***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: IMPORTANCE Repeated and deliberate practice is crucial in surgical skills training , and virtual reality ( VR ) simulation can provide self-directed training of basic surgical skills to meet the individual needs of the trainee . Assessment of the learning curves of surgical procedures is pivotal in underst and ing skills acquisition and best- practice implementation and organization of training . OBJECTIVE To explore the learning curves of VR simulation training of mastoidectomy and the effects of different practice sequences with the aim of proposing the optimal organization of training . DESIGN , SETTING , AND PARTICIPANTS A prospect i ve trial with a 2 × 2 design was conducted at an academic teaching hospital . Participants included 43 novice medical students . Of these , 21 students completed time-distributed practice from October 14 to November 29 , 2013 , and a separate group of 19 students completed massed practice on May 16 , 17 , or 18 , 2014 . Data analysis was performed from June 6 , 2014 , to March 3 , 2015 . INTERVENTIONS Participants performed 12 repeated virtual mastoidectomies using a temporal bone surgical simulator in either a distributed ( practice blocks spaced in time ) or massed ( all practice in 1 day ) training program with r and omization for simulator-integrated tutoring during the first 5 sessions . MAIN OUTCOMES AND MEASURES Performance was assessed using a modified Welling Scale for final product analysis by 2 blinded senior otologists . RESULTS Compared with the 19 students in the massed practice group , the 21 students in the distributed practice group were older ( mean age , 25.1 years ) , more often male ( 15 [ 62 % ] ) , and had slightly higher mean gaming frequency ( 2.3 on a 1 - 5 Likert scale ) . Learning curves were established and distributed practice was found to be superior to massed practice , reported as mean end score ( 95 % CI ) of 15.7 ( 14.4 - 17.0 ) in distributed practice vs. 13.0 ( 11.9 - 14.1 ) with massed practice ( P = .002 ) . Simulator-integrated tutoring accelerated the initial performance , with mean score for tutored sessions of 14.6 ( 13.9 - 15.2 ) vs. 13.4 ( 12.8 - 14.0 ) for corresponding nontutored sessions ( P < .01 ) but at the cost of a drop in performance once tutoring ceased . The performance drop was less with distributed practice , suggesting a protective effect when acquired skills were consoli date d over time . The mean performance of the nontutored participants in the distributed practice group plateaued on a score of 16.0 ( 15.3 - 16.7 ) at approximately the ninth repetition , but the individual learning curves were highly variable . CONCLUSIONS AND RELEVANCE Novices can acquire basic mastoidectomy competencies with self-directed VR simulation training . Training should be organized with distributed practice , and simulator-integrated tutoring can be useful to accelerate the initial learning curve . Practice should be deliberate and toward a st and ard set level of proficiency that remains to be defined rather than toward the mean learning curve plateau BACKGROUND / PURPOSE Conventional training in bronchoscopy may increase patient 's discomfort and procedure-related morbidity .  Computer-based bronchoscopy simulator ( CBBS ) permits the acquisition and evaluation of the necessary skills through a realistic bronchoscopic experience . This study was conducted to vali date the use of a CBBS system developed in Taiwan as a learning and assessment tool . METHODS Twenty novice bronchoscopists and 10 expert bronchoscopists were enrolled as subjects in this prospect i ve study . The 20 novice bronchoscopists were r and omized into two groups , which received conventional bronchoscopic training or CBBS training and then completed a satisfaction survey . Subsequently , the novices who received CBBS training underwent an observational performance trial and the results were compared with those of expert bronchoscopists . All 10 expert bronchoscopists completed a  realism survey  and observational trial after CBBS performance . RESULTS The satisfaction survey showed that the CBBS training program significantly increased participants ' satisfaction ( p = 0.002 ) and interest in learning ( p < 0.001 ) . The realism survey by the 10 expert bronchoscopists indicated that CBBS provides a favorable degree of realism with regard to the mechanical and visual parameters examined . Analysis of the performance results showed that the following parameters were capable of differentiating the participants by level of expertise : total procedure time ( p = 0.002 ) , percentage of bronchial segments entered ( p = 0.012 ) , percentage of bronchial segments identified ( p < 0.001 ) , percentage of repeated bronchial segments entered ( p = 0.004 ) , percentage of pathologies identified ( p < 0.001 ) , number of times that the bronchoscope tip collided with airway walls ( p = 0.013 ) , and number of times oral instruction was needed ( p = 0.01 ) . CONCLUSION CBBS is a valid training method that increases interest in learning and provides a favorable degree of virtual realism . It can also distinguish various levels of competence at actual bronchoscopy and may have a useful role in the bronchoscopic training curriculum Background : Conventional transbronchial needle aspiration ( TBNA ) can be learned using high-fidelity virtual-reality platforms and low-fidelity models comprised of molded silicone or excised animal airways . Objectives : The purpose of this study was to determine perceptions and preferences of learners and instructors regarding the comparative effectiveness of low-fidelity and high-fidelity bronchoscopy simulation for training in TBNA . Methods : During the 2008 annual CHEST conference , a prospect i ve r and omized crossover design was used to train study participants in three methods of conventional TBNA using low- and high-fidelity models . Likert style questions were administered to learners and instructors in order to elicit preferences and opinions regarding educational effectiveness of the models . Results were tabulated and depicted in graphic format , with medians calculated . Results : Learners felt that the models were equally enjoyable ( 13–13 ) and enthusiasm generating ( low 17-high 15 ) . There was preference for low-fidelity in terms of realism ( 23–17 ) , ease of learning ( 20–6 ) , and learning all three TBNA methods ( 31–7 for hub-against-wall , 31–6 for jabbing , 29–6 for piggyback ) . Low-fidelity was preferred as an ideal model overall ( 19–11 ) . Instructors thought that low-fidelity was more useful in teaching TBNA ( 9–0 for all three methods ) . Instructors perceived the low-fidelity model overall as an ideal tool for learning TBNA ( 8–0 ) and a more effective teaching instrument ( 8–0 ) . Conclusion : Based on learner and instructor perceptions , a low-fidelity model is superior to a high-fidelity platform for training in three methods of conventional TBNA Endobronchial ultrasound-guided transbronchial needle aspiration ( EBUS-TBNA ) is very operator dependent and has a long learning curve . Simulation-based training might shorten the learning curve , and an assessment tool with solid validity evidence could ensure basic competency before unsupervised performance . A total of 16 respiratory physicians , without EBUS experience , were r and omised to either virtual-reality simulator training or traditional apprenticeship training on patients , and then each physician performed EBUS-TBNA procedures on three patients . Three blinded , independent assessor assessed the video recordings of the procedures using a newly developed EBUS assessment tool ( EBUSAT ) . The internal consistency was high ( Cronbach 's α=0.95 ) ; the generalisability coefficient was good ( 0.86 ) , and the tool had discriminatory ability ( p<0.001 ) . Procedures performed by simulator-trained novices were rated higher than procedures performed by apprenticeship-trained novices : mean±sd are 24.2±7.9 points and 20.2±9.4 points , respectively ; p=0.006 . A pass/fail st and ard of 28.9 points was established using the contrasting groups method , result ing in 16 ( 67 % ) and 20 ( 83 % ) procedures performed by simulator-trained novices and apprenticeship-trained novices failing the test , respectively ; p<0.001 . The endobronchial ultrasound assessment tool could be used to provide reliable and valid assessment of competence in EBUS-TBNA , and act as an aid in certification . Virtual-reality simulator training was shown to be more effective than traditional apprenticeship training . Virtual-reality simulation-based training shortens the learning curve for endobronchial ultrasound ( EBUS ) BACKGROUND Learning medical procedures relies predominantly on the apprenticeship model , and competency is established based on the number of performed procedures . Our study aim ed to establish bronchoscopy competency metrics based on performance and enhanced learning with educational interventions . METHODS We conducted a prospect i ve study of the acquisition of bronchoscopy skills and cognitive knowledge in two successive cohorts of new pulmonary fellows between July 5 , 2006 , and June 30 , 2008 . At prespecified milestones , vali date d tools were used for testing : the Bronchoscopy Skills and Tasks Assessment Tool ( BSTAT ) , an objective evaluation of bronchoscopy skills with scores ranging from 0 to 24 , and written multiple-choice questions examinations . The first cohort received training in bronchoscopy as per the st and ards set by each institution , whereas the second cohort received educational interventions , including training in simulation bronchoscopy and an online bronchoscopy curriculum . RESULTS There was significant variation among study participants in bronchoscopy skills at their 50th bronchoscopy , the minimum number previously set to achieve competency in bronchoscopy . An educational intervention of incorporating simulation bronchoscopy enhanced the speed of acquisition of bronchoscopy skills , as shown by the statistically significant improvement in mean BSTAT scores for seven of the eight milestone bronchoscopies ( P < .05 ) . The online curriculum did not improve the performance on the written tests ; however , compliance of the learners with the curriculum was low . CONCLUSIONS Performance-based competency metrics can be used to evaluate bronchoscopy skills . Educational interventions , such as simulation-based training , accelerated the acquisition of bronchoscopy skills among first-year pulmonary fellows as assessed by a vali date d objective assessment tool BACKGROUND AND OBJECTIVE Endobronchial ultrasound with transbronchial needle aspiration ( EBUS-TBNA ) is a pulmonary procedure that can be challenging to learn . This study aims to compare trainee EBUS-TBNA performance during clinical procedures , following training with a computer EBUS-TBNA simulator versus conventional clinical EBUS-TBNA training . METHODS A prospect i ve study of pulmonary trainees performing EBUS-TBNA procedures on patients with suspected lung cancer and mediastinal adenopathy . Two cohorts of trainees were each evaluated while performing EBUS-TBNA on two patients . Group 1 received training by performing 15 cases on an EBUS-TBNA simulator ( n = 4 ) and had never performed a clinical EBUS-TBNA procedure . Group 2 received training by doing 15 - 25 EBUS-TBNA procedures on patients ( n = 4 ) . RESULTS There was no significant difference in the primary outcome measure of total EBUS-TBNA procedure time/number of successful aspirates between Groups 1 and 2 ( 3.95 ( ±0.93 ) vs 3.64 ( ±0.89 ) , P = 0.51 ) . Total learner EBUS-TBNA procedure time in minutes ( 23.67 ( ±5.58 ) vs 21.81 ( ±5.36 ) , P = 0.17 ) and percentage of successful aspirates ( 93.3 % ( ±5.8 % ) vs 86.3 % ( ±6.7 % ) , P = 0.12 ) were not significantly different between Group 1 and Group 2 . The only significant difference found between Group 1 and Group 2 was time to intubation in minutes ( 0.99 ( ±0.46 ) vs 0.50 ( ±0.42 ) , P = 0.04 ) . CONCLUSIONS EBUS-TBNA simulator use leads to rapid acquisition of clinical EBUS-TBNA skills comparable with that obtained with conventional training methods using practice on patients , suggesting that skills learned using an EBUS-TBNA simulator are transferable to clinical EBUS-TBNA performance . EBUS-TBNA simulators show promise for training , potentially minimizing the burden of procedural learning on patients OBJECTIVES Simulation training offers opportunities for unsupervised , self-regulated learning , yet little evidence is available to indicate the efficacy of this approach in the learning of procedural skills . We evaluated the effectiveness of directed self-regulated learning ( DSRL ) and instructor-regulated learning ( IRL ) , respectively , for teaching lumbar puncture ( LP ) using simulation . METHODS We r and omly assigned internal medicine residents in postgraduate year 1 to either DSRL ( ' directed ' to progress from easy to difficult LP simulators during self-regulated learning ) or IRL ( in groups of four led by an instructor ) . All participants practised for up to 50 minutes and completed a pre-test , post-test and delayed ( by 3 months ) retention test on the simulator . Pairs of blinded trained experts independently rated all videotaped performances using a vali date d global rating scale and a modified version of a vali date d checklist . Participants provided measures of LP experience and self-reported confidence . We analysed the pre-post ( n = 42 ) and pre- 
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Conclusions : Simulation-based training was demonstrated to be more efficient than the traditional apprenticeship model .
Physical models and virtual reality simulators complement each other .