title: Preoperative warm-up the key to improved resident technique: a randomized study.
abstract: BACKGROUND
  The ACGME has required that a skills lab be incorporated into the surgical residency curriculum. While the value of warm-up is generally accepted in other areas requiring complex motor skills, there is little evidence to support the benefits of warm-up prior to performing surgery. We are conducting this study in an attempt to identify whether a warm-up period prior to operating impacts operative technique.
  
  
  METHODS
  All general surgery residents and MIS fellows were included in this IRB-approved randomized study. Participants were randomized to either warm-up or no warm-up groups. Participants randomized to the warm-up group completed a 10 min practice session in the simulation lab within 1 h of starting the case, using an FLS training box. At the conclusion of the operation, the participant was evaluated by the attending surgeon using the validated global rating scales of Reznick and Vassiliou. The attending surgeons were blinded to the use of pre-procedure warm-up. The results of the questionnaire were analyzed using student's t test with p < 0.05 for significance.
  
  
  RESULTS
  Pilot data were obtained after completing 40 cases that were randomized to warm-up (19) or no warm-up (21). There was a statistically significant improvement in depth perception (p = 0.02), bimanual dexterity (p = 0.01), and efficiency of movements (p = 0.03) for those randomized to warm-up. There was statistical improvement when we preformed a composite scoring of the attending evaluations for each of the Reznick (p = 0.008) and the Vassiliou (p = 0.01) global rating scales.
  
  
  CONCLUSIONS
  Preoperative warm-up significantly improves depth perception, bimanual dexterity, and efficiency of movements, as well as improvement in composite scores as judged by the attending surgeon. The lack of self-perceived improvement by the residents may be a reflection of the high standards and intense self-critique that is common among surgical trainees. We believe that our findings, while preliminary, reflect that surgical performance can be enhanced through structured warm-up activities.
authors.affiliation: Department of Surgery, Johns Hopkins University School of Medicine, Suite 399, 4940 Eastern Ave 21224, Baltimore, MD, 21287, USA, erinmoranatkin@gmail.com.
authors.forename: Erin
authors.initials: E
authors.lastname: Moran-Atkin
authors.forename: Gamal
authors.initials: G
authors.lastname: Abdalla
authors.forename: Grace
authors.initials: G
authors.lastname: Chen
authors.forename: Thomas H
authors.initials: TH
authors.lastname: Magnuson
authors.forename: Anne O
authors.initials: AO
authors.lastname: Lidor
authors.forename: Michael A
authors.initials: MA
authors.lastname: Schweitzer
authors.forename: Kimberley E
authors.initials: KE
authors.lastname: Steele
mesh_terms: D004502:Education, Medical, Continuing / Q000379:methods*; D015444:Exercise / Q000502:physiology*; D013502:General Surgery / Q000193:education*; D006801:Humans; D007396:Internship and Residency; D057234:Preoperative Period; D012649:Self Concept; D066231:Surgeons / Q000592:standards*; D011795:Surveys and Questionnaires