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Mental practice in postgraduate training: a randomized controlled trial in mastoidectomy skills Conlin, Anne; Lea, Jane; Bance, Manohar; Chadha, Neil; Kilty, Shaun; Kozak, Frederick; Savage, Julian; Sidhu, Ravindar; Chen, Joseph; Westerberg, Brian D Sep 15, 2016

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ORIGINAL RESEARCH ARTICLE Open AccessMental practice in postgraduate training: arandomized controlled trial inmastoidectomy skillsAnne Conlin1, Jane Lea1, Manohar Bance2, Neil Chadha3, Shaun Kilty4,5, Frederick Kozak3, Julian Savage2,Ravindar Sidhu6, Joseph Chen7,8 and Brian D. Westerberg1*AbstractBackground: Mental practice, the cognitive rehearsal of a task in the absence of overt physical movement, hasbeen successfully used in teaching complex psychomotor tasks including sports and music, and recently, surgical skills.The objectives of this study were, 1) To develop and evaluate a mental practice protocol for mastoidectomy 2) To assessthe immediate impact of mental practice on a mastoidectomy surgical task among senior Otolaryngology─Head &Neck Surgery (OHNS) residents.Method: Three expert surgeons were interviewed using verbal protocol analysis to develop a mastoidectomy mentalpractice script. Twelve senior Residents from Canadian training programs were randomized into two groups. AllResidents were video-recorded performing a baseline mastoidectomy in a temporal bone lab. The intervention groupreceived mental practice training, while the control group undertook self-directed textbook study. All subjects werethen video-recorded performing a second mastoidectomy. Changes in pre- and post-test scores usingvalidated expert ratings, the Task Specific Evaluation of Mastoidectomy and the Global Evaluation of Mastoidectomy,were statistically analyzed.Results: A mental practice script was successfully developed based on interviews of three expert surgeon-educators.Task Specific Evaluation and Global Evaluation scores increased in both the mental practice and textbook study groups;there was no significant difference between the two groups in the change in scores post-intervention. There was ahigh and statistically signficant correlation between evaluators on the outcome measures.Conclusions: We were not able to demonstrate a significant difference for the benefits of mental practice inmastoidectomy, possibly due to the sample size. However, mental practice is a surgical education tool which isportable, accessible, inexpensive and safe.Keywords: Mastoid, Imagery, Motor skills, Education, Medical, GraduateBackgroundMultiple factors may have a negative impact on technicaltraining of surgical Residents, including time constraintsin operating rooms, financial limitations, patient safetyconcerns and the ratio of patients to Residents. Shiftingpatterns of health care delivery and working hours re-strictions have led to a significant reduction in trainingopportunities [1]. Concurrently, there has been an in-creased awareness of medical errors and a recognitionof the deficiencies in evaluating the performance andcompetence of practicing surgeons [2]. Poor technicalperformance and preventable surgical complications maycontribute to a large proportion of medical errors [3].The ideal method of teaching surgical Residents mustbe effective, safe, accessible and affordable. Currenttrends in surgical education have demonstrated superioroutcomes among Residents who engage in learning ac-tivities such as computer-based video training and theuse of simulators [4–11]. While these have expedited the* Correspondence: BWesterberg@providencehealth.bc.ca1Division of Otolaryngology-Head and Neck Surgery, B. C. Rotary Hearing andBalance Centre at St Paul’s Hospital, University of British Columbia,Providence 2 - 1081 Burrard Street, Vancouver, BC V6Z 1Y6, CanadaFull list of author information is available at the end of the article© 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Conlin et al. Journal of Otolaryngology - Head and Neck Surgery  (2016) 45:46 DOI 10.1186/s40463-016-0162-2rate of acquisition of surgical skills, they are procedure-specific, expensive and often difficult to access.Mental practice is “the cognitive rehearsal of a task inthe absence of overt physical movement” [12]. In essence,the performer systematically uses mental imagery to re-hearse a skill. Mental practice has been used successfullyin teaching and rehearsing complex psychomotor tasks inseveral domains, including sports and music [12–14] andrecently, surgical skills acquisition [15, 16]. The process ofmental practice typically involves a period of relaxationexercises, followed by an expert educator reciting a mentalimagery script with emphasis on visual, kinesthetic andcognitive cues [15, 16]. Meta-analyses have indicated thatmental practice is effective for all types of tasks, but ismost effective for tasks that have considerable cognitivecomponents [12, 17].The purpose of this pilot study was to assess the impactof mental practice on Residents’ surgical skills during mas-toidectomy, a challenging surgical procedure both to learnand to teach. The specific objectives of the study were:first, to develop a mental practice protocol for mastoidec-tomy created from expert educators’ instructional inputand further tailored based on actual residents’ feedback;and second, to quantitatively and qualitatively assess theimpact of mental practice on mastoidectomy surgical skillsamong senior residents, specifically in Post-Graduate Year5 (PGY-5), from training programs across Canada.MethodsDevelopment of the mental practice protocolTo develop the mental practice script, semi-structuredfocused interviews were held with expert practicing sur-geons (MB, JC, BDW). Using a cognitive walk-throughtechnique and verbal protocol analysis [18] the expertsurgeons identified the steps in performing a mastoidec-tomy. Specifically, the surgeons were prompted to reportthe visual, cognitive and kinesthetic cues involved in theprocedure. Interviews were audiotaped and transcribed.The transcripts were then coded by one coder (AC)using emergent theme analysis on a coding framework[19], based on a previously published, validated frame-work of the steps for completion of a mastoidectomy,geared towards Residents [20]. The findings from thethree interviews were merged to create a single mentalpractice script.To evaluate the mental practice protocol, all six Resi-dents in Post-Graduate Years 3–5 in the Otolaryngology-Head & Neck Surgery (OHNS) program at the Universityof British Columbia were enrolled. All subjects had partici-pated in mastoidectomy surgery in both the temporal bonelaboratory and operating rooms. Informed consent wasobtained from all participants. After a brief introduc-tion to the field of mental practice, the subjects listenedto an audio copy of the mental practice script. Thesubjects assessed the quality of the mental practice scriptusing the standardized Mental Imagery Questionnaire-Revised (MIQ-R).Impact of mental practice on mastoidectomy skillsThe impact of the mental practice protocol on mastoid-ectomy skills was assessed among 12 OHNS Residentsattending an annual national specialty review course inHalifax, Nova Scotia. To be included in the study, sub-jects had to be enrolled in PGY-5 (the final training yearfor OHNS in Canada) of a Canadian OHNS Residencyprogram and provide informed consent. Residents fromUBC involved in the evaluation phase of the study wereexcluded. Individuals who had previously trained orpracticed in a foreign country, and were currently en-rolled in a Canadian OHNS Residency program, werealso excluded from the study. A total of 36 individualswere enrolled in the review course, and all participantswere contacted as potential subjects. Thirteen individ-uals were excluded due to not meeting inclusion criteria.A further eleven potential subjects declined to partici-pate. The remaining 12 individuals were enrolled in thestudy in parallel treatment arms with equal allocation.All subjects completed a baseline questionnaire to de-termine demographic characteristics and previous ex-perience in mastoidectomy. Subjects were randomizedto one of two groups using a random number generator.Participant enrollment and implementation of the ran-dom allocation sequence was done by one of the authors(AC) who was not one of the study evaluators.Subjects were video recorded performing a baselinemastoidectomy in the temporal bone laboratory setting.Subjects were randomly assigned to dissect either theleft or right side as the baseline dissection by randomnumber generator. Care was taken to capture the sub-jects’ hands, only; no identifying features were recordedto ensure anonymity for the subjects and blinding forthe study evaluators. Subjects were given both verbaland written instructions specifically to “dissect the fol-lowing temporal bone structures: tegmen, external audi-tory canal, sigmoid sinus, sinodural angle, antrum, shortprocess of the incus, facial recess, chorda tympani andfacial nerve.” Subjects were given a 25-min time limit inwhich to perform the procedure.Upon completion of the baseline dissection, all sub-jects in both groups were given a textbook excerpt [21]and instructed to study the material before completing asecond temporal bone dissection in the laboratory 48 hlater as is standard practice for preparation for manytemporal bone dissection courses. In addition, subjectsin the textbook study group were given an opportunityto review the textbook material for approximately tenminutes before completing the second temporal bonedissection. Subjects in the treatment group (n = 6) wereConlin et al. Journal of Otolaryngology - Head and Neck Surgery  (2016) 45:46 Page 2 of 8enrolled in the mental practice protocol. The protocolwas administered to the subjects by one of the authors(AC) immediately after the first dissection. Upon com-pletion of a brief relaxation period and introduction tothe concept of mental practice, the subjects were readthe mental practice script. To accommodate variouslearning types (i.e. visual and auditory), subjects wereprovided with both a written copy of the script and aset of ten detailed illustrations to read and/or viewwhile the script was read to the subjects out loud..These illustrations were identical to the diagrams inthe textbook excerpt. Subjects were encouraged topay attention to the visual, cognitive and kinestheticcues emphasized in the script, and to actively imagineperforming a mastoidectomy. Subjects in the treat-ment group were given a copy of the mental practicescript to take home with them to review prior to thesecond mastoidectomy 48 h later.Each subject was then video-recorded completing asecond, post-intervention mastoidectomy in the tem-poral bone dissection laboratory. The dissection was per-formed at the same drilling station on the contra-lateralside of the same cadaveric specimen, as there is a highdegree of correlation in temporal bone volume and sur-face anatomy between left and right sides of the samespecimen [22]. Subjects were provided with a new set ofthe same sized burs for each dissection. Upon comple-tion of the final dissection, subjects in the mental prac-tice group also assessed the quality of the mentalpractice script using the standardized Mental ImageryQuestionnaire-Revised (MIQ-R).A complete set of digital recordings of all 24 temporalbone dissections was created for each independent re-viewer. The order in which the reviewers were to evalu-ate each set of dissections was determined using arandom number generator to ensure that the evaluatorcould not determine whether a given dissection was per-formed pre- or post-intervention, nor whether the sub-ject was in the control or treatment group. Eachevaluator reviewed all the dissections but in a differentorder. There were no deviations from the intendedprotocol; all subjects received the intended treatment, allsubjects were analyzed for all outcome measures andthere were no losses or exclusions after randomization.Two experienced Otologists (BDW, MB) working fromseparate sites reviewed and coded each dissection inde-pendently, on two separate occasions separated by atleast 4 weeks. The evaluators reviewed the entirety ofeach 25-min dissection, and were permitted to rewind orrepeat their viewing of any segment of the recording attheir discretion. Each video recording was evaluatedusing two validated, reliable instruments for evaluatingmastoidectomy performed in the temporal bone lab [20]:the Task Specific Evaluation of Mastoidectomy (primaryoutcome) and the Global Evaluation of Mastoidectomy(secondary outcome) (Additional file 1). The Task SpecificEvaluation checklist includes evaluation of seven tasks in-volved in completing a mastoidectomy; subjects were notrequired to complete the dissection of the digastric ridge,and therefore, this task was scored “not applicable” foreach subject. The Global Evaluation checklist includesgeneral evaluation of proficiency with use of equipment,flow of the surgery and a score for overall surgical per-formance. Before reviewing any of the digital recordingsof the subjects’ mastoidectomy, the evaluators were giventhe opportunity to openly discuss these evaluation check-lists with each other and clarify any potential sources ofdiscrepancy. Each evaluator then worked independently toscore the recorded dissections.Statistical methodsPre-intervention and post-intervention Task SpecificEvaluation of Mastoidectomy, and Global Evaluation ofMastoidectomy scores were compared between thegroups using a two-factor ANOVA with repeated mea-sures test. The two evaluators were compared to eachother for each of the two scores using a Spearman Rankcorrelation test and for correlation between their ownTask Specific Evaluation of Mastoidectomy scores andGlobal Evaluation of Mastoidectomy scores using theSpearman Rank correlation test. For all tests a p valueless than 0.05 was required to reject the null hypothesis.ResultsDevelopment of the mental practice protocolTable 1 provides an example of excerpts from the semi-structured focused interviews held with expert surgeonsin development of the mastoidectomy mental practiceTable 1 Example excerpts from interviews and mental practice script cuesInterviewer’s prompt Excerpt from interview transcript Imagery cues in final Mental Practice script“Discuss proper placementof the initial bone cuts alongthe posterior canal.”“Find the spine of Henle, and basically hug the posteriorear canal…place the suction in the ear canal so you canuse a kinesthetic feel of the suction and drill to see howclosely they are to each other while drilling.”Kinesthetic:“By placing your suction in the ear canal, you get akinesthetic feel, tactile feedback telling you thethickness of the bone.”“Discuss identification of thefacial recess.”“From the line through the body of the incus and inferiorlyinto the posterior canal, that line delineates the facial recess,what Residents are taught is to be faithful to that line.”Visual:“Now, you clearly visualize a line through the bodyof the incus pointing inferiorly along the posterior earcanal. You start drilling, remaining faithful to this line.”Conlin et al. Journal of Otolaryngology - Head and Neck Surgery  (2016) 45:46 Page 3 of 8script, including examples of visual and kinestheticcues. The mental practice script was assessed prior toimplementation by six OHNS Residents, PGY3 to 5.The mean overall score was 5.8 (5 = somewhat helpful;6 = helpful) (Range: 4–7). The script was also evaluatedpost-implementation by the six mental practice subjects;the mean overall score was 5.3.Impact of mental practice on mastoidectomy skillsBaseline demographic characteristics and mastoidectomyexperience of the subjects in each group were compar-able (Table 2). Although the Mental Practice Group mayhave performed more mastoidectomy procedures as thefirst surgeon, this was countered in the control group bya greater number of procedures performed as secondsurgeon and a greater number of lab dissections per-formed. The comparability of groups is further reflectedin the identical baseline pre-intervention Task SpecificEvaluation of Mastoidectomy scores (Table 3).As would be expected, both groups of subjects demon-strated improvement on the second dissection relative tothe first. On total Task-Specific Evaluation for Mastoid-ectomy score (primary outcome), subjects in the MentalPractice group had higher post-intervention total scorethan the Textbook Study group but did not reach statisticalsignificance (p = 0.736). Each group had a non-statisticallysignificant higher total score post-intervention than pre-intervention (p = 0.182) (Table 3). Using the two-factorANOVA with repeated measures test, there was no inter-action (no significant difference between the two groups inthe change in scores post-intervention) between the groupand the test run (p = 0.922). Both groups had a slightlynon-statistically significant higher score on the TotalGlobal Evaluation of Mastoidectomy score (secondaryoutcome), following the intervention (p = 0.395). Therewas no statistical difference between the two groups onthe Total Global Evaluation score (p = 0.657) (Table 4).Using the two-factor ANOVA with repeated measurestest, there was no interaction between the group andthe test run (p = 1.00); there was no significant differencebetween the two groups in the change in scores post-intervention.Overall, there was significant correlation (Spearman’srho = 0.495; p = 0.0153) between the two evaluators onthe primary outcome measure of the study, the totalTask Specific Evaluation of Mastoidectomy score (Fig. 1).However, the correlation between the evaluators on thesecondary outcome measure, total Global Evaluation ofMastoidectomy score was non-significant (Spearman’srho = 0.350; p = 0.0852) (Fig. 2). Each evaluator showedvery high consistency with statistically significant intra-evaluator correlations (Spearman’s rho = 0.809, p < 0.001for Evaluator A; Spearman’s rho = 0.811, p < 0.001 forEvaluator B) (Fig. 3).DiscussionWith input from three expert surgeons we developed aclear, unified and reproducible mental practice scriptcontaining visual, cognitive and kinesthetic cues, whichOHNS Residents in their senior years found helpful invisualizing the surgical steps required for mastoidec-tomy. Mental practice may have a concurrent role byResidents along with simulation and cadaveric dissectionin attainment of competency in mastoid surgery.Recently, greater attention has been paid to the uniquechallenges in training Residents in mastoidectomy sur-gery [23]. Previously, residency training programs reliedupon volume of exposure, but more recently, educationtheory has been applied to surgical training in order toevaluate means of skill acquisition in a more structuredway. Fitts and Posner’s Theory of Motor Skill Acquisi-tion describes three distinct phases through which alearner must pass in obtaining a new motor skill. Stage1, the cognitive stages, is the process of intellectualizingthe task, whereby performance is erratic and the proced-ure is carried out in distinct steps. Traditional textbookstudy has been an effective method to aid a learner inStage 1, as a significant volume of knowledge must beTable 2 Baseline demographic characteristics andmastoidectomy experience, comparisons between groupsVariable Group 1(Textbook)Group 2(Mental Practice)No. of subjects 6 6Mean age (yrs) 35 31Mean no. first surgeon procedures 17 22Mean no. second surgeon procedures 21 13Mean no. lab dissections 11 7Mean no. of courses 2 2Table 3 Comparison between mean total Task SpecificEvaluation of Mastoidectomy score, Textbook Study group versusMental Practice groupTextbook Study GroupMean (standard deviation)Mental Practice GroupMean (standard deviation)Pre-intervention 40.8 (11.1) 42.3 (5.0)Post intervention 44.2 (15.3) 46.3 (7.6)Table 4 Comparison between mean total Global Evaluation ofMastoidectomy score, Textbook Study group versus MentalPractice groupTextbook Study GroupMean (standard deviation)Mental Practice GroupMean (standard deviation)Pre-intervention 11.6 (3.3) 13.1 (1.8)Postintervention12.3 (5.0) 13.6 (3.0)Conlin et al. Journal of Otolaryngology - Head and Neck Surgery  (2016) 45:46 Page 4 of 8obtained by a Resident at the outset of learning to performfor instance a mastoidectomy. Stage 2, the integrativestage, is marked by the transfer of knowledge to behavior;in Stage 3, the autonomous stage, the performance issmoother, there is no need to think about movements,and the student can concentrate on higher learning [23].Our concern with traditional teaching methods, suchas textbook learning, is that they have primarily focussedon the cognitive stage. Mental practice, however, is ateaching method developed with the fundamental goalof helping the learner perform a mastoidectomy in anintegrative and autonomous manner. Put another way,Fig. 1 Correlation between evaluators based on total Task Specific Evaluation of Mastoidectomy scoresFig. 2 Correlation between evaluators based on total Total Global Evaluation of Mastoidectomy scoresConlin et al. Journal of Otolaryngology - Head and Neck Surgery  (2016) 45:46 Page 5 of 8we feel that mental practice fundamentally differs fromtraditional textbook learning methods, in that the em-phasis is on mastery and autonomy of a surgical skill,rather than simple acquisition of knowledge.There are many challenges inherent to studying thebenefit of any adjunctive intervention in surgical skillsacquisition. We chose two validated tools designed toevaluate trainee competency in mastoidectomy. Our se-lected outcome measures (Task Specific Evaluation ofMastoidectomy: Global Evaluation of Mastoidectomy),demonstrated high and statistically significant inter-raterreliability, a finding not replicated in other mental practicestudies [16, 24, 25], implying generalizability of the resultsof this study. We failed to demonstrate a statisticallysignificant benefit for mental practice, possibly becausethe study was underpowered to detect such a difference ifone existed. Our sample size (n = 12) is similar to those ofother published research studies involving Residents’learning of mastoidectomy skills. Francis et al [26] en-rolled nine Residents in their study defining milestones inmastoidectomy competency; Francis and colleagues stud-ied 15 Residents to develop an objective assessment toolfor Residents performing mastoidectomy in the operatingroom [27]. A larger sampling of Residents in their senioryear of training would require a multi-national and prob-ably multi-year study with additional inherent limitations.Mental practice may have greater benefit when repeatedand with active engagement by the learner in a relaxedsetting [26], such that if it were performed repeatedlythroughout a 5-year residency training program, sequen-tial additional improvement in performance may be seen.Additionally, the effectiveness of mental practice insurgical skill acquisition has been corroborated in non-otologic procedures, specifically on junior Residents’performance of a vaginal hysterectomy [24]. Few ran-domized controlled trials have been published regardingtraining adjuncts for Residents learning mastoidectomy.Greater improvement on temporal bone dissection aftersupervised training using a virtual reality simulator thanwith traditional teaching methods was demonstrated ina randomized controlled trial involving 20 trainees [11].However, the virtual reality simulator requires significantconstraints on time and financial resources, whereas men-tal practice is an intervention that is portable, accessibleand inexpensive. Mental practice has in fact been de-scribed as, “the simulation centre in the mind [16].”Prior mental practice research in surgery has been criti-cized for having a rather poorly specified imagery inter-vention [15]. Interventions with greater degrees ofvisualization exercises have demonstrated superior results.For instance, when junior Residents rehearsed perform-ance of cystoscopy and were required to not only visualizebut also describe to a surgeon-educator the steps involvedin performance of cystoscopy, statistically-significantlyhigher scores among subjects in the mental practice groupwere recorded upon completion of their first cystoscopy[25]. Because the benefit of mental practice disappearedafter subjects performed only one cystoscopy, the authorshypothesized that physical practice may have played alarge role in cystoscopy skill acquisition, and that mentalpractice may have greater benefit in more complicatedprocedures with a larger cognitive component [25]. Argu-ably, performance of mastoidectomy has a larger cognitivecomponent.Other surgical education studies on mental practicefor other surgical specialties have been criticised for notincluding a method to validate the mental practice script[15]. Content of this mental practice script was based onexpert reviewers and analysed using standard qualitativeresearch techniques to ensure consensus across the threeexperts. We then used quantitative methods to evaluatethe imagery within the script, insofar as whether a Residentcould see the dissection in the mind’s eye. If the descriptionwas rich enough, we believed that any surgeon, resident orconsultant, ought to be able to imagine the dissection. Boththe group of Residents who previewed the script and thegroup of Residents who applied the script in the laboratorygave it a rating between “somewhat helpful” and “helpful.”Fig. 3 a Correlation between total Task Specific Evaluation of Mastoidectomy score and total Global Evaluation score for evaluator A.b Correlation between total Task Specific Evaluation of Mastoidectomy score and total Global Evaluation score for evaluator BConlin et al. Journal of Otolaryngology - Head and Neck Surgery  (2016) 45:46 Page 6 of 8Determining means to improve these scores (for example,by improving the mental practice script itself or providingResidents more opportunities to learn and apply mentalpractice techniques in residency) may lead to greater bene-fit for the learner. A variety of mental practice protocolshave been used in surgical education studies. One suchprotocol involved a clinical psychologist guiding subjectsthrough a 30-min period of relaxation exercises and mentalimagery immediately before completing the surgical task[16], a technique that would be difficult to incorporate intothe daily routine of a surgical trainee. Our mental practicescript was developed on the premise it should be easily ap-plicable, and easily incorporated into the surgeon’s dailyroutine. If mental practice were to be incorporated intomainstream surgical education, it would be ideal to deter-mine to whom, when and how often this form of learningshould be ideally applied.We employed a systematic process in development ofthe mental practice script, incorporating the results ofinterviews of three different surgeon-educators fromthree different training programs across Canada, hopingto be representative of the actual surgical trainee’s ex-perience, with pearls of wisdom gleaned from multiplesurgeon-educators. Educators can expect that some of thevariability of effectiveness of mental practice is learnerspecific; just as there are different learning styles regardingauditory, visual and tactile input, there may be learnerswho are more adept at learning through mental practiceparadigms. Our mental practice script tried to incorporatethe visual, cognitive and kinesthetic cues involved in theperformance of the procedure.ConclusionsThe realities of the contemporary surgical training envir-onment are such that effective and inexpensive learningopportunities are critical; both educators and traineesneed to do more with less. Mental practice is a means ofsurgical training that is portable, accessible, inexpensiveand safe. We offer support for further investigation andrefinement of this technique for training Residents inmastoidectomy surgery. Although unlikely to replaceother adjunctive modalities for surgical education, it mayserve a concurrent role in surgical skills acquisition bysurgeons in training.Additional fileAdditional file 1: Checklist 1: Task-specific evaluation of mastoidectomy[22]. Checklist 2: Global evaluation of mastoidectomy [22]. (ZIP 10 kb)AcknowledgmentsThis research was supported through Otolaryngology Departmental researchfunds from the University of British Columbia, University of Ottawa andDalhousie University.FundingThere are no sponsorships to disclose. No external financial support wasreceived in producing this paper.Availability of data and materialsAll data generated or analyzed during this study are included in thispublished article (and its supplementary information files).Authors’ contributionsAC analyzed and interpreted the data and was a major contributor in writingthe manuscript. BW analyzed and interpreted the data and was a contributorin writing the manuscript. All authors read and approved the finalmanuscript.Competing interestsThe authors declare that they have no competing interests.Consent for publicationNot applicable.Ethics approval and consent to participateThe ethics application has not yet been submitted to the Providence HealthResearch Board at St. Paul’s Hospital. Following publication of thismanuscript, an application will be submitted to the ethics board.Author details1Division of Otolaryngology-Head and Neck Surgery, B. C. Rotary Hearing andBalance Centre at St Paul’s Hospital, University of British Columbia,Providence 2 - 1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada. 2Divisionof Otolaryngology-Head & Neck Surgery, Dalhousie University, Halifax, NS,Canada. 3Division of Pediatric Otolaryngology-Head and Neck Surgery, B.C.Children’s Hospital, Vancouver, BC, Canada. 4Department ofOtolaryngology-Head & Neck Surgery, The Ottawa Hospital, Ottawa, ON,Canada. 5Ottawa Hospital Research Institute, Ottawa, ON, Canada. 6Divisionof Vascular Surgery, University of British Columbia, Vancouver, BC, Canada.7Department of Otolaryngology-Head & Neck Surgery, University of Toronto,Toronto, ON, Canada. 8Sunnybrook Health Sciences Centre, Toronto, ON,Canada.Received: 17 March 2016 Accepted: 10 September 2016References1. Tooke J. Aspiring to excellence: final report of the independent inquiry intomodernizing medical careers. London: MMC Inquiry; 2008.2. Kohn LT, Corrigan JM, Donaldson MS. 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Defining milestones towardcompetency in mastoidectomy using a skills assessment paradigm.Laryngoscope. 2010;120:1417–21.27. Francis HW, Masood H, Chaudhry, et al. Objective assessment ofmastoidectomy skills in the operating room. Otol Neurotol. 2010;31(5):759–65.•  We accept pre-submission inquiries •  Our selector tool helps you to find the most relevant journal•  We provide round the clock customer support •  Convenient online submission•  Thorough peer review•  Inclusion in PubMed and all major indexing services •  Maximum visibility for your researchSubmit your manuscript atwww.biomedcentral.com/submitSubmit your next manuscript to BioMed Central and we will help you at every step:Conlin et al. Journal of Otolaryngology - Head and Neck Surgery  (2016) 45:46 Page 8 of 8


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