Closing the gap in operative performance between novices and experts: does harder mean better for laparoscopic simulator training?

Background: We have previously shown that reaching expert performance on an fundamentals of laparoscopic surgery (FLS)-type simulator model for laparoscopic suturing results in measurable improvement during an actual operation; trained novices, however, demonstrate inferior operative performance compared with experts. We hypothesized that simulator training under more difficult and realistic conditions would enhance the operative performance of novices.
Study Design: Medical students (n=32) participated in an IRB-approved, randomized, controlled trial. All participants were pretested in laparoscopic suturing on a previously validated porcine Nissen model and were randomized into three groups: group I (n=6) received no training, group II (n=13) trained on the FLS videotrainer model until a previously published proficiency score (512) was achieved on 2 consecutive and 10 additional attempts, group III (n=13) trained to the same goal but had to practice in a constrained space, with a shorter suture, starting with a dropped needle, and listening to operating room noise. Training workload was measured with the validated NASA-TLX (Task Load Index) questionnaire after each training session. All groups were posttested on the porcine model. Results were compared using ANOVA; p < 0.05 was considered significant.
Results: All group II and III participants reached the training goal. At posttesting, group II and group III participants performed similarly, but substantially better than group I did (210+/-140 versus 218+/-139 versus 0+/-0, respectively; p < 0.001). Compared with group II, group III participants trained longer (329+/-71 minutes versus 239+/-69 minutes, p < 0.001), performed more repetitions (81+/-15 versus 59+/-14, p < 0.001), and their workload improved less by the end of training (5% versus 23%, p < 0.001).
Conclusions: Proficiency-based simulator training reliably results in improved operative performance. Although increasing the level of training difficulty increased trainees' workload, the strategy we used in this study did not enhance their operative performance. Other methods for curriculum optimization are needed.