Association of gender and specialty interest with video-gaming, three-dimensional spatial analysis, and entry-level laparoscopic skills in third-year veterinary students

Heather R. Bragg BluePearl Specialty Partners, 11950 W 110th St, Overland Park, KS 66210.

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Heather A. Towle Millard BluePearl Specialty Partners, 11950 W 110th St, Overland Park, KS 66210.

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Ralph P. Millard BluePearl Specialty Partners, 11950 W 110th St, Overland Park, KS 66210.

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Peter D. Constable Office of the Dean, College of Veterinary Medicine, University of Illinois, Urbana, IL 61802.

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Lyn J. Freeman Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Purdue University, West Lafayette, IN 47907.

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Abstract

OBJECTIVE To determine whether gender or interest in pursuing specialty certification in internal medicine or surgery was associated with video-gaming, 3-D spatial analysis, or entry-level laparoscopic skills in third-year veterinary students.

DESIGN Cross-sectional study.

SAMPLE A convenience sample of 68 (42 female and 26 male) third-year veterinary students.

PROCEDURES Participants completed a survey asking about their interest in pursuing specialty certification in internal medicine or surgery. Subsequently, participants’ entry-level laparoscopic skills were assessed with 3 procedures performed in box trainers, their video-gaming skills were tested with 3 video games, and their 3-D spatial analysis skills were evaluated with the Purdue University Visualization of Rotations Spatial Test. Scores were assigned for laparoscopic, video-gaming, and 3-D spatial analysis skills.

RESULTS Significantly more female than male students were interested in pursuing specialty certification in internal medicine (23/42 vs 7/26), and significantly more male than female students were interested in pursuing specialty certification in surgery (19/26 vs 19/42). Males had significantly higher video-gaming skills scores than did females, but spatial analysis and laparoscopic skills scores did not differ between males and females. Students interested in pursuing specialty certification in surgery had higher video-gaming and spatial analysis skills scores than did students interested in pursuing specialty certification in internal medicine, but laparoscopic skills scores did not differ between these 2 groups.

CONCLUSIONS AND CLINICAL RELEVANCE For this group of students, neither gender nor interest in specialty certification in internal medicine versus surgery was associated with entry-level laparoscopy skills.

Abstract

OBJECTIVE To determine whether gender or interest in pursuing specialty certification in internal medicine or surgery was associated with video-gaming, 3-D spatial analysis, or entry-level laparoscopic skills in third-year veterinary students.

DESIGN Cross-sectional study.

SAMPLE A convenience sample of 68 (42 female and 26 male) third-year veterinary students.

PROCEDURES Participants completed a survey asking about their interest in pursuing specialty certification in internal medicine or surgery. Subsequently, participants’ entry-level laparoscopic skills were assessed with 3 procedures performed in box trainers, their video-gaming skills were tested with 3 video games, and their 3-D spatial analysis skills were evaluated with the Purdue University Visualization of Rotations Spatial Test. Scores were assigned for laparoscopic, video-gaming, and 3-D spatial analysis skills.

RESULTS Significantly more female than male students were interested in pursuing specialty certification in internal medicine (23/42 vs 7/26), and significantly more male than female students were interested in pursuing specialty certification in surgery (19/26 vs 19/42). Males had significantly higher video-gaming skills scores than did females, but spatial analysis and laparoscopic skills scores did not differ between males and females. Students interested in pursuing specialty certification in surgery had higher video-gaming and spatial analysis skills scores than did students interested in pursuing specialty certification in internal medicine, but laparoscopic skills scores did not differ between these 2 groups.

CONCLUSIONS AND CLINICAL RELEVANCE For this group of students, neither gender nor interest in specialty certification in internal medicine versus surgery was associated with entry-level laparoscopy skills.

Minimally invasive procedures are becoming increasingly popular in veterinary and human medicine because of improved patient comfort and cosmesis and decreased intra- and postoperative morbidity rates and hospitalization times, compared with conventional procedures.1,2 In veterinary medicine, these procedures are performed not only by board-certified specialists in internal medicine and surgery but also by general practitioners. Colleges of veterinary medicine, therefore, have begun incorporating training in these procedures into their curricula. However, fiscal constraints, time limitations, ethical and legal considerations associated with using patients for student training, and difficulties associated with acquiring and storing cadavers have driven teaching institutions to turn to alternative training methods.3–6 Video games and box trainer laparoscopic simulators are 2 alternative methods of training in minimally invasive procedures that have been well documented in human medicine and, to a lesser extent, veterinary medicine.7–11 Studies have shown that laparoscopic skills can be developed and improved through the use of strategically chosen video games and box trainer tasks.12–15

In human medicine, gender, performance on psychomotor tests, previous and current video-gaming experience, and previous box trainer experience have been found to be associated with skill level when performing minimally invasive procedures.16,17,a Historically, most medical and veterinary students were male, but the percentages of female students have increased substantially in both fields.18,19 Thus, information on possible associations between gender and skill when performing minimally invasive procedures would be of interest to educators. The purpose of the study reported here was to determine whether gender or interest in pursuing specialty certification in internal medicine or surgery was associated with video-gaming, 3-D spatial analysis, or entry-level laparoscopic skills among female and male third-year veterinary students. Our null hypothesis was that neither gender nor specialty interest would be associated with laparoscopic, video-gaming, or spatial analysis skills.

Materials and Methods

Study participants

The study protocol was approved by the Purdue University Institutional Review Board. In September of 2012 and 2013, students in the third year of the veterinary curriculum at the Purdue University College of Veterinary Medicine were invited to participate in the study through an announcement given prior to a lecture. Students who agreed to participate signed an informed consent document and completed a questionnaireb regarding previous and current video-gaming experience, experience in using the laparoscopic box trainer, gender, and interest in pursuing specialty certification in internal medicine or surgery. Students were excluded from the study if they had previously played the video games used in the study or if they had previous experience with the laparoscopic box trainer. To avoid selecting students with a specific interest in surgery versus internal medicine, potential participants were not told whether endoscopy techniques used in the study would be flexible or rigid.

After participants completed the questionnaire, they rotated among 3 stations designed to test video gaming, 3-D spatial analysis, and entry-level laparoscopic skills, as described.11 An online randomization programc was used to determine the order in which participants rotated through stations and the order of tasks within each station. Before beginning each task, participants were given 5 minutes to read written instructions explaining the task and scoring criteria. Scorekeepers were the same for all participants. Each task was scored separately, and the scorekeeper for each task was not aware of scores assigned for the other tasks.

Video-gaming skills evaluation

Three identical video game consolesd were used to assess participants’ video-gaming skills. Each console was connected to a 91-cm, high-definition, flat-screen monitor. Participants stood 2.3 m in front of the monitor. The normal difficulty setting and a standardized video game character was used for each of the 3 games. Participants were allowed 6 minutes to complete each game. Participants who completed a game before the 6-minute period ended were allowed to begin the game again and play until the designated time limit. For these participants, the maximum score obtained was used to calculate the video-gaming skills score.

For video game 1, participants played a skeet-shooting gamee that involved moving an on-screen aiming cursor to eliminate moving disk targets. The aiming cursor was controlled with a remote controller held in the participant's hand of choice. The objective was to place the cursor over moving targets to eliminate as many targets as possible.

For video game 2, participants played an archery gamef that involved simultaneously moving 2 cursors controlled with remote controllers held in the participant's hands of choice. The objective was to place the cursors over a stationary target to hit the center of a bulls-eye target.

For video game 3, participants played a target-shooting gameg that involved moving an on-screen aiming cursor controlled with a remote controller held in the participant's hand of choice. The objective was to place the cursor over stationary and moving targets of various sizes and to hit the center of a bulls-eye target.

Game consoles generated scores for each of the 3 video games at the end of each designated play period. For each game, the highest score obtained by a participant for the 6-minute play period was assigned 100%; all other participant scores were then expressed as a percentage of the highest score (range, 0% to 100%) to calculate a video-gaming skills score for that game. An overall video-gaming skills score was then obtained for each participant by calculating the participant's mean percentage score for the 3 games.

3-D spatial analysis skills evaluation

The Purdue University Visualization of Rotations Spatial Test was used to evaluate 3-D spatial skills.20 The test consisted of 20 questions, and participants were allowed 20 minutes to complete the test. Each question consisted of an image of an object in the upper left portion of the page and an image of this same object in a different orientation in the upper right portion of the page. An image of a different object was placed in the middle of the page, with 5 images of this object in various orientations at the bottom of the page. Participants were instructed to select the image at the bottom of the page that would represent the position of the object in the middle of the page if it had been rotated in the same direction and degree that the object in the upper left portion of the page had been rotated to achieve the orientation in the upper right portion of the page. A 3-D spatial analysis score was calculated as the percentage of correct responses out of 20.

Laparoscopic skills evaluation

Each station for assessing laparoscopic skills of the participants had a box trainer, light source, camera, 5-mm-diameter rigid endoscope, video monitor, and appropriate endoscopic instruments. Each participant was asked to perform 3 tasks.

For the first task, sugar cubes were randomly placed in the working area of the trainer. Participants were provided 2 endoscopic grasping forceps and allowed 6 minutes to stack columns of 6 sugar cubes. A score for this task was assigned by counting the number of columns of 6 cubes that remained upright for at least 30 seconds (score range, 0 to 3).

For the second task, a block containing 3 pegs spaced 2 cm apart was placed in the working area of the trainer box. Participants were provided 2 endoscopic grasping forceps and given 6 minutes to place 6 circular rings (internal diameter of central hole, 5 mm) onto each peg. The score was recorded as the number of pegs that were filled with 6 rings (score range, 0 to 3).

For the third task, a nonsterile surgical glove with 3 sets of parallel lines drawn transversely on each glove finger was secured in the working area of the box trainer. Parallel lines in each set were 0.25 cm apart, and each set of lines was separated from the adjacent set by 1.5 cm. Participants were provided endoscopic scissors and grasping forceps and instructed to cut between the most distal set of parallel lines on each finger, followed by the middle set of parallel lines, and then the most proximal set of parallel lines. Participants were given 6 minutes to complete the task. Cuts made outside the lines were assigned a score of 0. The final score was the number of accurate cuts that were made during the 6-minute period (score range, 0 to 15).

Scores for each of the 3 tasks were recorded. For each task, the highest score obtained was assigned 100%; all other participant scores were then expressed as a percentage of the highest score (range, 0% to 100%). A summary score for laparoscopic skills was developed by expressing each individual's score as a percentage of the maximum recorded score for the number of complete sugar cube columns stacked vertically, the number of pegs completely filled with rings, and the number of accurate cuts made and then determining the mean value for the 3 skills.

Statistical analysis

A commercially available spreadsheeth was used to record data for each student, and a commercially available software programi was used for statistical analyses. The χ2 test was used to evaluate the association between gender (2 levels; male or female) and specialty certification interest (2 levels; internal medicine or surgery).

The summary scoring method provided a theoretical range of scores from 0% to 100% for each of the 3 skills. The Spearman rank order correlation method was used to test for associations between scores for each of the 3 skills. In addition, for each of the 3 skills, the Mann-Whitney U test was used to test whether gender or specialty certification interest was associated with scores for the task. Values of P < 0.05 were considered significant.

Results

Sixty-eight students volunteered to participate in the study (42 females and 26 males). None of the students had previous experience with the laparoscopic box trainer, had played the specific video games used in the study, or had previously taken the Purdue University Visualization of Rotations Spatial Test. All participants reported previous video-gaming experience.

Of the 42 female participants, 23 were interested in pursuing specialty certification in internal medicine and 19 in pursuing specialty certification in surgery. Of the 26 male participants, 7 were interested in pursuing specialty certification in internal medicine and 19 in pursuing specialty certification in surgery. There was a significant (P = 0.025) association between gender and specialty certification interest, with males more likely to be interested in pursuing specialty certification in surgery than females, and females more likely to be interested in pursuing specialty certification in internal medicine than males.

There were weak positive associations between video-gaming skills and spatial analysis skills scores (rs = 0.32; P = 0.008; Figure 1) and between video-gaming skills and laparoscopic skills scores (rs = 0.46; P < 0.001; Figure 2). However, there was not a significant (P = 0.64) association between laparoscopic skills and spatial analysis skills scores.

Figure 1—
Figure 1—

Scatterplot of video-gaming versus spatial analysis skills scores for 68 third-year veterinary students. For each student, scores for video-gaming skills and spatial analysis skills were expressed as a percentage of the maximum recorded score (range, 0% to 100%). There was a weak positive association between the 2 variables (rs = 0.32; P = 0.008).

Citation: Journal of the American Veterinary Medical Association 248, 12; 10.2460/javma.248.12.1414

Figure 2—
Figure 2—

Scatterplot of video-gaming versus laparoscopic (assessed in a box trainer) skills scores for 68 third-year veterinary students. For each student, scores for video-gaming skills and laparoscopic skills were expressed as a percentage of the maximum recorded score (range, 0% to 100%). There was a weak positive association between the 2 variables (rs = 0.46; P < 0.001).

Citation: Journal of the American Veterinary Medical Association 248, 12; 10.2460/javma.248.12.1414

Males had significantly (P = 0.014) higher video-gaming skills scores than did females. However, laparoscopic skills scores (P = 0.14) and spatial analysis skills scores (P = 0.27) did not differ significantly between males and females (Table 1).

Table 1—

Median (range) video-gaming, 3-D spatial analysis, and laparoscopic skills scores for a convenience sample of 68 third-year veterinary students grouped on the basis of gender or specialty certification interest (surgery vs internal medicine).

FactorNo. of studentsVideo-gaming score (%)3-D spatial analysis score (%)Laparoscopy score (%)
Gender
 Male2659 (34–91)85 (53–100)53 (11–76)
 Female4252 (31–69)75 (35–100)41 (9–80)
 P value 0.0140.270.14
Specialty interest
 Surgery3855 (34–91)85 (35–100)47 (13–80)
 Internal medicine3049 (310–69)75 (40–100)38 (9–76)
 P value 0.0230.0400.11

Video-gaming skills were assessed with 3 video games, laparoscopic skills were assessed with 3 tasks performed in a box trainer, and spatial analysis skills were assessed with the Purdue University Visualization of Rotations Spatial Test. For all 3 skills, scores were expressed as a percentage of the maximum recorded or maximum possible score. Possible scores ranged from 0% to 100%.

Students who were interested in pursuing specialty certification in surgery had higher video-gaming skills scores (P = 0.023) and spatial analysis skills scores (P = 0.040) than did students who were interested in pursuing specialty certification in internal medicine. However, laparoscopic skills scores did not differ significantly (P = 0.11) between students interested in pursuing specialty certification in surgery and students interested in pursuing specialty certification in internal medicine (Table 1).

Discussion

Results of the present study suggested that there was a weak positive association between video-gaming skills and entry-level laparoscopic skills among third-year veterinary students. This was in agreement with results of a previous study11 involving a different group of veterinary students and was consistent with findings for the human medical field.7,15,21,22 When tested on simulated laparoscopic tasks, medical students and experienced laparoscopists who have ongoing video-gaming experience have shorter times to completion, higher efficiency, and fewer errors, compared with their non-gaming counterparts.23–25

On the other hand, neither gender nor specialty interest (internal medicine vs surgery) was associated with laparoscopic skills scores in the present study. In contrast, a study26 of medical students found that surgical interest was the only significant predictor of laparoscopic skill scores. In veterinary medicine, laparoscopic procedures are commonly performed by specialists in both surgery and internal medicine, which may help explain the lack of association between laparoscopic skills and specialty interest.

Gender as a predictive factor of minimally invasive skills has been extensively investigated in the human medical field,17,27–29 with a recent meta-analysisa of 113 medical research studies finding that the minimally invasive surgical skills of male participants were superior to those of female participants. In contrast, although males in our study had better video-gaming skills than females, we did not find a significant difference between male and female students in regard to laparoscopic skills. Many previous studies28,30,31 focused only on time to task completion and did not adjust for level of completeness, precision, errors, or previous video-game experience. More recent studies16,21 that take these factors into account have found no difference in laparoscopic skills performance related to gender, which is in agreement with our results.

Limitations of the present study included the small number of participants and the fact that participants were limited to a single veterinary school. Third-year students are at the early stage of their veterinary career and do not always have a chosen career track. A similar study with current internal medicine and surgery residents would be interesting, because these participants would be less likely to change their specialty.

In conclusion, for this group of third-year veterinary students, those with an interest in surgery had better video-gaming and spatial analysis skills than did those with an interest in internal medicine. Although males were more likely to be interested in surgery and had better video-gaming skills than females, they did not have higher entry-level laparoscopic skills than did females. Neither a specific interest in internal medicine versus surgery nor gender was associated with entry-level laparoscopic skills.

Acknowledgments

None of the authors had any financial or personal relationships that could have inappropriately influenced or biased the content of this report.

Presented as a podium presentation at the 11th Annual Veterinary Endoscopy Society Meeting, Florence, Italy, June 2014.

The authors thank Marianne D'Altilio, Jolene Knuth, and Cassandra Simmons for assistance in data acquisition.

Footnotes

a.

Liu LL, Uttal DH, Marulis LM, et al. Training spatial skills: what works, for whom, why and for how long? (poster presentation). 20th Annu Meet Assoc Psych Sci, Chicago, 2008.

b.

Copies of the video game experience questionnaire are available on request from the corresponding author.

c.

True random number generator. Available at: www.random.org. Accessed Oct 10, 2015.

d.

Nintendo Wii, Nintendo of America Inc, Redmond, Wash.

e.

Skeet shooting, Mario and Sonic at the London 2012 Olympic Games, Nintendo of America Inc, Redmond, Wash.

f.

Archery, Mario and Sonic at the Beijing 2008 Olympic Games, Nintendo of America Inc, Redmond, Wash.

g.

Target shooting, Mario and Sonic at the London 2012 Olympic Games, Nintendo of America Inc, Redmond, Wash.

h.

Microsoft Excel, version 14.0.6129.5000, Microsoft Corp, Redmond, Wash.

i.

SAS, version 9.3, SAS Inc, Cary, NC.

References

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  • Figure 1—

    Scatterplot of video-gaming versus spatial analysis skills scores for 68 third-year veterinary students. For each student, scores for video-gaming skills and spatial analysis skills were expressed as a percentage of the maximum recorded score (range, 0% to 100%). There was a weak positive association between the 2 variables (rs = 0.32; P = 0.008).

  • Figure 2—

    Scatterplot of video-gaming versus laparoscopic (assessed in a box trainer) skills scores for 68 third-year veterinary students. For each student, scores for video-gaming skills and laparoscopic skills were expressed as a percentage of the maximum recorded score (range, 0% to 100%). There was a weak positive association between the 2 variables (rs = 0.46; P < 0.001).

  • 1. Milovancev M, Townsend KL. Current concepts in minimally invasive surgery of the abdomen. Vet Clin North Am Small Anim Pract 2015, 45:507522.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 2. Tsui C, Klein R, Garabrant M. Minimally invasive surgery: national trends in adoption and future directions for hospital strategy. Surg Endosc 2013, 27:22532257.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 3. Langebæk R, Berendt M, Pedersen LT, et al.Features that contribute to the usefulness of low-fidelity models for surgical skills training. Vet Rec 2012, 170:361.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 4. Lynch J, Aughwane P, Hammond TM. Video games and surgical ability: a literature review. J Surg Educ 2010, 67:184189.

  • 5. Reiley CE, Lin HC, Yuh DD, et al.Review of methods for objective surgical skill evaluation. Surg Endosc 2011, 25:356366.

  • 6. Stefanidis D, Korndorffer JR, Black F, et al.Psychomotor testing predicts rate of skill acquisition for proficiency-based laparoscopic skills training. Surgery 2006, 140:252262.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 7. Badurdeen S, Abdul-Samad O, Story G, et al.Nintendo Wii video-gaming ability predicts laparoscopic skill. Surg Endosc 2010, 24:18241828.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 8. Fransson BA, Ragle CA. Assessment of laparoscopic skills before and after simulation training with a canine abdominal model. J Am Vet Med Assoc 2010, 236:10791084.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 9. Fransson BA, Ragle CA, Bryan ME. A laparoscopic surgical skills assessment tool for veterinarians. J Vet Med Educ 2010, 37:304313.

  • 10. Fransson BA, Ragle CA, Bryan ME. Effects of two training curricula on basic laparoscopic skills and surgical performance among veterinarians. J Am Vet Med Assoc 2012, 241:451460.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 11. Towle Millard HA, Millard RP, Constable PD, et al.Relationships among video gaming proficiency and spatial orientation, laparoscopic, and traditional surgical skills of third-year veterinary students. J Am Vet Med Assoc 2014, 244:357362.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 12. Adams BJ, Margaron F, Kaplan BJ. Comparing video games and laparoscopic simulators in the development of laparoscopic skills in surgical residents. J Surg Educ 2012, 69:714717.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 13. Diesen DL, Erhunmwunsee L, Bennett KM, et al.Effectiveness of laparoscopic computer simulator versus usage of box trainer for endoscopic surgery training of novices. J Surg Educ 2011, 68:282289.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 14. Giannotti D, Patrizi G, Di Rocco G, et al.Play to become a surgeon: impact of Nintendo Wii training on laparoscopic skills. PLoS ONE 2013, 8:e57372.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 15. Rosser JC, Lynch PJ, Cuddihy L, et al.The impact of video games on training surgeons in the 21st century. Arch Surg 2007, 142:181186.

  • 16. Ali A, Subhi Y, Ringsted C, et al.Gender differences in the acquisition of surgical skills: a systematic review. Surg Endosc 2015, 29:30653073.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 17. Spence I, Yu JJ, Feng J. Women match men when learning a spatial skill. J Exp Psychol Learn Mem Cogn 2009, 35:10971103.

  • 18. Chieffo C, Kelly AM, Ferguson J. Trends in gender, employment, salary, and debt of graduates of US veterinary medical schools and colleges. J Am Vet Med Assoc 2008, 233:910917.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 19. Wirtzfeld DA. The history of women in surgery. Can J Surg 2009, 52:317320.

  • 20. Bodner GM, Guay RB. The Purdue Visualization of Rotations Test. Chem Educ 1997, 2:118.

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