR), The Netherlands 4Department of Education, Erasmus University Medical Center, Rotterdam, The Netherlands 5Department of Surgery, IJsselland Hospital, Capelle aan den IJssel, The Netherlands 6Department of Educational Development and Research, Faculty of Health, Medicine & Life Sciences Maastricht University, Maastricht, The Netherlands 7Incision Academy, Mauritskade 63, Amsterdam, The Netherlands Received: 05 November, 2019 Accepted: 30 November, 2019 Published: 02 December, 2019 *Corresponding author: Tahmina Nazari, MD, Department of Surgery, Erasmus University Medical Center, Doctor Molewaterplein, 40, 3015, GD Rotterdam, The Netherlands, E-mail:


Introduction
To prepare for a surgical procedure, learners may use many resources (journals, books, video, et cetera) including learning from their superiors by watching them perform the surgery in the operating room, known as the master-apprentice model [1].
Due to work hour regulations and decreased exposure time in the operating room, the emphasis today in surgical education is on better preparation before entering the operating room [2,3]. A framework based on anatomical structures has been proposed by our group to segment surgical procedures into steps in a standardized manner [4]. An international expert panel supported the preciseness, usefulness, and applicability of the step-by-step framework. We pondered that the stepby-step framework may also facilitate surgical training for anatomical knowledge using the video-demonstration of a surgical procedure.
The process of learning and the effectiveness of instructional design choices should be understood to optimize the teaching process. The cognitive theory of multimedia learning can explain the learning process from dynamic visualizations such as video and animation [5]. An assumption in this theory is that learners have a limited cognitive capacity available to process new information [6].
The cognitive capacity needed to process new information is known as cognitive load [7]. When this new information is presented as a video or animation (streaming information), the cognitive load can be high because information that is disappearing from the screen needs to be retained and processed in working memory, or otherwise information that is later presented on the screen cannot be understood (also called transiency of information).
Citation: Nazari  To lower the cognitive load, the segmentation principle in the cognitive theory of multimedia learning can be applied [8]. With the segmentation principle, the video is divided into smaller parts with pauses in between, allowing learners to completely process one segment before moving on to the following segment. Segmentation could also lower the cognitive load by constructing a cognitive schema of the task [9]. The construction of cognitive schemas is especially useful for novices as they do not possess the schemas to comprehend a complex task yet [8].
In the surgical fi eld, the effects of the step-by-step framework on learning surgical anatomy have not been proven.
The current study aimed to investigate the effects of an online course based on the step-by-step framework, consisting of a video-demonstration and textual description of the knowledge of the surgical anatomy of a surgical procedure in pre-novices, such as high school students. The primary endpoints are anatomical knowledge and cognitive load.

Design
It was a randomized study with two groups: an online course containing continuous video-demonstration and textual description (continuous group) and an online course containing segmented video-demonstration and textual description (step-by-step group). Random assignment to one of the two groups was realized on the school level in which all students of each participating school were included within the same group to prevent contamination. This cluster randomization was chosen as students from the same classes, and teachers cannot be randomized on an individual basis as there is too much risk of contamination. The risk of cluster randomization is an imbalance between the groups, a recruitment bias, such as different teachers, different amounts of attention to the study, etcetera. This problem has been addressed by a large sample size [10]. The randomization was blinded for the researchers.
The open inguinal hernia repair was chosen as a surgical example for the study since this procedure is complicated and execution cannot be performed without adequate anatomical knowledge. One week before the test, the high school students were granted access to their group-specifi c online course to prepare for the test. During the test day, the students fi lled in a questionnaire and were examined on their anatomical knowledge using a simulation model representing all relevant anatomical structures. Figure 1 outlines the study design.

Participants
The participants were 220 high school students (64 male and 156 female) from 10 high schools in or near Rochester, Minnesota, in the United States. The participants' average age was 15 years (SD ±2, range 12 to 18) with a median grade of 11 (range 7 th to 12 th grade).
The study took place within the Mayo Clinic in Rochester, Minnesota, as part of a more extensive seminar involving other medical learning experiences (The "Saving Lives with Gus" seminar offered exposure to CPR, using a defi brillator, tying surgical knots, using an ultrasound machine, et cetera.) Participation was voluntary and all participants consented to the study.

Online course
One week before the seminar, the students could access an online course where they were instructed to study a surgical procedure (open inguinal hernia repair) and Con nuous video & text

Con nuous Group
Step-by-step Group   anatomy (male groin). The students had one week to study the course. The course consisted of an introduction and the video-demonstration and textual description of the open inguinal hernia repair including all the anatomical terms. The difference between the two groups was the continuous videodemonstration and textual description versus a step-by-step video-demonstration and textual description of the surgical procedure. The rest of the course, including the information about anatomy, was identical.
The introduction contained a text and a video of 2:39 minutes, which explained an inguinal hernia. The text also explained a hernia and medical jargon such as medial and lateral. The introduction was similar for both groups.

Questionnaire
The high school students were asked to fi ll in a questionnaire regarding their time spent studying the online course and how they perceived their cognitive load during the online course (Appendix A). The questionnaire also inquired if the teacher had discussed the course in class, and if so, how many hours.
The cognitive load during preparation was measured using a shortened rating scale of Leppink [11]. The questionnaire included four statements concerning cognitive load (Table 1).
Each statement was scored on a 10-point Likert scale, ranging from 0 "not at all" to 10 "completely".

Anatomy knowledge test
The learning outcomes were assessed using an anatomy knowledge test in which the students had to recognize the correct anatomical structures in the simulation model.
During the exam, the high school students received a list of 8 anatomical structure names that had to be linked to the 6 questioned anatomical structures in the simulation model ( Table 2). The maximum score was 6 correct answers. The simulation model used during the experiment was identical to the model used in the video-demonstration during the online course.

Statistical analysis
All statistical analyses were done with SPSS (IBM Corp.

Results
A total of 220 high school students from ten high schools

Continuous group
Step-bystep group
In the complete selection (n=220), the continuous group had an average of 2.1 answers correct (±SD 1.2) out of the 6 anatomy knowledge questions compared to 1.7 in the stepby-step group (±SD 1.3), U=4826, p=0.008 (Table 4). Variables that had a signifi cant effect on the number of correct answers on the anatomy knowledge test were watching the videodemonstration (U=3916, p<0.001), age (p=0.017) and additional lessons of the high school teachers (U=2857, p=0.004). Table 4, independent of the intervention, the students that watched the video-demonstration answered 2.2 anatomy knowledge test questions correctly in comparison

Continuous group (n=108)
Step-by-step group (n=112)  to 1.5 correct answers in the students that did not watch the video-demonstration, U=3916, p<0.001. Within the continuous and step-by-step group, the students that watched the videodemonstration scored signifi cantly higher on the anatomy knowledge test than students that did not watch the video, p<0.001 and p=0.031, respectively ( Table 5). The gender and age of the students that watched and did not watch the videodemonstration were similar. In the continuous group, more students watched the video-demonstration when the high school teacher spent more time in class discussing the online course (p=0.011). In the step-by-step group, more students watched the video-demonstration when the high school teacher gave additional lessons (p=0.002) and spent more time in class (p=0.001). Table 5 shows the subanalysis of the students that watched the video-demonstration. Of the 124 participants (56.4%) that watched the video-demonstration of the surgical procedure, the students within the continuous group answered an average of 2.4 questions correctly, and the students in the step-bystep group answered 1.9 questions correctly, U=1392, p=0.010.

Watched videodemonstration
In this sub-selection, age (p=0.111) and additional lessons of high school teachers (U=1227, p=0.058) were non-confounding variables.
On the different statements of the cognitive load (internal consistency of Cronbach's alfa=0.707) and the total rating of the cognitive load, no signifi cant differences were found between the continuous and the step-by-step group (Table 1).

Discussion
In this study, the effects of a video-demonstration of a surgical procedure based on the step-by-step framework on anatomy knowledge and cognitive load were compared to a continuous video-demonstration. High school students studied a surgical procedure with an emphasis on anatomical structures and were tested on their anatomical knowledge. The continuous group answered slightly more questions correct on the anatomy knowledge test compared to the step-by-step group. The cognitive load was similar for the continuous group and the step-by-step group.
The continuous group was on average older than the step by step group, which was a confounding variable. In the subselection of the students that watched the video-demonstration, age was, however, no confounding variable. A more critical factor for answering more correct answers was the preparation by watching the demonstration video. Our results suggest that the transfer of anatomical knowledge in pre-novices may be better when information is presented continuously.
Based on previous studies, the expectation was that the stepby-step group would score higher on the anatomy knowledge test and lower on the cognitive load [12][13][14]. Moreno reported that the segmentation group outperformed the continuous group and had a lower cognitive load [14]. The data suggested a similar experienced cognitive load in both groups. This was, however, not measured immediately after viewing the course, but during the test day. Furthermore, the assessment included the entire online course and not the video-demonstration exclusively, which could also explain the same cognitive load in both groups [11].
We expected that some high school teachers would discuss the online course in class. In the continuous and the step-by- In the step-by-step group, we built-in a pause of 3 seconds after each segment. All participants could pause and rewatch the video-demonstration themselves. Indeed, in the continuous group, this perhaps led learners to create their own segmentation. We could not monitor how many times the students paused or watched the video-demonstration. In case the continuous group students watched or paused the videodemonstration more times compared to the step-by-step group, the segmentation effect of the step-by-step group may have been diminished [12].
The cluster randomization occurred by school in order to avoid students sharing access to the continuous and stepby-step video-demonstrations. Unfortunately, this led to a signifi cant difference in the age distribution between the groups.
In the complete selection, older age resulted in signifi cantly more answers correct in the anatomy knowledge test. Within Citation: Nazari  the selection that watched the video-demonstration, age did not affect the mean correct answers of the anatomy knowledge test. Before cluster randomization, the differences per high school should have been assessed.

Conclusion
In summary, we found that the continuous group scored slightly higher on the anatomy knowledge test compared to the segmented step-by-step group. The subjects in this study might have been too novice as both groups answered a low number of anatomical questions correct. Further research on online video-based course on inguinal hernia repair should test more experienced learners to investigate the hypothesis that a step-by-step framework facilitates learning by optimizing the use of the cognitive capacity and subsequently, the learning process.