Research on the Effects of Media

© 2008-2011 Douglas A. Gentile; All Rights Reserved

Douglas A. Gentile, Ph.D.
Research Article
The impact of video games in surgical training
James Rosser, Paul Lynch, Laurie Haskamp, Douglas Gentile, & Asaf Yalif

How to cite:  Rosser, J. C., Lynch, P. J. Haskamp, L., Gentile, D. A., & Yalif, A. (2007).  The impact of video games in surgical training.  Archives of Surgery, 142, 181-186.

Note: Due to HTML formatting limitations, the references are not clearly labeled on this page, and there are several other minor differences from the final published version.

Abstract

CONTEXT Video games have become extensively integrated into popular culture.  Anecdotal observations of young surgeons suggest that video game play contributes to performance excellence in laparoscopic surgery. Training benefits for surgeons who play video games can be quantified.
HYPOTHESIS We hypothesize a potential link between video game play and laparoscopic surgical skill and suturing.
DESIGN Cross-sectional analysis of the performance of surgical residents and attending physicians participating in the Rosser Top Gun Laparoscopic Skills and Suturing Course was applied. Three different video game exercises were performed and surveys were completed to assess past experience with video games and current level of play as well as each subject’s level of surgical training, number of laparoscopic cases performed and number of years in medical practice.
SETTING Academic medical center and surgical training program.
PARTICIPANTS Thirty-three residents and attending physicians participating in the Top Gun Laparoscopic Skills and Suturing Course during 2001-2003.
MAIN OUTCOME MEASURES  The primary outcome measures were correlated between participants’ laparoscopic skills and suturing capability, video game scores and video game experience.
RESULTS Past video game play in excess of three hours per week correlated with 37% fewer errors (p < 0.02) and 27% faster completion (p < 0.03). Overall Top Gun score (time and errors) was 33% better (p < 0.005) for video games players and 42% better (p < 0.01) if they played greater than 3 hours per week.  Current video game players made 32% (p < 0.035) fewer errors, performed 24% (p< 0.036) faster and scored 26% better overall (time and errors) than their non-playing colleagues.  When comparing demonstrated video gaming skills, those in the top tertile made 47% (p < 0.00) fewer errors, performed 39% (p < 0.00) faster and scored 41% (p < 0.00) better on the overall Top Gun score.  In regression analysis also indicated that video game skill and past video game experience are significant predictors of demonstrated laparoscopic skills.
CONCLUSIONS Video game skill correlates with laparoscopic surgical skills. Training curricula that include video games may help thin the technical interface between surgeons and screen mediated applications such as laparoscopic surgery. Video games may be a practical teaching tool to help train surgeons.

INTRODUCTION

Sales in the video game industry approached $10 billion in the United States in 2002.[1]   Ninety-four percent of adolescents play video games for an average of 9 hours per week (13 hours for boys),  and interestingly, many of the same people that began playing video games in the 1970s have continued to play making the average age of a video gamer 29 years old.    Widespread internet use and increasing bandwidth availability have facilitated cooperative play for individuals across the world, thereby further increasing video game popularity.   Video games have become an integral part of the daily lives of nearly two generations of Americans.  The possible effects of video games have received considerable attention in general media as well as in the scientific literature.
 
Disturbing negative correlations with video game play include lower grades in school[2], aggressive thoughts, emotions and actions (including physical fights) as well as decreasing positive pro-social behaviors[2]. Excessive game playing has also been linked to childhood obesity , muscular and skeletal disorders ,  and even to epileptic seizures .  Other physical findings have included increases in blood pressure, heart rate and stress hormones (norepinephrine, epinephrine). However, positive benefits of video game play include increased performance on eye-hand coordination, reaction time, spatial visualization, neuro-psychological tests, and mental rotation.
 
A recent study assessed video gaming enhancement of visual attention (e.g., increased ability to process information over time and an increase in the number of visual items that can be apprehended) and its spatial distribution (e.g., enhanced allocation of spatial attention over the visual field).    They found a positive correlation between video gaming and visual attention processing and suggested a correlation with competence in analogous tasks.
Video games that require interaction with virtual reality situations – simulator training - can potentially lead to acquisition of complex, real-world skills such as driving,  flying airplanes, and even playing golf.   Skill transfer does not require force feedback if visual information compensates.  An example of this was seen in a study of sixty-two right-hand dominant men (mean age ~ 20 years old) with no previous golf experience. The participants were divided into 5 groups (after controlling for visual imagery abilities).  The groups consisted of one control group, two learning groups (with the intent to improve in actual putting), and two enjoyment groups (with the intent to simply enjoy the game).  The results indicated that the two learning groups showed the most improvement in golf putting.  All four of the experimental groups improved their posttest scores, demonstrating that video games can be an effective skill-transfer tool even without haptic references, particularly if a user is engaged in a skill learning strategy.18
 
Increasing scrutiny of physician training has been especially acute in surgery especially with the introduction of laparoscopic surgery.  The traditional medical model of “see one, do one, teach one” is no longer adequate to train physicians, since many skills cannot be developed by merely watching an expert. ,   Subsequently, during the early adoption phase of new procedures, a “learning curve” is encountered.  During this introductory period, the risk of complications and deaths are the highest.  Medical errors have become the eighth leading cause of death in this country – as many as 44,000 to 98,000 per year – with an estimated cost of $37.6 billion per annum.   A variety of approaches teach procedural skills with the focus on error prevention. Artificial tissues are useful for skill development, but the scope of activities that can be learned from their use is limited.  Simulator training in technique building for laparoscopic surgery,22,   Colonoscopy,  sinus endoscopy  and trauma training has been effective.    Simulator techniques have been successful in the military and aerospace industries, focusing on training, performance enhancement and error prevention.  Video games may constitute a training resource, not as simulation but as a gradual path of analogous or parallel skill acquisition.
 
It has been suggested that younger surgeons may acquire skills in laparoscopic surgery more rapidly than their elder colleagues, possibly because they have been exposed to video games at a young age and thus have had more experience with screen-mediated task execution.   Other studies have shown that subjects with previous regular engagement in video game play tend to be more skillful at video-endoscopic surgical tasks.28,  Video games are frequently a person’s first contact with a Graphical User Interface (GUI).  Therefore, they could promote familiarity in other screen interfaces such as in laparoscopic surgery.  This study correlates participant performance in video games with laparoscopic surgical skills.
 
METHODS and MATERIALS

Thirty-three surgeons (21 residents and 12 attending physicians) from Beth Israel Medical Center in New York City participated in this study.  The study design centered on the Rosser Top Gun laparoscopic Skills and Suturing Program,23 and data were gathered from May through August 2002 at Beth Israel Medical Center in New York, New York. The goal of the Top Gun course is to build skill sets that enable surgeons to function effectively in the videoscopic surgical environment.  In addition, it teaches surgeons suturing intracorporeal, perhaps the most challenging task in laparoscopy.  Top Gun has been featured in the scientific section of the American College of Surgeons annual convention since 1996 as well as the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) and the Society of Laparoscopic Surgeons (SLS) congresses. Thousands of trainees around the world have validated the course for advanced skill acquistion.24
  
This study consisted of three elements and each subject participated in all.  Element one consisted of a questionnaire to assess video game play, surgery experience and other demographic information including age, gender and hand dominance.  The video game portion of the questionnaire asked questions pertaining to episodes of play, length of time playing, types of games played and familiarity with specific genres of games.  The surgical experience portion assessed the subjects’ level of training or years in practice, number of laparoscopic cases performed, and subspecialty.  This element of the study occurred at the orientation of the Top Gun course before any video games or surgical drills had begun.
  
Element two was the Top Gun course itself, which was conducted over one and one half days. The Top Gun Basic Skills and Intracorporeal Suturing Courses involve preparatory laparoscopic drills, as well as interrupted suturing on porcine bowel.  The preparatory drills emphasize non-dominant hand dexterity, two-handed choreography, 2D depth perception compensation and targeting.  The first drill is the Cobra Rope Drill, requiring participants to unwind and pass a string using two standardized laparoscopic graspers, targeting specific colored sections of the string.  The second drill is the Terrible Triangle Drill, which involves lifting and moving five triangular shaped objects from one designated point to another by placing a needle through a metal loop atop each triangle utilizing an instrument with the non-dominant hand.  The third drill is the Cup Drop Drill, during which participants move beans from a designated area into a cup with a 1cm aperture using a standard laparoscopic grasper in the non-dominant hand.  Lastly, interrupted sutures are placed into porcine intestine. This complex task is executed utilizing a standardized technique algorithm.  Time to complete each task is recorded and an electronic proctor registers and tabulates errors committed by inaccurate instrument movements.  These parameters serve as a measure of performance.  The course has been previously reported in detail. 22
 
Element three consisted of three video games.  Subjects were taken in groups of three for 25 minutes of video game play.  Eight of the 33 subjects were recalled to complete the video game tasks having participated in the Top Gun course between 12 and 24 months previously.  All other participants completed the surgery, course and goal performance at the same time.  The 8 were not selected but were the trainees of the previous groups who could return for testing.  Participants were given standard set instructions, a brief demonstration and asked to begin play.
 
Three representative games were selected from one hundred of the most popular video games. Each game was chosen based on their applicability to the development of specific skills required for completion of the Top Gun laparoscopic skills and suturing course. The skills tested by these games included fine motor control, visual attention processing, spatial distribution, reaction time, eye-hand coordination, targeting, non-dominant hand emphasis, and 2D depth perception compensation.  Games were also selected based on their ease of measurement and lack of “bonus scores” which could skew data away from the mean, thus creating a non-representative bimodal distribution of scores. Therefore, two games were scored purely as total time to complete while the third measured total targets hit.  Gender neutrality and game novelty were also selection criteria.  None of the subjects had ever played any of the three video games used for this study.
 
The first video game was Super Monkey Ball™ 2 (Sega of America Inc, © 2001, 2002.  San Francisco, CA) for Nintendo Gamecube™ (Nintendo Co. Ltd. Tokyo, Japan) where the player pilots a spherical ball around a dynamic undulating course while targeting specific items.  Performance was scored by total time to complete the course.  If the course was not completed in 300 seconds, a value of 300 seconds was assigned.
 
The second video game was Star Wars®: Racer Revenge™ (LucasArts Entertainment Company, LLC ©2002 San Rafael, CA) for Sony PlayStation® 2 (Sony Computer Entertainment, Inc. Tokyo, Japan) where players navigated a serpentine canyon track competing against five other computer controlled racers.  The score was total time to complete a single lap.  All games were viewed on either a Sony 20-inch TV monitor or an 18-inch Sony Trinitron Flatscreen monitor (Sony Corporation; Tokyo, Japan) such as those used in laparoscopic surgery.
 
The third video game selected, Silent Scope® (Konami Co., Ltd. © 1999 Tokyo, Japan) for Microsoft Xbox™ (Microsoft Corp. Redmond, WA) required the player to shoot as many screen targets as possible in two minutes and thirty seconds.  The score was the total number of targets hit.
  
Data scale formation
A composite video game score averaged the three standardized video game scores. Participants’ scores from playing the three video games were reversed such that higher numbers were indicative of better play.  The video game skill scale was reliable as measured by Cronbach’s alpha (= .81).
 
The Amount of Video Game Experience scale was created in a similar fashion.  Participants’ self-reported responses to five items measuring past and present involvement in video games were scored such that higher numbers were indicative of greater involvement and then were standardized.  The Amount of Video Game Experience Scale was created by averaging the five standardized items.  This scale was reliable as measured by Cronbach’s alpha (= .90).
 
RESULTS

Top Gun scores were grouped according to video experience analyzed and compared based upon three criteria – (1) “key player” (participants who currently playing video games based upon survey responses), (2) “past player” (those who had played video games at some point in the past based upon survey responses) and (3) those participants with “demonstrated skill” as measured in the video games outlined previously.  These criteria were then compared to participants who had never played video games (“non-player” based upon survey responses).
 
Past Video Game Play Experience
Fifty-nine percent of surgeons reported playing video games at some point in the past while 41% reported never playing. Those that reported playing video games in the past were asked how often they played video games at the height of their gaming.  Thirty-two percent of the surgeons reported playing almost every day. Participants reported having played for an average of 8 years (SD = ±10.2). At the height of video game playing, 15% played between 0 and 1 hour, 12% played between 1 and 3 hours, 3% played between 3 and 5 hours, 18% played between 5 and 10 hours, 6% played between 10-15 hours, and 3% played more than 15 hours per week.  Men were historically more likely to play video games frequently (t =2.59, df = 31, p<.05).  Men were also more likely to have spent more hours per week playing than women (2 =8.4, df = 6, p<.05).
 
Analyses of variance compared surgeons who had never played video games in the past, those who reported playing 0 to 3 hours per week, and those who reported playing more than 3 hours per week at the height of their playing. These categories were determined empirically, attempting to have approximately equal numbers of surgeons in each group (Ns = 15, 9, and 9, respectively).  The analyses of variance were conducted to test differences between surgeons with different amounts of play on both time to complete Top Gun drills and the number of errors.  Significant differences emerged for both time (F(2,30) = 4.1, p = 0.027) and errors (F(2,30) = 3.9, p < 0.031).  Post-hoc Bonferroni tests showed that the significant effects are due to the difference between the surgeons who never played video games and those who played more than 3 hours per week.  Surgeons who never played video games took more time to complete the Top Gun drills (M = 5224) than surgeons who played 0 to 3 hours per week (M = 4135), or those who played more than 3 hours per week (M = 3802), although only the difference between the two extreme groups was significant (F (2,30) = 4.1, p = 0.027).  Surgeons who never played video games also made more errors in the Top Gun drills (M = 314) than surgeons who played 0 to 3 hours per week (M = 257), or those who played more than 3 hours per week (M = 197), although only the difference between the two extreme groups was significant (F(2,30) = 3.9, p = 0.031). Overall, the Top Gun scores (time and errors) of surgeons who played video games in the past were 33% better (t = -3.04, df = 31, p<0.005).  If the surgeons were past players that played more than 3 hours per week, they had an overall Top Gun score 42% better than the non video gaming group (p<0.01).
 
Current Video Game Play Experience
Thirty-six percent of the surgeons reported currently playing video games averaging 19 minutes (SD = 32.8) at one sitting.  Men were more likely to play video games frequently (t =3.15, df = 31, p<.01), and had been playing for significantly more years than women (means = 14.2 and 2.1 years, respectively; t =4.18, df = 31, p<.001).  Men were more likely to spend more hours per week playing than women (2 =8.4, df = 3, p<.05).
The differences between current video game players’ and non-players’ laparoscopic skill and suturing scores were evaluated. Current video game players made 32% fewer errors (t = 2.2, df = 31, p = 0.035) and performed 24% faster (t = 2.2,df = 31, p <0.036) than their non-video game playing colleagues.  If they were current players, they scored 26% better overall (time and errors) at the Top Gun suturing course (t = -3.04, df = 31, p<0.005).
 
Demonstrated Video Game Skill
Each of the video games used to quantify the subjects’ demonstrated video game skill were highly correlated with laparoscopic skill and suturing ability.  Super Monkey Ball showed the highest correlation (r=0.631, p=0.00), followed by Silent Scope (r=0.495, p=0.003) and Star Wars: Racer Revenge (r=0.482, p=0.004).  An overall video game skill scale was also created as previously described, which was also highly correlated with laparoscopic skill and suturing ability (r=0.631, p=0.00).  Demonstrated video game skill as a predictor of laparoscopic skill and suturing scores was studied.  This was done by dividing the participants into tertiles based upon their demonstrated video game skill on the three video games.  When comparing the subjects from the top tertile to the bottom tertile, it was found that the subjects in the top tertile made 47% fewer errors (F(2,30)=10.0, p<0.000), performed 39% faster (F(2,30)=11.9, p<0.000) and scored 41% better in their overall Top Gun score (F(2,30)=15.5, p<0.000).
 
Regressions Analysis Predicting Laparoscopic Skills
A regression analysis was performed to test further the relationship between laparoscopic skills and both demonstrated video game skills and past video game experience.  The first three demographic variables (years of training, number of laparoscopic cases, gender) did not predict a significant amount of variance in Top Gun scores. However, amount of past video game experience (B=-0.11, p=0.03) and demonstrated skill (B=-0.76, p<0.001) predicted a significant amount of variance in Top Gun scores after controlling for gender, amount of training, and number of laparoscopic cases completed.
 
Johnson's relative weight analysis was conducted to determine the relative importance of each of the predictors. ,    Relative weight analysis estimates the proportionate contribution each predictor makes to the overall variance while considering both its unique contribution and its contribution when combined with other variables.30  Of the individual variables, demonstrated video game skill accounts for the greatest amount of variance (31%), and amount of past video game experience accounted for an additional 10 percent of the variance.  The number of laparoscopic cases performed and the surgeon's gender both accounted for two percent of the variance, and years of training were unrelated to demonstrated laparoscopic skill as determined by the Top Gun Course (0.3 %).
 
CONCLUSIONS
 
 
Surgeons who had played video games in the past for more than 3 hours per week made 37% fewer errors, were 27% faster and scored 46% better overall than surgeons who never played video games. Current video game players made 32% fewer errors, were 24% faster and scored 26% better overall than their non-player colleagues.   All three video games used in this study were highly correlated with laparoscopic skills.  Consistently throughout this study, past, current and demonstrated video game skill was found not only to increase speed, but to also decrease errors.  It is the error reduction that will have the most significant impact on patient safety.
  
Regression analysis suggested that past and current video gaming capability were more important than traditionally recognized factors such as years of training or number of laparoscopic cases.  The amount of time playing video games in the past was also a significant predictor of demonstrated laparoscopic skill.
 
This is a correlational study and therefore causality cannot be definitely determined.  It is possible that the possession of laparoscopic skills may improve video game performance.  But, it is very clear that the surgeons tested were not superiorly skilled in advanced laparoscopic surgery.  It is likely that video game skills are a better predictor of demonstrated laparoscopic skills and suturing than years of experience with laparoscopy because many laparoscopic procedures do not require the advanced skill sets as measured in the course.
  
There is ample evidence to suggest that games with certain design characteristics and focused duration of exposure can execute pre-determined participant effects.2, ,   The amount and content of video game play have been studied and found to have significant impact on behavior and performance.8,9, ,  ,  ,  ,  , ,   As argued elsewhere, it is also likely that the form and mechanics of video games can have important effects, and that they are more likely (than amount or content) to be the mechanisms by which video gaming may improve laparoscopic skills. ,   The formal features that define video game play include aspects of game design such as amount of visual attention needed or reaction time that is required to perform well. To the extent that games can be designed with specific formal features, it is possible that the effects on users could be tailored to specific dimensions.  The use of task-related mechanics for game controllers can also produce positive effects (e.g., driving simulators with a steering wheel should transfer better than steering with a computer mouse).  Theoretically, game controllers could be designed so that they resemble laparoscopic instruments and other medical appliances.  Video games could be created with specific game forms and mechanics, content and play time constructs that coordinate directly with the development of medically related fine motor skills, eye-hand coordination, visual attention, depth perception and computer competency.
  
Video games have been accepted and have become an integral part of American and global culture. They are relatively inexpensive, portable, and reliable. Video gaming has been incorporated into training by industries and organizations where routine training scenarios are too dangerous or expensive.  The U.S. Army has recognized the benefits of video games for teaching skills, and has licensed the popular violent video game series Rainbow Six to train their special operations forces because it is an excellent way to teach all of the steps necessary to plan and conduct a successful special operations mission.30 Hopefully, in a similar fashion, medicine can tap into training and technology conditioning capability of video games.
 
Video games are a popular and durable part of leisure activity.  Negative aspects of excessive video games include time lost from other more useful activities and the element of violence in the content of many games.34 However, in this study a history of video game play correlated with facility in laparoscopic skills. Game time of three hours per week seemed to be critical exposure with 37% fewer errors and 27% faster skill execution with a 42% better overall score in a standard and highly validated training construct. Improved performance correlated strongly with the inclusion of video game play as part of laparoscopic skill instruction. Regression analysis demonstrated the importance of video game play over such predictors as years of training or specific experience in laparoscopic surgery. The results are highly significant and invite creative inclusion of video game play as an adjunct for skill training in laparoscopic surgery. This is a correlational study and conclusions as to causation for the superior performance of the video game players would be speculative. However, the correlation is strong enough that considering the inclusion of video games into teaching curricula certainly seems appropriate. It could be argued that experience in laparoscopic surgery improves video game performance or makes video game play more appealing.  That inference does not seem justified, given that all of participants were surgeons. Most of the experience laparoscopy registered by the participants was in basic maneuvers and not advanced laparoscopic skills of the course such as endocorporeal suturing.22, 23 Although surgeons who played the greatest amount of video games in the past demonstrated both better speed and accuracy, it is important to note that the significant amount of gaming time demonstrated in this study was 3 hours or more per week at the peak of play.  This is greatly under the average for today’s adolescents, who average 9 hours per week (13 hours per week for boys, 5 hours for girls).2 Furthermore, research on the amount of gaming has shown a negative correlation with school performance, both for adolescents and college students.2,33 Therefore, indiscriminate video game play is not a panacea.  There is evidence that games with certain design characteristics could improve certain analog skills in other activities.2,35,36 The amount and content of games in fact seem to have great impact on behavior and performance.8,9,33,37,38,39,40,42 Further study of each specific dimension of video games (i.e., amount, content, form, & mechanics) could identify pedagogic advantages appropriate to surgeon training or any mechanical skill acquisitions. It is interesting that although video game play was more likely to be a pursuit for men rather than women, correction for actual game play time showed there was no gender difference in skill acquisition. Video game design could affect the appeal no only to gender but could be a strong element in recruiting young people in general to professions that require eye-hand coordination and spatial awareness such as laparoscopic surgery. Given the broad and sustained appeal of video games among younger people it seems reasonable to explore their positive aspects in the interest of education, skill acquisition and skill maintenance.
 
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Note: The version presented on this website differs in small ways from the final published version.