Proficiency in doing surgical procedures is one of the major competencies required to graduate an independent practicing surgeon. This operative competence requires more than the pure technical competence, the psychomotor skills. In fact, the cognitive domain, which entails the appreciation of the anatomy and the comprehension of the procedural steps, plays a critical role (1-4). Indeed, the importance of the cognitive competence overcomes that of the pure technical counterpart (5). It was reported that only 25% of important events are related to the technical skills (6). Similarly, other researchers found that the non-technical aspects of performance accounts for many of operative adverse events encountered. This explains the great emphasis on focusing on the cognitive part of the procedural training.
The principle model used in procedural training is the observational theory, which states that residents learn by observation (7). In surgical training, this is very well encountered through the commonly used phrase "see one, do one, teach one" which is still used and said to depict the sequence of learning a surgical procedure (8). Interestingly, research has confirmed that observing a procedure prior to doing it results in better performance (9).
The observational theory stems from the famous social cognitive theory (10). This theory describes the concept of the interaction between the person, the surrounding environment and his/her behavior. More interestingly, Prof. Bandura describes a reciprocal effect of those factors as shown in figure 1.
This theory describes important phenomena. It shows the interaction between the environment and the behavior. First, people learn by watching and then imitating the way someone else performs a task. Second, people learn by observing others’ success or failure during the performance of a task. Those observations show how the environment affect behavior. On the other hand, the behavior of a person can affect the surrounding environment.
Another interesting and relevant phenomenon is the interaction between personal factors with behavior and environment(11). Personal factors refer to level of interest, self-efficacy and cognitive ability. Of interest, the perceived self-efficacy, which is defined as how someone believes in his ability to perform a task, affects his/her behavior and his/her learning from the environment. Self-confident people are more likely to have better learning from their environments and better performance of tasks. In the same time, the environment and the behavior affect the perceived self-efficacy of a person. For instance, having successful task performance and positive environment is more likely to result in improved feeling of self-efficacy.
Traditionally, for the procedural knowledge, residents prepare by using mainly atlases and textbooks (12). Interestingly, residents find those resources marginally useful to address their knowledge gaps (13, 14).
Recently, the increasing number of residents which leads to fewer learning opportunities (15-17) along with increasing the cost on the institutions and the strain on the teaching staffs (18, 19). Additionally, there is an increased attention towards the patients' safety (20, 21). Those factors promoted the call for changes in the surgical curricula. Multiple educational interventions, for instance, video demonstrations, simulations etc.
Instructional videos can be defined as videos which are made to teach a specific task or set of tasks. Interestingly, instructional videos are shown to be the most time and cost effective, which drive the focus and the interest of this paper (22). Instructional videos are considered major vehicles for observational learning since the development of computers, internet and social media (23) and they are also are considered valuable sources for professional learning (7). Generally, instructional videos offer multiple advantages as shown in multiple domains; dentistry, computer science, etc. They are observed to be associated with better long-term retention as compared to the traditional methods (24, 25). Students prefer videos over formal instructions because of reply function, being enjoyable, interesting and informative (26). Additionally, instructional videos are found to provide a uniform, efficient and safe learning environment (21).
In the context of surgical proficiency, the instructional videos are made to address mainly the procedural knowledge or specific technical skills. Surgical procedural knowledge has been defined as “the ability to enumerate the steps of a given surgical procedure in the order that they occur in the OR” (3). On the other hand, procedural skills are mainly about the technicality aspect used to perform a procedure. The primary intended rule of the instructional videos is adjunctive to the current surgical curriculum. As observed in the context of instructional videos made to model the procedural skills is which showed that they cannot substitute the observation of an actual procedure, rather, they can synergistically support the learning (7).
The procedural knowledge instructional videos were not investigated until recently when Hayden (2015) investigated the use of an instructional video for lobectomy, the removal of one lobe of a lung, made upon the needs assessment done in their institute. The video was made up of voice-over narration of schematic representation of the procedure or thoracoscopic video footage in addition to a thoracoscopic video explanation of the technique. The focus of the study was to test for the usefulness and the appropriateness of the video as assessed by residents and their training consultants assessed by a questionnaire. Residents who replied to the questionnaire reported that videos were helpful and give appropriate review of the procedure. The critique for this study is, first, that only 8/20 residents filled up the questionnaire. Second, the educational effect was not measured in this study objectively; rather, the assessment tool is subjective and asks whether the video was helpful or not.
In this paper, the aim is to study the effect of watching procedural knowledge instructional videos on trainers' self-efficacy and the procedural knowledge, which are the training outcomes that influence task performance (27). This topic is important to be studied because if those selected YouTube videos are shown to be effective, their ubiquitous availability makes them a valuable and cost-effective resource for education in general surgery.
Research Question:
- Do selected instructional videos from YouTube for general surgical procedures have an educational effect on the procedural steps knowledge of the residents?
- Do selected instructional videos from YouTube for general surgical procedures improve the perceived self-efficacy of the residents in general surgery?