Suture Training: Retention Through Ongoing Instruction and Practice
As discussed in our last post, studies have shown that medical students benefit significantly from simulation-based learning. Practicing suture techniques on high fidelity simulators yields increased confidence and better skill transfer – a significant improvement over training on subpar materials such as pigs’ feet or banana peels.
However, working with high fidelity simulators is just one element of effective suture training. Studies also show that skill retention improves when training unfolds over time and students are given opportunities to continue to practice beyond the initial training session. Simply providing students with one-off training sessions is inadequate to prepare them for real world practice.
A study1 of final year medical students traced their retention of basic skills over the course of the year. Students were trained in basic surgical skills including: surgical instrument
identification, simple interrupted suturing and one-handed knot tying. Students were then divided into cohorts and tested intermittently throughout the year. While the first cohort was tested five times throughout the year and the second cohort tested only three times, neither group adequately retained the necessary skills.
The study found that although students achieved proficiency at the basic skills during their initial training sessions, without continued practice, periodic assessments were ineffective for achieving retention. In other words, merely testing students at various intervals did not prevent “a significant drop in all the three areas tested, especially in knot tying and suturing.”1 The two cohorts did not reflect a statistically significant difference in their retention, and all students’ skills decayed over the course of the year.
Routt et al2 ran a somewhat similar study, but they condensed their evaluations to a 30 day period rather than stretched out over a year. In this study, both cohorts received the same initial instruction, with a test group receiving follow-up evaluations at 10, 20, and 30 days, versus just a 30 day evaluation for the control group. Importantly, the study found that “Students in the control group had a 0% pass rate at the 30-day initial proficiency test, while students in the experimental group had a 91.7% pass rate at day 30.” This indicates that requiring students to perform basic suture skills every 10 days yielded dramatically better skill retention over the course of a month.
The authors, therefore, suggest an instructional model in which learning is scaffolded and unfolds over time. Students are first prepared with instructional videos followed by instructor demonstration and in-class or lab practice to achieve basic proficiency. Importantly, students should then be given the opportunity for independent practice. Practicing suture skills outside of class and in between evaluations is hugely beneficial when it comes to retaining skills. The authors’ recommendation is for students to practice placing at least 10 sutures every 10 days to maintain proficiency.
Khunger and Kathuria3 offer a similarly scaffolded model for simulation-based learning that spaces out instruction and encourages regular practice. Their suggested approach begins with preparatory material directed by the instructor – these could include books, videos, diagrams, or other modeling and observation based materials. This is followed by in-class or lab training directed by the instructor, preferably on higher fidelity models. As they note, Rothenberger et al4 found that medical students demonstrated significant improvement in competence when taught surgical skills using fresh human skin models. When such tissues are not available or practical, simulators that closely resemble human tissue are an excellent option. Suture practice kits are also helpful in fulfilling Khunger and Kathuria’s third stage of simulation-based learning: self-directed training outside the classroom.
Ultimately, the more students are given the opportunity to practice over time, the better they retain the skills they have been taught. Without ongoing practice, one-off lessons are likely to fade quickly from memory. High quality suture training pads, ones that students can use to practice with at home and place multiple stitches, are an excellent way to ensure ongoing training and retention.
- Bekele A, Wondimu S, Firdu N, et al: Trends in Retention and Decay of Basic Surgical Skills: Evidence from Addis Ababa University, Ethiopia: A Prospective Case-Control Cohort Study. World J Surg 43: 9-15, 2019.
- Routt E, Mansouri Y, de Moll E, et al: Teaching the Simple Suture to Medical Students for Long-term Retention of Skill. JAMA Dermatol 151(7):761-765, 2015.
- Khunger N, Kathuria S: Mastering Surgical Skills Through Simulation-Based Learning: Practice Makes One Perfect. J Cutan Aesthet Surg 9: 27–31, 2016.
- Rothenberger J, Seyed Jafari SM, Schnabel KP, et al: Evaluation of medical students attitudes and performance of basic surgery skills in training program using fresh human skin, excised during body contouring surgeries. J Surg Educ. 72: 868–74, 2015.