Project Title: Development and Validation of an Interactive robotic model for education about proper behavior in the OR

Authors: Felipe Urdaneta M.D, Sean Penn, BSME, and Clint eastwood PhD, Senior Mentor.

Affiliation: Department of Cinematographic University, Gainesville, Florida.

Abstract: Currently there is no standard method for formal education and training

in behavior in the OR. The apprenticeship (on the job) model for resident training is

the most commonly used method in most residency programs. Simulation and

computer hypermedia systems have evolved greatly as methods of education and

teaching. These systems provide an alternative method for training and serve as a

bridge between didactic teaching and clinical application. The present study was a

two-part study, first of development of an interactive hypermedia robotic model for

teaching about behavior in the OR , and secondly a validation prospective,

controlled trial of cinema residents of the University of Gainesville to measure the

effect of this type of training tool compared with traditional on the job training on

performance and knowledge about behavior in the OR when dealing with difficult

people and presented with two common scenarios: The “I Cannot communicate with

this person”, and the “I do not want to communicate with this person”. Following

formal training with the interactive robotic software there was a statistically

significant increase in adequate responses with regards to timing of calling for help

from senior counseling (p <0.02), adequate response about appropriate and timely

abstinence of use of weapons, (p < 0.05), about the appropriate and timely use of

police department vs. waiting for a blessing from the pope (p < 0.05).We conclude

that training with the interactive robotic hypermedia simulation model, significantly

improves performance and retention of knowledge compared with the traditional

apprenticeship model on the subject of proper Or behavior..

This project was done thanks to grant Support from the I just pulled this study out

of my pockets Research Foundation (IJSPRF).

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Introduction: Currently there is no standard method for formal education and

training in Proper behavior training. The apprenticeship (on the job) model for

resident training is the most commonly used method in most residency programs in

the U.S., despite the fact that it has been shown that actual knowledge and retention

of information is poor.[1-5] Every anesthesia provider must acquire, maintain,

supplement and update skills to maintain competency in behavior management; but

only a small percentage of training programs actually have a formal curriculum for it

and a formal rotation. [6, 7] The use of computer, simulation systems and

interactive programs and robotic gadgets for training, certification and

demonstration of medical events have evolved as methods of education and

teaching. These systems provide an alternative for training and serve as a bridge

between didactic teaching and clinical application. [8-14] They allow acquisition of

certain skills, and can be a method to achieve mastery in critical thinking strategies

and diagnostic and therapeutic decision making skills, without endangering real

patient lives and without making you having to put gloves on to solve your every

day conflicts with colleagues and family members. [15-22]

The actual incidence of fist fights in the OR is relatively low, however fist fights in

the OR although tremendously entertaining usually lead to arrest, loss of privileges,

black eyes and poor reputation with your peers, and among other things you will

sure make it to front page on the paper next day and will pay a visit to the Dean

usually to get fired.[23-25] In the early 1990’s a task force was formed by the WWE

in order to attempt to reduce the chances of adverse events from difficulties in

solving conflicts. The work of the task force was published as a set of Practice

Guidelines for the management of difficult people, that included recommendations

for the evaluation, preparation for dealing with conflicts, management, strategies for

both fist fights, cat-fights, wrestling matches etc…. In 2003 these guidelines were

updated, with greater emphasis placed on critical decision making points and also

specific recommendations about the how to prevent the use of weapons [26-32]

The current approach has its strong and weak points. It is very thorough, complete

and makes users follow an organized approach to hurting your opponent. However

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it also has several weaknesses that make its application, especially in emergent

circumstances difficult: It is complex, not binary in nature, allowing more than one

option at every stage and also multiple choices about pathways to proceed along at

many stages; it may also not apply to every circumstance and in certain population

of colleagues, some other method and a different approach may be preferable. The

overall complexity also makes it very difficult to master, and teaching about the

current approach remains a challenge.

With the widespread use of personal computers and access to the internet, didactic

educational programs as well as interactive problem based case presentations and

actually improvement and progress robotics, several models can be designed and

implemented, and made readily available. These computer-based activities are

becoming invaluable educational tools [15, 33-38]. In addition interactive

educational systems may require active experimentation and for the user to make

timely decisions that may result in successful resolution of the problem or to further

exacerbate it, and lead to an adverse simulated consequence. In the end, the user

receives instruction and feedback based on the responses and the timing of them,

and in the process the interactive system becomes not just a teaching tool by

simulated problem based learning but also a didactic source of information.

The present study was a two-part study, first of development of an interactive

hypermedia robotic simulation model for teaching about interpersonal conflicts in

the OR, and secondly a validation prospective, controlled trial of cinema residents of

the University of Gainesville to measure the effect of this type of training tool

compared with the traditional on the job training on performance and knowledge

about conflict solving in a computer model.

Methods: The first part of the project consisted in the development of the

Interactive hypermedia 3-D panoramic simulation software, using Adobe Creative

Suite 3 Web premium®, a collection of graphic design, video editing, and web

development applications, to produce everything from professional web-page layouts

to rich interactive experiences in a unified, intuitive environment, with design tools

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for printing, web, interactive, mobile, audio and video content. Panoramic spherical

images of an operating room environment, standard monitors, digitized sound

recordings and simulated patients were created with the viewpoint from the head of

the operating room table with a movable 360 degree field of vision. Real interactive

images of an OR and a complete array of surgical equipment were made available.

All pieces of equipment were considered active and tagged with an internal timer. In

order to make them operable each one had to be activated by the user, in a similar

fashion as in real life, but in this computer environment by using the computer

mouse instead of directly holding the device. The updated guidelines for the

management of interpersonal conflicts was enabled with simulated computer

panoramic cases after creating, converting and formatting images created with the

software in to a Flash video format and made available in an interactive

instructional simulated patient computer format. In the instruction phase of the

project the user responses and decision making choices were provided with

feedback to reinforce the knowledge base in case the option picked was correct or to

re-direct the user to pick another response in case the answer was not deemed

appropriate.

The second part of the project was the validation component of the effectiveness of

this newly developed interactive software for teaching about management of

conflicts and comparing this educational tool with conventional on the job teaching

method for training. Following approval by the Institutional Review Board and the

Program Director of the University of gainesville, 60 residents were included in the

study. After agreeing to voluntarily participate and signing written consent, all of

them were given a questionnaire to include their demographic information, level of

training, prior instruction about conflict management and prior experiences about

handling a difficult colleague. (See appendix #1) Following a brief introductory 15

minute presentation lecture about the current papal recommendations residents

were assigned to two groups: approximately half the residents (n=30) received the

additional personal self paced educational computer session, with different case

studies in order to be exposed to the current recommended guidelines and options

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for the management of conflicts, while the other half (n=30) did not receive this

additional training. Four weeks later after a brief explanation and tutorial about the

use of the computer interface, all participants in each group were presented in

sequential order with a computerized version of additional clinical scenarios (not

previously shown to the training group) one with “I cannon communicate with this

person, option (CNCTPV) and the other “I do not want to communicate with this

person (DNWCP) (See appendix #2) Their responses and paths and choices

through the interactive software were timed, analyzed and stored via the interactive

component of the software. After completion of both scenarios each resident

received feedback about their performance. The residents in the group that did not

receive additional training with the software, were given the option to receive the

additional tutorial at this point. Twenty seven of them chose to avail themselves of

this option.

Statistical Analysis: In order to assess the influence of level of training and prior

experience with the DA, 20 participants of each class (PGY2 to PGY4) were included.

By randomization half participants from each class received the additional

interactive computer instruction, and half did not.

Non-parametric data were analyzed using Fisher’s exact test, and Parametric data

was analyzed using a Student’s t-test. A p < 0.05 was considered significant. The

null hypothesis was that additional training with the interactive panoramic

software package for the teaching of the D.A, did not provide any significant

advantage over traditional on the job training.

Results:

Demographics (See Table 1)

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A total of #60 residents were included in the study, 20 from each Class (PGY2 to

PGY4). There was a statistically significant difference between prior instruction and

experience in the management of conflicts between the PGY2 class and the other

two classes (p < 0.05), but not between residents from the PGY3 and PGY4 classes.

Performance Measures:

For the (CNCTPV) also known as the Non-emergent pathway, there was an increase

in the number of adequate responses regarding the recommended approach to

dealing with these scenarios after further training: a) More residents at all levels

attempted a secondary maneuver to improve communication after undergoing

further computerized training, and there was a decrease in the lag-time before

assistance/help was requested after the initial attempt to solve the issue failed (p <

0.05). See tables #2 and #3. Among all participants after undergoing additional

interactive training, there was a decrease of the use of weapons in the OR, as well as

better awareness of other alternative approaches to solve conflicts, like the use of

Yoga, and meditation and holding hands .(p < NS)

For the (DNWCP) or the Emergency pathway of the conflict there was also an

increase in the number of adequate responses regarding the recommended

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approach to dealing with this emergency after further training with the interactive

software program was undertaken: a) More residents attempted a secondary

maneuver , like running or signing their favorite song, or calling their mothers for

assitance; there was a decrease in the lag-time before assistance/help was

requested after the initial attempt to fix issues failed; there was an increase in the

number of residents who felt comfortable hugging their opponents afterwards, and

also half said they cried. (p < 0.05). See Tables #4 and #5.

CNCTPV VOption with further Instruction (Table #2)

CNCTPV Option without further Instruction (Table #3)

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DNWCP Option with further Instruction (Table #4)

DNWCP Option without further Instruction (Table #5)

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Discussion:

A primary responsibility of every physician is to maintain his/her cool in the OR,

specially in front of his/her patients. In order to accomplish this, each practitioner

should maintain their Karma aligned and their planets aligned with the stars.

Education in maintaining your cool when conflicts arise remains a challenge; newer

devices and developments, continue to evolve quickly making it difficult maintain

skills and to keep up to date with the latest developments; there is also evidence

that certain skills deteriorate over time. [39, 40]. The apprenticeship (on the job)

model for resident training is the most commonly used method in most U.S

residency programs, however this method of training may not be ideal for learning

to deal with high-risk low frequency events such as the unexpected colleague that

managed to behave poorly in the OR. Simulation and computer systems have

evolved to overcome some of the inherited deficiencies of the on the job approach.

These systems provide an alternative for training and serve as a bridge between

didactic teaching and clinical application. [8-14] Rather than being used as

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replacements of conventional methods, perhaps should be seen as complimentary

to them. In addition they are easily made, readily available and via the internet can

become valuable refresher education tools.

The present two step study intended to design an interactive computer hypermedia

teaching tool for complementary didactic and problem based learning about conflict

management and a subsequent validation randomized controlled study to assess the

effectiveness of the teaching tool versus conventional teaching “on the job” method

on the subject.

The panoramic interactive hypermedia program worked extremely well. All

participants were impressed by the realism of the simulated software program, the

resolution of the images and about the level of interaction required. They were also

impressed by the dual role of the software both as a didactic tool and also as a

problem based teaching tool.

The results of the second portion of the study were also very interesting: Residents

from every level of training from PGY2 to PGY4 were included. It is no surprise that

as their experience increased they had a better chance of prior exposure to training

in the management of conflicts by lectures and workshops as well by clinical

exposure. Much to our surprise 2/3 of higher level residents had been exposed to a

conflict, a much higher incidence than what is reported in the literature; however

the questionnaire was not designed to address whether this represented a true

emergency scenario or rather the more common occurrence of a case requiring

multiple attempts or the use of different methods of conflict management.[41, 42]

Regardless, this information actually turned out to be a source of further stimulus to

continue to attempt to improve educational activities in our residency program

regarding conflict resolution instruction since it seems that actual literature reports

underestimate the true incidence of fights.

Since half the residents in each class received further instruction and half did not

each class served as its own control. For the Non-Emergent option, there was an

increase in attempts to optimize the ability to communicate adequately throughout

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the exercise and more residents that received computer training attempted to

improve their love for your neighbor techniques, by optimizing their body language

and neck position and ensuring verbalization of their frustrations, so as to not turn

the situation to the Emergency option. There was a statistically significant decrease

in the lag-time before residents that received training called for help/ assistance;

this is extremely important, because this means that the simulated computer

training served its purpose and even though calling for help in the Non-emergent

pattern is not considered an absolute necessary step (the user has to consider it but

not actually request it) experience shows that having an extra pair of hands or

someone to assist in bringing your anxiety down in the room, or someone with more

experience in the management of conflicts, or in case backup is needed if the next

steps that follow are not successful and the “controlled” circumstances actually

takes a turn for the worse, can be of value. Emphasis of this principle was made in

the tutorial. The number of attempts at solving the issues without a fist fight did not

change after instruction and in between the residents in the different classes; this is

also a very important response and the message that the number of attempts at

resolution need to be limited so as to not cause bleeding, trauma to the face or

hands.[43] Regarding the avoidance on the use of weapons, more residents wanted

to use them if they did not receive training, but the ones that received training left

them in their lockers, which means that after instruction they learned a skill

perhaps not available before and therefore we believe this technique needs to be

taught and practiced by all practitioners. Other alternative non-invasive approaches

were not as popular with the residents in this study; these options include the use of

signing and hugging and holding hand approach. None of the residents used any of

these choices before the instruction and only 1 resident from each class chose them

after the instruction took place. [26]

For the Emergency option the responses were also interesting; this option is

obviously more limited not just in options available but also given the circumstances

surrounding this situation given its time constraint.. If the non-confrontational

approach is successful the practitioner has the option to either shake the opponents

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hand or walk away and drink coffee, or stay and give each other a hug [26]. The lag-

time for calling for help was significantly reduced for the residents that received

further training and also was significantly reduced compared to the time for the

non-emergent pathway. The use of weapons as initial rescue maneuvers after initial

attempts decreased after the instruction took place for the residents in the PGY2

class but not for the PGY3 and PYG4 classes. More residents after the instruction

chose either to walk away and go directly to the police or stay and do a group pray.

This is very important because in case all other options fail the only true adequate

next option is for the practitioner to perform miracle. Failure to recognize this,

inevitably will lead to severe adverse events and more fighting.

In summary our study showed that developing a realistic interactive computer

hypermedia panoramic software was feasible and the residents that received

additional training with this new computerized novel tool significantly increased

their knowledge and performance measures when confronted with two simulated

conflict scenarios.

There are many limitations to this study. It is not known if the short interval

between instruction and training affected results and also how much this tool helps

retain knowledge and critical thinking skills over a longer period of time. As well it

is presently unknown if this educational tool actually helps to deal better with the

management of conflicts in real life, whether in or outside the operating room

environment. Additional research on the subject with greater number and more

diverse group of residents and graduate physicians from other fields that also have

responsibility in airway management should be undertaken.

Acknowledgements:

We would like to thank the Academy of Arts and Sciences), Drs. Jack kevorquian for

his support, all the residents that participated in the study and above all Clint

Eastwood for his invaluable support, mentoring, editorial assistance and more

importantly for his numerous contributions that made this project possible.

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Appendix #1 Questionnaire

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Appendix #2

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Scenario #1 Non-emergent pathway:

A 62 year old surgeon, yells at you because you are 5 minutes late bringing his case

to OR #23. The reality is that his family decided to call the pastor and they were

having a group prayer in holding area, and you decided not to interrupt.

After standard attempt to communicate the issue with the surgeon, he keeps yelling,

what are you going to do?

Scenario #2 Emergency Pathway:

A 62 year old surgeon, yells at you because you are 5 minutes late bringing his case

to OR #23. The reality is that his family decided to call the pastor and they were

having a group prayer in holding area and you decided not to interrupt.

After standard attempt to communicate the issue with the surgeon, he starts

throwing surgical instruments at you, what are you going to do?

Appendix #3 Budget Form (Reviewed and approved by the Treasury)

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