Reinvestment and laparoscopic training
Original Article
Title: Conscious motor processing and movement self-consciousness: Two dimensions of
personality that influence laparoscopic training
Neha Malhotra1*§, Jamie M Poolton1*, Mark R Wilson3* Joe KM Fan2* & Rich SW Masters1*
1 Institute of Human Performance, University of Hong Kong, Hong Kong
2 Department of Surgery, University of Hong Kong, Hong Kong
3 School of Sport and Health Sciences, College of Life and Environmental Sciences,
University of Exeter, UK
*These authors contributed equally to this work
§ Corresponding author
Corresponding Author:
Neha Malhotra
Institute of Performance
3/F, The Hong Kong Jockey Club Building for Interdisciplinary Research
5 Sassoon Road,
Pokfulam,
Hong Kong
Tel: +852 28315282
Fax: +852 28551712
nehamal@hku.hk
Acknowledgments
The authors wish to thank Sadahiro Omuro for his assistance during the data collection phase.
This work was supported by a GRF grant from the Research Grants Council, Hong Kong
(HKU752211H).
Keywords: Personality factors, reinvestment, self-consciousness, conscious control, laparoscopic
training, cross-handed technique
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Reinvestment and laparoscopic training
Abstract
Background
Identifying personality factors that account for individual differences in surgical training and
performance has practical implications for surgical education. Movement specific reinvestment
is a potentially relevant personality factor that has a moderating effect on laparoscopic
performance under time pressure. Movement specific reinvestment has two dimensions, which
represent an individual’s propensity to consciously control movements (conscious motor
processing) or to consciously monitor their ‘style’ of movement (movement self-consciousness).
Objective
This study aimed at investigating the moderating effects of the two dimensions of movement
specific reinvestment in the learning and updating (cross-handed technique) of laparoscopic
skills.
Methods
Medical students completed the Movement Specific Reinvestment Scale, a psychometric
assessment tool that evaluates the conscious motor processing and movement self-consciousness
dimensions of movement specific reinvestment. They were then trained to a criterion level of
proficiency on a Fundamental Laparoscopic Skills (FLS) task and were tested on a novel crosshanded technique. Completion times were recorded for early-learning, late-learning and crosshanded trials.
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Reinvestment and laparoscopic training
Results
Propensity for movement self-consciousness but not conscious motor processing was a
significant predictor of task completion times both early (p = 0.036) and late (p = 0.002) in
learning, but completion times during the cross-handed trials were predicted by the propensity
for conscious motor processing (p = 0.04), rather than movement self-consciousness (p = 0.21).
Conclusion
Higher propensity for movement self-consciousness is associated with slower performance times
on novel and well-practiced laparoscopic tasks. For complex surgical techniques, however,
conscious motor processing plays a more influential role in performance than movement selfconsciousness. The findings imply that these two dimensions of movement specific reinvestment
have a differential influence in the learning and updating of laparoscopic skills.
ACGME competencies: Practice based learning and improvement
3
Reinvestment and laparoscopic training
Introduction
Anecdotal evidence of the “surgical personality” 1 has been supplemented by limited
empirical data, 2 and 3 but recently surgical educators have emphasized the need to investigate
personality factors that account for individual differences in performance. 4 One personality
factor that is associated with the capacity to cope with time pressure when completing a
fundamental laparoscopic task 5 is movement specific reinvestment. Models of skill learning
developed in the motor learning literature argue that learning can be characterized by progression
from conscious control of movements early in learning to automatic, non-conscious control of
movements later in learning. 6, 7 and 8 However, the theory of reinvestment 9, 10 and 11 proposes that
contingencies, such as psychological stress or time pressure, can cause performers to consciously
monitor and control their movements in order to maintain their proficiency. Conscious
monitoring and control can disrupt automatic performance, 12, 13 and 14 with normally ‘smooth’
expert-like performance regressing to the more erratic style of a trainee, which increases the
probability of operator error. Here we examine the role of two unique dimensions of movement
specific reinvestment in laparoscopic performance.
Individual differences in the propensity for movement specific reinvestment can be
quantified using the validated and extensively employed Movement Specific Reinvestment Scale
(MSRS). 11 and 15 The MSRS evaluates two dimensions of reinvestment, conscious motor
processing and movement self-consciousness. Conscious motor processing reflects an
individual’s tendency to attempt to consciously control the underlying mechanics of a skill online. Movement self-consciousness reflects an individual’s tendency to monitor the ‘style’ of his
or her movement. Although movement specific reinvestment can be considered a
unidimensional construct, 5 each dimension may play a distinct role in learning and performance.
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Reinvestment and laparoscopic training
Furthermore, the extent to which each dimension has a moderating effect on performance may be
dependent on the performance context.11 For instance, novel or challenging environments may be
more likely to evoke conscious motor processing, whereas, evaluative environments that raise
motivation to appear proficient or increase personal concerns about appearing awkward 16 and 17
may be more likely to evoke movement self-consciousness.
The progressive nature of surgical practice demands that surgeons periodically up-skill,
in order to utilize advances in technological equipment (e.g., robotic surgery), or update their
skills, in order to perform familiar procedures using new, cutting edge techniques. 18 and 19 The
advent of single incision laparoscopy (SILS), for example, has resulted in the promotion of the
cross-handed technique, which requires surgeons to modify their well-practiced (automatic)
movements dramatically to overcome the constraints of a single port. 20 and 21 Processes of upskilling and modifying well-practiced movements are likely to trigger conscious control, 22 but
the extent of engagement and thus the impact on learning and performance may be dependent on
an individual’s propensity for movement specific reinvestment. Consequently, an understanding
of the role of movement specific reinvestment in the learning and updating of surgical skills is
important for curriculum design.
This study was undertaken to examine the moderating effect of conscious motor
processing and movement self-consciousness on performance of a fundamental laparoscopic skill
(peg transfer) early and late in learning and when the constraints of the task dramatically change
(cross-handed technique). Specifically, a higher propensity for conscious motor processing was
expected to facilitate the search for motor solutions both early in learning and when the crosshanded technique was used, but not later in learning when trainees no longer needed to search for
motor solutions because they had achieved proficiency at the task.. The role of movement self5
Reinvestment and laparoscopic training
consciousness at each stage was less clear; however, given that novel tasks tend to raise personal
concerns about appearing awkward, movement self-consciousness was also expected to play a
significant role in performance early in learning.
Materials and Methods
Seventeen Year 5 undergraduate medical students (age range 21- 25 years, M= 22.76 ±
0.24) from the University of Hong Kong with no prior experience in laparoscopy volunteered to
participate in the study. Ethical approval was obtained from the Institutional Review Board and
all participants provided written informed consent.
Individual training sessions were conducted in a simulated operating theatre (OT) in the
Surgical Skills Centre (The University of Hong Kong) (see Fig 1.). Participants trained
individually on the Fundamentals of Laparoscopic Surgery (FLS) peg transfer training module
developed by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). 23
An instructional video was shown before the training session to familiarize participants with the
task requirements. The task involved the use of laparoscopic graspers to pick up, transfer and
position six plastic objects from one side of a pegboard to the other side and back again. During
the first half of the trial, participants transferred the objects from the grasper held in the nondominant hand to the grasper held in the dominant hand and for the second half of the trial the
process was reversed.
Performance on the first two trials was recorded as a representation of performance early
in learning (early-learning trials). The training session was concluded when an expert-derived
proficiency level was attained, in which two consecutive trials were completed in less than 54
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Reinvestment and laparoscopic training
seconds followed by an additional ten trials (not necessarily consecutive) at criterion level. 24
Participants were informed about the proficiency criteria and were provided feedback upon
request. After training, participants were asked to complete the 10-item Movement Specific
Reinvestment Scale (MSRS). The MSRS comprises two dimensions of movement specific
reinvestment and includes five items that assess conscious motor processing, such as, “I am
always trying to think about my movements when I carry them out” and 5 items that assess
movement self-consciousness, such as, “I am concerned about my style of moving”. Both factors
have good internal reliability and test-re-test reliability. 15 Responses to the items were made on a
6-point Likert scale ranging from strongly disagree (1) to strongly agree (6) and total scores on
each factor ranged from 5 to 30 points. High scores represent a strong propensity for either
conscious motor processing or movement self-consciousness.
On a separate day, participants continued to perform the peg transfer task until two
consecutive trials were completed in less than 54 seconds. Performance on the next two trials, in
which participants were simply asked to try their best, was recorded as a representation of
performance later in learning (late-learning trials). Finally, participants were asked to perform
the same peg transfer task for two cross-handed trials. Verbal instructions and a pictorial
depiction of the cross-handed technique were provided. 20
Participants completed the 20 point Likert component of the SURG-TLX after the earlylearning trials, the late-learning trials and the cross-handed trials. 25 The SURG-TLX is a
validated instrument that indicates perceived surgical workload (low to high) across the
dimensions of temporal demands, physical demands, task complexity, mental demands
situational stress and distraction. As such, it is a valuable tool for determining an individual’s
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Reinvestment and laparoscopic training
subjective perceptions of the task demands. Medical educators recommend its use to assess
surgical workload in the operating room.26
**Figure 1 near here**
Statistical Analysis
Completion times (seconds) and number of drops were recorded in the two early-learning
trials, in the two late-learning trials and in the two cross-handed trials. The average number of
drops in the late-learning trials (0.03 ± 0.12) and the cross-handed trials (0.88 ± 0.96) was
negligible, so completion time was taken as the dependent measure of performance.
Simple regression analyses were used to test if the conscious motor processing and
movement self-consciousness factors independently predicted completion times during earlylearning, late-learning and cross-handed trials. Perceived surgical workload of early-learning,
late-learning and cross-handed trials was examined by computing mean workload scores for each
of the six dimensions of the SURG-TLX and by conducting separate one-way analyses of
variance. Significant main effects were followed up with Bonferroni adjusted pairwise
comparisons.
Results
Participants took on average 42.82 ± 2.93 trials to reach proficiency. Mean best
completion time during training was 43.65 ± 0.71 seconds. Completion times were slowest
during cross-handed trials (149.38 ± 6.89 seconds), followed by early-learning trials (128.88 ±
6.39 seconds) and late-learning trials (50.32 ± 1 second).
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Reinvestment and laparoscopic training
Simple regression analyses revealed that movement self-consciousness score was a
significant predictor of task completion time in early-learning (ß = 2.62, p = 0.036), explaining
26% of the variance (see Fig. 2a). The model predicted that for every unit increase in movement
self-consciousness score, completion times would slow by 2.62 seconds. Movement selfconsciousness score was also a significant predictor of task completion time in late-learning (ß =
0.56, p = 0.002), explaining 48.6 % of the variance (see Fig. 2c). The model predicted that for
every unit increase in movement self-consciousness score, completion times would slow by 0.56
seconds. Conscious motor processing score was not a predictor of completion time early in
learning (ß = -1.04, p = 0.626) or late in learning (ß = -0.092, p = 0.784) (see Fig. 2b & 2d).
Simple regression analysis revealed that conscious motor processing score was a
significant predictor of task completion time during cross-handed trials (ß = 4.36, p = 0.04),
explaining 24.6% of the variance. The model predicted that for every unit increase in conscious
motor processing score, completion times would slow by 4.36 seconds. Movement selfconsciousness scores did not predict task completion times in the cross-handed trials (ß = 1.79, p
= 0.21) (see Fig. 3a & 3b).
**Figure 2 & 3 near here**
Analysis of the workload dimensions of the SURG-TLX revealed that perceived temporal
demands (F(2,32) = 8.71 , p = 0.001), physical demands (F(2,32) = 39.53 , p < 0.001), task
complexity (F(2,32) = 43.96, p < 0.001) and mental demands (F(2,32) = 10.44, p < 0.001) but
not situational stress (p = 0.650) or distraction (p = 0.646), were influenced by training and/or
cross-handed performance. Follow-up analyses (using Bonferroni adjustments) were carried out
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Reinvestment and laparoscopic training
to explain the main effects. As shown in Fig. 4, temporal demands were perceived to be higher
during early-learning trials than late-learning (p = 0.045) or cross-handed (p = 0.003) trials,
which were not significantly different from each other (p = 0.788). Physical demands were
perceived to be higher during cross-handed trials than early-learning (p = 0.009) or late- learning
(p < 0.001) trials. Furthermore, the early-learning trials were perceived as more physically
demanding than the late-learning (p < 0.001) trials. Task complexity was also perceived to be
higher in the cross-handed trials than during early-learning or late-learning (all p’s < 0.001)
trials. Furthermore, early- learning trials were perceived to be more complex than late-learning
(p = 0.022) trials. Mental demands were also perceived to be higher in the cross-handed trials
than during early- learning (p = 0.025) or late-learning (p < 0.001) which were not significantly
different from each other (p = 1).
**Figure 4 near here**
Discussion
Prior research has revealed a moderating effect of movement specific reinvestment on
laparoscopic performance. 5 Early in learning, skill execution is normally associated with
conscious processing mechanisms that guide movement, 6, 7, and 8 so we expected that the
conscious motor processing dimension of movement specific reinvestment would be implicated
in performance outcome (completion time) during early-learning of a laparoscopic task. This was
not the case. Rather, medical students with a higher propensity for movement self-consciousness
displayed worse performance (slower completion times) than participants with a lower
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Reinvestment and laparoscopic training
propensity. Exposing the medical students to a novel laparoscopic task in a simulated OT
environment may have caused them to prioritize the ‘style’ of their movements over performance
(i.e., rapid completion time) in order to look like a surgeon.
Movement self-consciousness continued to predict poor performance when an expertderived proficiency level was achieved (late-learning trials), suggesting that medical students
with a high propensity for movement self-consciousness prioritized ‘style’ over substance (i.e.,
task completion times) in order to better demonstrate their surgical aptitude. Surgical trainees
often first learn surgical skills under the direct supervision of senior surgeons, so pressure to look
and behave like a surgeon may provoke debilitative movement self-conscious behavior in
susceptible individuals. 27 and 28 One way to reduce such pressures is to modify the training
environment so that movement self-consciousness is not provoked (e.g., bar senior surgeons
from the room). This is not feasible, so an alternative option is to reduce the propensity for
movement self-consciousness in susceptible trainees (i.e., individuals who display higher than
normal scores on the movement self-consciousness dimension of the Movement Specific
Reinvestment Scale). In the non-surgical domain, training interventions have been used
successfully to acclimatize performers to self-consciousness, 22 and 29 so tailored acclimatization
interventions may have a place in the technical skills training domain.
When the task constraints were dramatically changed by introduction of the cross-handed
technique, the medical students reported that the technique was more complex than their
practiced technique, and more physically and mentally demanding. Performance by students with
a high propensity for conscious motor processing was slower, presumably as they searched for
new motor solutions. It is therefore not surprising, that students with a greater propensity for
conscious motor processing displayed slower task completion times.
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Reinvestment and laparoscopic training
For complex surgical tasks or sudden changes during an operation (e.g., surgical
complications, equipment problems), engaging consciousness in the control of movements may
expedite the identification of appropriate movement adaptations. 30, 31, 32 and 33 However, later in
learning, when execution is automatic, conscious control is likely to be cognitively inefficient 34
and potentially disruptive, 10, 11, 12, 13 and 14 especially if attention is needed concurrently for
important non-technical skills, such as decision-making or team communication. Implicit motor
learning interventions have been specifically developed for both non-surgical 9, 35 and 36 and
surgical skills (e.g., suturing and knot tying tasks 37) to protect individuals from the disruptive
effects of conscious motor processing [see 35 for a review]. Interventions of this kind may be
particularly beneficial for trainees with a high propensity for conscious motor processing, as
identified by the Movement Specific Reinvestment Scale.
The present study was constrained by the nature of the laparoscopic training module that
was used. Proficiency on the FLS peg transfer task is determined by a crude performance
outcome measure (i.e., time to completion) that in some ways de-emphasizes movement
efficiency and/or accuracy. Future work should adopt tasks that place equal emphasis on
performance outcomes as well as process tracing measures (e.g., movement efficiency). 38 Such
fine-grained analysis of movement kinematics will help us better understand the mechanisms by
which personality factors account for individual differences in laparoscopic performance.
Furthermore, in order to ascertain the clinical implications of the current findings, future studies
need to investigate their influence under a wide variety of contingencies commonly encountered
in clinical settings (see 39 for a comprehensive list of intra-operative stressors), which may
evoke conscious motor processing and/or movement self-consciousness.
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Figure Legends
Fig.1. Experimental setup, showing a participant performing the Fundamentals of
Laparoscopic Surgery peg transfer task during training
Fig.2. Scatterplots showing the association between mean completion times (seconds) and
movement self-consciousness scores or conscious motor processing scores during early-learning
trials (panels a and b, respectively), and late-learning trials (panels c and d, respectively)
Fig.3. Scatterplots showing the association between mean completion times (seconds) and
movement self-consciousness scores (panel a) or conscious motor processing scores (panel b)
during cross-handed trials
Fig.4. Mean workload score for the temporal demands (TD), physical demands (PD), task
complexity (TC), mental demands (MD), situational stress (SS) and distractions (D) dimensions
of the SURG-TLX during the early-learning, late-learning and cross-handed trials
17