Acquisition Of Psychomotor Skills Research Articles

内視鏡外科手術の教育におけるバーチャルリアリティ手術シミュレータの役割

Objective : This study aimed to evaluate the impact of virtual reality (VR) surgical simulator training on improvement of individual skills for endoscopic surgery and to consider its role in the training system. Methods : (1) Forty-one subjects were assigned to one of the three groups : experienced surgeons experiencing >50 endoscopic procedures (n=12), inexperienced surgeons (1～30 endoscopic procedures, n=9), and medical students with no prior experience (n=20). The participants were trained with LapSim® simulator, and their skills were evaluated with LapSim® “Cutting” task before and after the training. (2) Twenty subjects received training for endoscopic suturing using two types of VR simulator and a training box. After the training, they were asked to select the best training modality. Results : (1) Significant improvements in laparoscopic skills were observed in all three groups after the training. The significant differences in surgical skills observed between each group diminished following the training. (2) Most (15/20) subjects chose the box training as the best training method due to its authenticity. Conclusions : VR simulator is useful in the acquisition of psychomotor skills, but not sufficient for training the suturing technique. The role of VR simulator, currently limited in the training of endoscopic surgery, is expected to expand pending future progress of VR technology.

Preparing Pediatric Nurses: The Role of Simulation-Based Learning

Simulation-based learning is increasingly being integrated into pediatric nursing education for students as well as novice nurses in practice. Various levels of technology in simulation provide for a range of cognitive, psychomotor, and affective skills acquisition within the controlled setting provided by this teaching strategy. This article provides an overview of simulation, the emergence of simulation in nursing education with an emphasis on pediatric nursing, a description of one baccalaureate program's experience in developing a state-of-the-art maternal child-simulation skills laboratory, and the role of simulation-based learning in continuing education.

The value of haptic feedback in conventional and robot-assisted minimal invasive surgery and virtual reality training: a current review.

BackgroundVirtual reality (VR) as surgical training tool has become a state-of-the-art technique in training and teaching skills for minimally invasive surgery (MIS). Although intuitively appealing, the true benefits of haptic (VR training) platforms are unknown. Many questions about haptic feedback in the different areas of surgical skills (training) need to be answered before adding costly haptic feedback in VR simulation for MIS training. This study was designed to review the current status and value of haptic feedback in conventional and robot-assisted MIS and training by using virtual reality simulation.MethodsA systematic review of the literature was undertaken using PubMed and MEDLINE. The following search terms were used: Haptic feedback OR Haptics OR Force feedback AND/OR Minimal Invasive SurgeryAND/OR Minimal Access Surgery AND/OR Robotics AND/OR Robotic Surgery AND/OR Endoscopic Surgery AND/OR Virtual Reality AND/OR Simulation OR Surgical Training/Education.ResultsThe results were assessed according to level of evidence as reflected by the Oxford Centre of Evidence-based Medicine Levels of Evidence.ConclusionsIn the current literature, no firm consensus exists on the importance of haptic feedback in performing minimally invasive surgery. Although the majority of the results show positive assessment of the benefits of force feedback, results are ambivalent and not unanimous on the subject. Benefits are least disputed when related to surgery using robotics, because there is no haptic feedback in currently used robotics. The addition of haptics is believed to reduce surgical errors resulting from a lack of it, especially in knot tying. Little research has been performed in the area of robot-assisted endoscopic surgical training, but results seem promising. Concerning VR training, results indicate that haptic feedback is important during the early phase of psychomotor skill acquisition.

Experienced Endovascular Interventionalists Objectively Improve their Skills by Attending Carotid Artery Stent Training Courses

Objective: Carotid artery stenting (CAS) is an advanced endovascular intervention with a steep learning curve. Virtual reality (VR) simulation has been proposed as a means to train and objectively assess technical performance. Aim: To objectively assess psychomotor skills acquisition of experienced interventionalists attending a two-day CAS course, using a VR simulator. Methods: Both cognitive and technical skills of 11 interventionalists were trained in a two-day course using didactic sessions, case reviews, supervised VR simulation and live-cases. Pre- and post-course skills were assessed through performance on the same CAS procedure using metrics derived from the simulator. Results: Significant differences were noted between pre- and post-course performance for procedure (36 vs. 20 min., p = 0.005), X-ray (20 vs. 11 min., p = 0.016) and delivery-retrieval time of the embolic protection device (12 vs. 9 min., p = 0.007). Advancement of the guiding catheter without a leading wire occurred to a greater extent pre- versus post-course (199 vs. 152 mm., p = 0.050) as did spasm of the internal carotid artery (4 vs. 2, p = 0.049). Conclusions: This study has objectively proven a benefit for experienced interventionalists to attend CAS courses for skills acquisition measured by a VR simulator. These data can be used to offer participants an insight into their skills and objectively audit course efficacy.

Experienced Endovascular Interventionalists Objectively Improve their Skills by Attending Carotid Artery Stent Training Courses

Carotid artery stenting (CAS) is an advanced endovascular intervention with a steep learning curve. Virtual reality (VR) simulation has been proposed as a means to train and objectively assess technical performance. To objectively assess psychomotor skills acquisition of experienced interventionalists attending a two-day CAS course, using a VR simulator. Both cognitive and technical skills of 11 interventionalists were trained in a two-day course using didactic sessions, case reviews, supervised VR simulation and live-cases. Pre- and post-course skills were assessed through performance on the same CAS procedure using metrics derived from the simulator. Significant differences were noted between pre- and post-course performance for procedure (36 vs. 20min., p=0.005), X-ray (20 vs. 11min., p=0.016) and delivery-retrieval time of the embolic protection device (12 vs. 9min., p=0.007). Advancement of the guiding catheter without a leading wire occurred to a greater extent pre- versus post-course (199 vs. 152mm., p=0.050) as did spasm of the internal carotid artery (4 vs. 2, p=0.049). This study has objectively proven a benefit for experienced interventionalists to attend CAS courses for skills acquisition measured by a VR simulator. These data can be used to offer participants an insight into their skills and objectively audit course efficacy.

52. Simulation based training improves resident competence in the performance of critical resuscitation procedures

We sought to assess the impact of procedural skills simulation training on residents’ competence in performing critical resuscitation skills. Our study was a prospective, cross-sectional study of residents from three residency training programs (Family Medicine, Emergency Medicine and Internal Medicine) at the University of Calgary. Participants completed a survey measuring competence in the performance of the procedural skills required to manage hemodynamic instability. The study intervention was an 8 hour simulation based training program focused on resuscitation procedure psychomotor skill acquisition. Competence was criterion validated at the Right Internal Jugular Central Venous Catheter Insertion station by an expert observer using a standardized checklist (Observed Structured Clinical Examination (OSCE) format). At the completion of the simulation course participants repeated the self-assessment survey. Descriptive Statistics, Cronbach’s alpha, Pearson’s correlation coefficient and Paired Sample t-test statistical tools were applied to the analyze the data.
 Thirty-five of 37 residents (9 FRCPC Emergency Medicine, 4 CCFP-Emergency Medicine, 17 CCFP, and 5 Internal Medicine) completed both survey instruments and the eight hour course. Seventy-two percent of participants were PGY-1 or 2. Mean age was 30.7 years of age. Cronbach’s alpha for the survey instrument was 0.944. Pearson’s Correlation Coefficient was 0.69 (p < 0.001) for relationship between Expert Assessment and Self-Assessment. The mean improvement in competence score pre- to post-intervention was 6.77 (p < 0.01, 95% CI 5.23-8.32).
 Residents from a variety of training programs (Internal Medicine, Emergency Medicine and Family Medicine) demonstrated a statistically significant improvement in competence with critical resuscitation procedural skills following an intensive simulation based training program. Self-assessment of competence was validated using correlation data based on expert assessments. 
 Dawson S. Procedural simulation: a primer. J Vasc Interv Radiol. 2006; 17(2.1):205-13.
 Vozenilek J, Huff JS, Reznek M, Gordon JA. See one, do one, teach one: advanced technology in medical education. Acad Emerg Med. 2004; 11(11):1149-54.
 Ziv A, Wolpe PR, Small SD, Glick S. Simulation-based medical education: an ethical imperative. Acad Med. 2003; 78(8):783-8.

How Do Feedback and Instructions Affect the Performance of a Simulated Surgical Task?

This study was conducted to objectively evaluate the effect of feedback and instructional material on the acquisition of surgical psychomotor skills for a model system based on mandibular fracture repair. This study was a prospective cohort study comprised of students in the preclinical years of dental or medical education. The students were divided into 4 groups and exposed to different levels of feedback/written instructions (including none) in the testing environment. Each subject was given a pair of aluminum bars, representing a fractured human mandible, and a standardized set of tools, including a fixed length of stainless steel wire to fix the bars together. The strength of fixation was measured, using a calibrated testing apparatus, as the amount of load that the fixed sample could tolerate to the point of failure. All subjects completed 5 successive trials under the same conditions. Descriptive statistics were recorded to provide comparisons between groups. Bivariate statistics were computed to compare the different study groups; multiple-comparison testing was used to evaluate differences among the groups. A P value <or= .05 was considered statistically significant. The sample was comprised of 61 students, divided into 4 groups. The students who received neither instructions nor feedback had the lowest average performance scores. Those who received both feedback and instructions had the highest average performance scores. The students who received instructions only fared better than those who received feedback only, but only immediately after receiving instructions. Differences between the groups tended to dissipate after a few trials. Written instructions and performance feedback can enhance the acquisition of psychomotor skills related to the performance of a complex task.

The effect of escalating feedback on the acquisition of psychomotor skills for laparoscopy

In the acquisition of new skills that are difficult to master, such as those required for laparoscopy, feedback is a crucial component of the learning experience. Optimally, feedback should accurately reflect the task performance to be improved and be proximal to the training experience. In surgery, however, feedback typically is in vivo. The development of virtual reality training systems currently offers new training options. This study investigated the effect of feedback type and quality on laparoscopic skills acquisition. For this study, 32 laparoscopic novices were prospectively randomized into four training conditions, with 8 in each group. Group 1 (control) had no feedback. Group 2 (buzzer) had audio feedback when the edges were touched. Group 3 (voiced error) had an examiner voicing the word "error" each time the walls were touched. Group 4 (both) received both the audio buzzer and "error" voiced by the examiner All the subjects performed a maze-tracking task with a laparoscopic stylus inserted through a 5-mm port to simulate the fulcrum effect in minimally invasive surgery (MIS). A computer connected to the stylus scored an error each time the edge of the maze was touched, and the subjects were made aware of the error in the aforementioned manner. Ten 2-min trials were performed by the subjects while viewing a monitor. At the conclusion of training, all the subjects completed a 2-min trial of a simple laparoscopic cutting task, with the number of correct and incorrect incisions recorded. Group 4 (both) made significantly more correct incisions than the other three groups (F = 12.13; df = 3, 28; p < 0.001), and also made significantly fewer errors or incorrect incisions (F = 14.4; p < 0.0001). Group 4 also made three times more correct incisions and 7.4 times fewer incorrect incisions than group 1 (control). The type and quality of feedback during psychomotor skill acquisition for MIS have a large effect on the strength of skills generalization to a simple MIS task and should be given serious consideration in curriculum design for surgical training using simulation tasks.

Could simulated emergency procedures practised in a static environment improve the clinical performance of a Critical Care Air Support Team (CCAST)?: A literature review

The Royal Air Force Critical Care Air Support Teams (CCASTs) have a philosophy to undertake transfers of critically ill patients from anywhere in the world back to a UK medical facility in a stable or improved clinical condition. The training they receive is primarily taught by traditional didactic methods, with no standardisation of education between teams that are expected to deliver care to the same standard. Notwithstanding there being no current compromise to patient care during air transfer, it was important to consider the benefits of an alternative experiential teaching modality. Experiential learning utilised in the static environment could potentially improve the current CCAST training curriculum and, therefore, improve clinical performance during air transfer. In the absence of primary research evidence investigating beneficial teaching modalities for medical flight crews, a review of recent literature was undertaken to observe any potential relevance to the aeromedical specialty. This critical review examined recent quantitative research on various modalities of experiential learning and their influence on the critical thinking, higher cognitive and psychomotor skill acquisition by healthcare professionals in a static hospital environment. The main databases were interrogated using the following inclusion criteria: patient simulation, clinical competence, aeromedical, education, computer simulation, critical thinking and problem-based learning. The number of articles obtained was 13; these were coded on methodological strength to reduce the potential for inclusion bias. Nine studies were finally selected for review. Many small studies have been undertaken, primarily observing benefits of experiential learning to medical students and doctors. No studies show conclusively that simulated learning improves patient outcome, but the body of evidence suggests human patient simulators to be advantageous over other modalities because of their realistic recreation of critical events. They have proven to be at least as effective as traditional teaching by didactic methods. For CCASTs to have a standardised training curriculum, they should undertake real-time missions in a flight simulator, supported by a human patient simulator programmed to respond to the physiological changes associated with altitude. Real scenarios could then be practised, on demand, in a safe environment as an augmentation to the current training programme. Consequently, those acquired skills could then be carried out with improved proficiency during real missions with a concomitant potential for improvement in the standard of patient care.

Effect of Interactive Multimedia on Basic Clinical Psychomotor Skill Performance by Physical Therapist Students

Background and Purpose. Physical therapist educators are challenged to provide quality instruction in psychomotor skills. Multimedia instruction may facilitate and enhance psychomotor skill acquisition and therefore is of significant interest to physical therapist educators. The purpose of this study was to examine the differences between physical therapist student cognitive and psychomotor performance on basic clinical skills when taught traditionally versus with interactive multimedia. Subjects. Participants were recruited from 2 physical therapist programs. Twenty-four students volunteered to participate from Program 1 and 21 students volunteered from Program 2. Methods. Students were randomly assigned to an instructional strategy: (1) an experimental group receiving an instructional CD of clinical orthopedic techniques for the knee and practice with instructor feedback, or (2) a control group receiving live demonstration of clinical orthopedic techniques for the knee and practice with instructor feedback. Instructional strategies were then switched for instruction of clinical skills for the ankle/foot. Results. Written examination scores improved with both instructional strategies, demonstrating no differences observed between the strategies. No differences in practical examination knee scores were observed between instructional strategy groups. Practical examination ankle scores were significantly higher in participants receiving CD instruction than in participants receiving live presentation. Age and sex were found to have no effect on written or practical scores. Discussion and Conclusion. This study supports the use of multimedia instruction as an effective strategy to instruct clinical skills related to the knee and ankle. A better understanding of the role of multimedia instruction in teaching psychomotor skills will aid physical therapist educators in improving the performance of clinical skills by future clinicians.

Appendix 1: Worksheet topics and authors

Appendix 1: Worksheet topics and authors

Assessment of psychomotor skills acquisition during laparoscopic cholecystectomy courses

Background Standardized short courses in laparoscopic cholecystectomy aim to teach laparoscopic skills to surgical trainees, although end-of-course assessments of performance remain subjective. The current study aims to objectively assess psychomotor skills acquisition of trainees attending laparoscopic cholecystectomy courses. Methods Thirty-seven junior surgical trainees had their laparoscopic skills assessed before and after attending 1 of 3 separate 2-day courses (A, B, and C), all with identical format. Assessments were comprised of a standardized simulated laparoscopic task, with performance measured using a valid electromagnetic hand-motion tracking device. Results Overall, trainees made significant improvements in path length ( P = .006), number of movements ( P < .001), and time taken ( P < .001). Analyzing the 3 courses separately, only trainees attending courses A and C made significant improvements. Discussion Objective validated methods can be used to assess learning of psychomotor skills on courses. In addition to providing participants with an insight into their skills, these data can be used to demonstrate course efficacy.

The laparoscopic performance of novice surgical trainees

It has been suggested that virtual reality (VR) might be useful for the selection of surgical trainees and the measurement of technical performance during preoperative training and retraining. This study was designed to determine whether it is possible to define and measure the acquisition, loss, and reacquisition of psychomotor skills in novice surgical trainees. Novice surgical trainees (NSTs n = 10, junior surgical registrars with little or no prior experience with laparoscopic surgery) were tested and retested after 1 month using the Minimally Invasive Surgical Trainer-Virtual Reality. Two tasks were used: the simple task [stretch diathermy (SD)] and the more complex task [manipulation diathermy (MD)]. The score was derived from the time taken to complete the task and the number of errors that occurred. Acquisition is the difference between the first and last score of the first training session, loss is the difference in score that occurs between the last score of the first training session and the first score of the second training session, and reacquisition is the difference in the first and last scores of the second training session. A performance criterion level was defined for each task by testing a group of experienced laparoscopic surgeons (n = 10). Groups were compared using the nonparametric Wilcoxon signed rank test, with p < 0.05 considered to be significant. Acquisition of skill was found for five of 10 NSTs with the SD task and 10/10 for the MD task. As a group the NSTs achieved the criterion level from the outset with the SD task and exceeded it by the eighth attempt for the MD task. The best score was achieved with fewer attempts during the second training session for the SD but not the MD task. The defined parameters are expressed as mean percentage score +/- SD for the 10 NSTs and for each task. There was a 36% (+/- 26) acquisition for the SD task compared with 50% (+/- 4) for the MD task (Wilcoxon p = 0.241). There was a 23% (+/- 19) loss for the SD task compared with 81% (+/- 16) for the MD task (p < 0.005). There was a 20% (+/- 10) reacquisition for the SD task compared with 54% (+/- 7) for the MD task (p < 0.005). The mean scores were greater for the more complex task (MD), which was more useful in discriminating between the individual trainees and the two training sessions. It is possible to use VR to define the acquisition, loss, and reacquisition of psychomotor skills in individual NSTs and to compare them with a predefined performance criterion level. This study defines parameters that will be useful in repeated training sessions of NSTs in the preoperative phase of training and during retraining.

Computer-Supported Collaborative Learning Requiring Immersive Presence (CSCLIP): An Introduction

The dramatic increase in distance learning (DL) enrollments in higher education is likely to continue. However, research on DL that includes psychomotor, cognitive, and affective skills is virtually non-existent. Indeed, DL for psychomotor skills has been viewed as impossible. Laboratory coursework, which we define as including the acquisition of psychomotor, cognitive, and affective skills, has become a limiting factor in the growth of DL. What is needed is a synergistic integration of technologies and Human-Computer Interface (HCI) principles from Computer Supported Collaborative Learning (CSCL), collaborative learning systems, and immersive presence technologies to enable achievement of psychomotor learning objectives. This paper defines the Computer Supported Collaborative Learning requiring Immersive Presence (CSCLIP) research area, and introduces this special issue of Information Systems Frontiers on CSCLIP and the six papers contained herein.

Effect of Computer-Assisted Instruction Versus Traditional Modes of Instruction on Student Learning of Musculoskeletal Special Tests

Background and Purpose. Physical therapist educators strive to maximize the effectiveness and efficiency of instruction by using optimal teaching methods. Most pedagogical research in allied health education has focused on acquisition and retention of cognitive knowledge rather than the development of psychomotor skills. The purpose of this study was to determine the effect of computer-assisted instruction (CAI), live demonstration (LD), and independent textbook instruction (TXT) on acquisition and retention of knowledge and skills related to musculoskeletal special tests. Subjects. Subjects were recruited over 2 consecutive physical therapy classes (2004, n=19, and 2005, n=24). Methods. Using stratified random assignment, subjects were assigned to 1 of 4 intervention groups: CAI, LD, TXT, or control. Pretest written and practical exams measured baseline knowledge and skill in 4 novel musculoskeletal special tests. Students then participated in their group's intervention. Written and practical examinations, identical to pretests, were administered immediately following the prescribed intervention to assess cognitive and psychomotor skill acquisition, and again 3 weeks later to assess retention of learning. Results. Friedman 2-Way ANOVA by Ranks revealed a significant difference in written and practical examination scores across time in each of the 3 intervention groups (P = 0.0001). Nemenyi post-hoc procedure established a significant improvement in each of these groups from pretest to acquisition (P = 0.001). No significant difference existed between acquisition and retention scores, supporting retention of acquired knowledge. Kruskal-Wallis 1-Way ANOVA by Ranks, followed by Dunn's test, revealed significant differences in learning only when the CAI and LD groups were each compared to the control group. Discussion and Conclusion. CAI was as effective as live demonstration and more effective than textbook instruction, particularly in facilitating psychomotor skill acquisition and retention. CAI is an effective and efficient mode of instructional delivery for use in physical therapist education that can be delivered anytime, anywhere.

Validation of a six-task simulation model in minimally invasive surgery

The content validity of currently available inanimate simulation models is questionable, because some tasks seem too far from clinical reality. The aim of this study was to validate a simulation model with six tasks commonly used in clinical practice (6-TSM) for the acquisition of psychomotor skills in minimally invasive surgery (MIS). This was a prospective randomized trial comparing the 6-TSM to a previously described three-task training method (3-TTM). All first, second, and third postgraduate year surgical residents were eligible. The 6-TSM included clipping and dividing of a vessel, excision of lesion, appendectomy, mesh repair, suturing perforation, and hand-sewn anastomosis. The outcome measures of 6-TSM included accuracy error, tissue damage, sliding knot, leak, operating time, and dangerous movements. After completion of training, 6-TSM and 3-TTN residents were tested by the Minimally Invasive Surgical Trainer-Virtual Reality (MIST-VR). Criterion-related and construct validity, responsiveness, test-retest, and interrater reliability were assessed. During six months, 17 residents underwent training with the 6-TSM or the 3-TTM as allocated. The mean duration of training with 6-TSM and 3-TTM was similar (7.8 vs 8.1 h). The criterion-related validity of the 6-TSM was shown by significantly increased skill improvement in the 6-TSM residents, as compared with the 3-TTM residents at MIST-VR. Construct validity the of 6-TSM was shown by the finding that the experts' baseline was superior to the residents' baseline. The responsiveness of the 6-TSM was shown by the significantly increased skill improvement of the 6-TSM residents in sliding knot, leak, and operating time. The test-retest reliability of the 6-TSM was good (> 0.80), except for accuracy error and dangerous movements (Cronbach's intraclass correlation coefficient alpha: 0.57, p < 0.0001; 0.62, p < 0.0001, respectively). The interrater reliability of the 6-TSM was good (>0.80) except for leak (Kendall's concordance coefficient tau_b:0.76, p = 0.06 for hand-sewn anastomosis) and dangerous movements (tau_b:0.72, p = 0.08 for suturing perforation and tau_b:0.68, p = 0.10 for hand-sewn anastomosis). The perresident cost for 6-TSM was 769 dollars. The 6-TSM is a valid and reliable learning tool for surgical residents' acquisition of laparoscopic motor skills.

Skillful Coaching: New Directions In Teaching Health Assessment

The purpose of this study was to examine differences in nursing student’s assessment skills before and after the implementation of a cognitive apprenticeship didactic approach including think-aloud and critical dialogue. In the nursing care of clients, a through and accurate holistic health assessment is essential. The content of the assessment task is taught in all nursing programs. Students must be competent not only in performing the examination but also in evaluating the information obtained and integrating it with the health history and lab findings. This extensive criteria makes assessment a challenging skill to master. Problems arise when students in nursing attempt to apply the theoretical assessment approaches to the clinical setting with real clients. Consequently, student’s performance outcomes are often unsatisfactory, as the teaching format usually focuses on the students’ acquisition of domain knowledge and psychomotor skills rather than on shaping the thinking processes involved. Students’ common problems with physical assessment shows that they struggle to manipulate the abstract positions involved.

Using Directed Instruction to Teach Initial Psychomotor-Skill Acquisition

Using Directed Instruction to Teach Initial Psychomotor-Skill Acquisition

Acquisition and Maintenance of Endoscopic Skills: Developing an endoscopic dexterity training system for anesthesiologists

The acquisition and maintenance of essential psychomotor skills that are only required sporadically is a significant problem in medical training and practice. It is of particular relevance to anesthesiologists with regard to fibreoptic intubation, a technique that may be under-utilized despite its central role in the management of the difficult airway. Dexterity deficit due to current training models, dexterity decay due to lack of practice, and situational stress related to the clinical environment may combine to impede effective training and confident use of endoscopes in airway management. An educational resource (DexterÔ) has been developed to overcome these problems. Dexter is a non-anatomical, endoscopic dexterity training system designed to encourage practice and help establish and maintain a state of procedural readiness, even if clinical exposure to difficult airway situations is sporadic.

Acquisition and maintenance of endoscopic skills: developing an endoscopic dexterity training system for anesthesiologists

The acquisition and maintenance of essential psychomotor skills that are only required sporadically is a significant problem in medical training and practice. It is of particular relevance to anesthesiologists with regard to fiberoptic intubation, a technique that may be under-utilized despite its central role in the management of the difficult airway. Dexterity deficit due to current training models, dexterity decay due to lack of practice, and situational stress related to the clinical environment may combine to impede effective training and confident use of endoscopes in airway management. We describe an educational resource (Dexter™), which has been developed to overcome these problems. Dexter™ is a nonanatomical, endoscopic dexterity training system designed to encourage practice and help establish and maintain a state of procedural readiness, even if clinical exposure to difficult airway situations is sporadic.