目的 分析并描绘麻醉科住院医师通过纤支镜定位技能的模拟训练学习曲线，探讨无操作经验的住院医师在接受模拟训练前后技能提升的情况。方法 记录2022年3月至5月期间，北京协和医院麻醉科的30名无纤支镜操作经验的住院医师，通过模拟器进行纤支镜定位技能的300次模拟训练学习经历。采用累积和分析法(cumulative sum analysis，CUSUM)来描绘学习曲线，旨在比较受试者培训前后在首次图像显示完成时间及完成全部6个图像所需时间上的变化，并探讨初步掌握该技能所需的操作例数。使用统计分析软件R(版本4。2。2)来对数据进行分析。计量资料用(均数±标准差)表示，采用Shapiro-Wilk法进行正态性检验。若数据服从正态分布，则使用独立样本t检验进行组间比较;服从偏态分布的计量资料组间比较采用Mann-Whitney U检验。学习曲线的拟合则通过CUSUM法完成。所有统计检验均设定为双侧检验，检验水准α=0。05。结果 在完成首个图像显示时间方面，达到CUSUM分界次数后，有5名受试者差异无统计学意义(P>0。05)。结合原始数据及CUSUM曲线分析，原因可能是其中4人在分界次数前后的操作时间波动较大，导致在分界次数上差异无统计意义;另外1人则可能因为在前3～4例中的学习时间较短，导致经过培训后提升不明显。在完成全部操作时间方面，达到CUSUM分界次数后，有4名受试者同样差异无统计学意义(P>0。05)。结合原始数据及CUSUM曲线分析，原因可能是其中3人在分界次数前后的操作时间波动较大，导致在分界次数上差异无统计学意义;另外1人也同样考虑在前3～4例中的学习时间较短，导致尽管经过培训但提升不明显。结论 综合考虑完成首个图像显示所需的时间及完成全部6个图像观察所需时间的变化，在经过模拟器进行纤支镜模拟训练后，无经验的麻醉科住院医师至少需进行4次操作，方可初步掌握纤支镜操作技能。
An exploration of training using the CUSUM method for depicting learning curves in simulation-based training for fiberoptic bronchoscopy
Objective To analyze and describe the learning curve of resident physicians in the Department of Anesthesiology during simulation-based training for positioning with fiberoptic bronchoscopy,and evaluate the improvement of skills after the simulation-based training of residents without operating experience.Methods The learning records of 300 training sessions using a simulator for bronchoscopy-based positioning were retrieved from March to May 2022 for 30 residents without experience in bronchoscopy in the Department of Anesthesiology of Peking Union Medical College Hospital.Cumulative sum analysis(CUSUM)was employed to depict the learning curve,aiming to compare changes in the time required to display the first image and to complete all six images before and after training,as well as to explore the number of operations necessary for the initial acquisition of this skill.Data analysis was performed using R statistical software(version 4.2.2).For quantitative data,the Shapiro-Wilk test was used to assess normality,and the data were expressed as mean±standard deviation.If the data followed a normal distribution,an independent samples t-test was used for comparisons between groups.For data that followed a skewed distribution,the Mann-Whitney U test was employed for comparisons between groups.The learning curve was fitted using the CUSUM method.All statistical tests were two-sided with a significance level of 0.05.Results In terms of the time required for completing the first image display,after reaching the CUSUM inflection point of operation times,five subjects did not show a significant difference(P>0.05).Based on the analysis of the raw data and the CUSUM curve,the observed insignificant difference may be attributed to the significant fluctuations in operating times for four individuals around the inflection point,resulting in no statistically significant differences in the operation times at the inflection point.Additionally,the fifth individual exhibited insignificant improvement following training due to relatively short learning time during the initial three to four operations.In terms of time to complete all operations,after reaching the CUSUM inflection point of operation times,four subjects did not show a significant difference(P>0.05).Based on the analysis of the raw data and the CUSUM curve,the insignificant difference may be attributed to the significant fluctuations in operating times for three individuals around the inflection point,resulting in no statistically significant differences in the operation times at the inflection point.Moreover,the fourth individual exhibited insignificant improvement following training due to relatively short learning time during the initial three to four operations.Conclusions Considering the variations in the time required to complete the first image display and the overall time required to observe all six images,inexperienced anesthesiology residents can initially acquire skills in bronchoscopy after at least four operations during simulation-based training for fiberoptic bronchoscopy.
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