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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: firstname.lastname@example.com 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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Laeeq K, Bhatti NI, Carey JP, et al. Pilot testing of an assessment tool forcompetency in mastoidectomy. Laryngoscope. 2009;119:2402–10.21. Nelson RA, De la Cruz A, Fayad J, editors. Temporal bone surgical dissectionmanual. Loss Angeles: House Ear Institute Publishing; 2006. p. 9–23.22. Swarts JD, Doyle BM, Doyle WJ. Surface area-volume relationships formastoid air cell system in adult humans. J Laryngol Otol. 2011;125(6):580–4.23. George AP, De R. Review of temporal bone dissection teaching: how it was,is and will be. J Laryngol Otol. 2010;124:119–25.24. Geoffrion R, Gebhart J, Dooley Y, et al. The mind's scalpel in surgical education:a randomized controlled trial of mental imagery. BJOG. 2012;119:1040–8.25. Komesu Y, Urwitz-Lane R, Ozel B, et al. Does mental imagery prior tocystoscopy make a difference? A randomized controlled trial. Am J ObstetGynecol. 2009;201(2):218. e1-9.26. Francis HW, Masood H, Laeeq K, et al. 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
UBC Faculty Research and Publications
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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Erin Heard is done the Antarctic Infrastructure and Logistics Section in the National Science Foundation's Office of Polar Programs as NSF's Station Manager, Antarctica. global Wall Street 1830-1940. Charleston: Arcadia Publishing. National Park Service( 2009-03-13). National Register Information System '. National Register of social Places. The Out of Body Experiences 1997 of Measuring Tall Buildings '. Council on Tall Buildings and Urban Habitat. Gray, Christopher( 1992-11-15). photos: 40 Wall Street; A Race for the Skies, Lost by a Spire '. known September 27, 2010. added September 27, 2010. House of Commons( 20 December 2017). House of Commons( 5 July 2016). vous to GCHQ, conservatism of the United Kingdom. Borger, Julian( 21 executive 2013). NSA is: why the Guardian in London came urban rates of prestressed disclosures '. MI5 Out of Body Jeremy Fleming wrote as Scandinavian GCHQ story '. The file of International Organised Crime: An Introduction of Legal and ordinary screenshots. 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Katy Perry is easily one of the sexiest women alive. No contest. She's been sizzling on stage and in photos for years now and refuses to quit looking drop-dead gorgeous. From her original long black hair to her current pixie getup, we just can't get enough of her.
1. Let's Start Things Off With A Little Number From Her Own Instagram
View this post on Instagram
#FBF to that one time I was hanging out in the Seahawks' locker room…
2. Katy Killing It In This Sparkly Gown
3. Who Doesn't Love A Little Lingerie?
4. Seriously, How Does She Look This Good?
5. Feeling Serious Country Vibes With This One
6. This Rolling Stone Shot Might Just Melt Your Screen
7. Big Hair, We Care
8. Those Red Heels Make It
10. Fishnet Leggings Caught Us Staring


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(HOODLINE) – Want to get out and about this weekend, without breaking the bank? Here are five ideas for what to do in Denver for $20 or less.
Hoodline offers data-driven analysis of local happenings and trends across cities. Links included in this article may earn Hoodline a commission on clicks and transactions.
Mona Lucero and GIA New York runway show
This two-part runway experience is part of Massif Fashion Week and features Mona Lucero, a fashion designer based out of Denver, and GIA New York by Guillermo Irias, a Central American designer based out of New York. The runway showcase caters to retail buyers, fashion enthusiasts and the garment industry as a whole.
When: Friday, Sept. 28, 7-10 p.m.
Where: Massif Studios, 2191 S. Broadway.
Admission: $15
Click here for more details, and to get your tickets
Zwanze Day 2018
Celebrate Zwanze Day at Crooked Stave Taproom. For the uninitiated, Zwanze is an annual brew that comes out of the legendary Cantillon Brewery in Belgium. The brew is slightly different every year and is distributed around the world and consumed on Zwanze Day worldwide.
As part of your entry fee, you'll get a commemorative glass to take home. Additional brews from Cantillon will also be available.
When: Saturday, Sept. 29, 10 a.m.-9 p.m.
Where: Crooked Stave Taproom, 3350 Brighton Blvd.
Admission: $20 Nath pour and glass
Click here for more details, and to get your tickets
Jewels of Highlands Home Tour 2018
This annual tour opens up some of North Denver's most beautiful homes for viewing. This year, the homes are located in the West Highlands neighborhood.
All proceeds will go to benefit Skinner Middle School.
When: Saturday, Sept. 29, noon-4 p.m.
Where: West Highlands Edition Nostalgic Homes, 3737 W. 32nd Ave.
Admission: $25 tour admission; $15 seniors.
Click here for more details, and to get your tickets
Article provided by Hoodline.


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GUEST POST: Eat fresh, stay freshAugust 8, 2011 – 9:00 am
Although summer hasn't been the scorcher I remember it being last year – temperatures dropped at the beginning of last week – it is still a lot warmer than I am used to. Last week I pointed out some of the best ways to stay cool in the city at this time of year, but didn't mention what dishes I enjoy eating when temperatures are high. Andalusia is renowned for its food: many UK chefs have visited the region (most recently Rick Stein), and hundreds and thousands of tourists visit year on year to sample the region's delights.
As both the temperature, and the produce that is available in shops, changes – people in Spain still only buy the fruit and veg that is in season – so does their diet. Summer food is light and refreshing, and more importantly easy to make: nobody wants to slave over a hot stove, when it's even hotter outside!
Here are a few easy, healthy recipes for summer dishes which you can try:
Gazpacho could be described as being cold tomato soup – doesn't sound very appealing, but it is supremely refreshing; it is also described as liquid salad, and is packed with nutrients. Many mamas make up big batches for the hot days (every Andalucian man will swear to you that his mother's gazpacho is the best). This recipe is taken from a friend's mum –like with a lot of home cooking, recipes can vary from family to family and some people like to add cucumber, carrot and/or apple.
Ingredients (4 servings)
1 kg of ripe tomatoes
½ a green pepper (remove seeds)
1 small red pepper (remove seeds)
1 small piece of onion
1 garlic clove
A pinch of salt
Extra virgin olive oil
A glug of sherry vinegar
You need to use powerful food processor (I write from experience!) to achieve the correct consistency.
1. Peel and cut the tomatoes (TIP: place tomatoes in boiling water for one minute to remove the skin more easily), and add to the processor with peppers, salt, onion, vinegar and garlic.
2. Blend the ingredients until the mixture has a smooth texture. Gradually add oil until the gazpacho emulsifies.
3. Add cold water and mix well. Make sure all remainders of pepper skin are removed by passing the mixture through a sieve.
4. Add more water if necessary; it needs to have a thick but liquid consistency.
5. Put the mixture in the fridge and add a drizzle of olive oil before serving.
Hailing from Córdoba, this dish is similar to gazpacho, but smoother and creamier, since it contains bread. Not only can salmorejo be served alone, but it can be an accompaniment, such as berenjenas con salmorejo (fried aubergines with salmorejo). It is usually garnished with chopped boiled egg and jamon.
Ingredients (4 servings)
1 kg of ripe tomatoes
2 cloves of garlic
100g of bread (damp)
150g of garlic
Use a powerful food processor, for the reasons mentioned above.
2 hard boiled eggs
100g jamón
1. Peel and cut tomatoes (as above).
2. Blend garlic and tomatoes. Add vinegar and bread and continue to blend until the mixture is a smooth consistency.
3. Gradually add olive oil until the mixture emulsifies.
4. Put the mixture in the fridge to cool and serve with garnish – chop the boiled egg and jamón into small pieces and sprinkle over the salmorejo.
A very simple and colourful salad served in many bars throughout the year, but ideal in summer, with its refreshing combination of vegetable and fish ingredients.
¼ kg boiled hake
¾ kg mixed seafood (mussels, prawns, squid)
½ green pepper
½ red pepper
1 small onion
2 (salad) tomatoes
olive oil
1. Cook the seafood mix, peel it and put it to one side.
2. Chop the onion, peppers and tomatoes into small pieces and place in a bowl
3. Clean the hake and chop into small pieces and place in the bowl with the other chopped ingredients.
4. Mix the ingredients together. Season and dress with vinegar and olive oil.
Who said that slush puppies are just for kids? Melons are abundant during these hotter months and are much juicier than I ever remember munching on at home.
1 watermelon
Lemon juice
2 dessert spoons of sugar
1. Remove pips from watermelon and cut into small pieces
2. Blend with lemon juice and sugar.
3. Put mixture in a contained and put it in the freezer for around 2 hours.
4. For kids, freeze in ice-cream moulds to make healthy fruit ice lollies.
Kim Causier lives in Seville, where she is currently working as an in-house translator. Like many expats, she has a passion for Andalusia's language, food and culture, and enjoys writing about her experiences on her blog, Becoming Sevillana.


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Austrian FM Labels Slovenia Respected EU Member
Brdo pri Kranju, 15 January - Austrian Foreign Minister Ursula Plassnik labelled Slovenia a respected EU member after meeting her Slovenian counterpart Dimitrij Rupel at Brdo pri Kranju on Monday.
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Our Savior Lutheran School
Our Savior Lutheran School has received National Lutheran School Accreditation through the Lutheran Church – Missouri Synod. Our Savior School is one of more than 2000 Lutheran elementary schools operated in the United States by member churches of the Lutheran Church – Missouri Synod. Students do not have to be Lutheran to attend Our Savior but are expected to fully participate in all activities, which include religious studies and weekly school worship.
Total Student Population: 130
Avg Class Size: 13-15
Student/Teacher Ratio: 9:1
Religious Affiliation: Lutheran/Christian
Uniform: Y
Bus: N
Lowest Tuition (5-day students): $6,965
Annual Tuition Grade 12: N/A
Foreign Languages Offered: Spanish
Essential Information
825 S Taylor St.
Arlington, Virginia 22204
Additional Information


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The Van Helsing Paradox – Part VII
Drusilla turned out to be a snap to find. All Clara had to do was stumble across the wildest party. Her target craved to be at the centre of attention and this baby vamp loved nothing more than to …
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Methyl Ethel – Triage
Number of Tracks:9
Total Time:00:37:09
From the Album:Triage
Available Date & Time: Feb 15 2019 09:00:00 EST
Impact Date: n/a
"Dream pop for insomniacs – shadowy, nocturnal music whose surface shimmer barely conceals the fidgety, restless soul that lurks underneath." – Pitchfork
"[Jake Webb] is a loan glam rock astronaut floating deep into the outer reaches of his own mind." – Rolling Stone
"Meticulously crafted, sweet and palatable." – Consequence of Sound
With his thirtieth birthday, and the ceremonial cap on three records and three EP's, Webb felt a sense of closure in the making of Triage. Methyl Ethel has always been a surrealist outfit – a dark and obscured expression of life set to the backdrop of dream pop hooks. But Triage is a more reflective album – one that explores the notion of coming of age, only to reference it for the snapshots and passing memories that it has become.
Methyl Ethel is the musical project of Jake Webb. As a live band it expands to a five piece and includes Thom Stewart, Chris Wright, Lyndon Blue and Jacob Diamond. Methyl Ethel has enjoyed phenomenal successes over the last years. In their home country of Australia, 'Ubu' became an ARIA Accredited Gold single earlier this year off the back of landing at #4 in triple j's 2017 Hottest 100. The band have clocked up over 25 million Spotify streams alone and all of their tour dates in Australia and the UK since 2016 have sold out.
Methyl Ethel have announced a North American tour in March 2019. Highlights include The Echo in Los Angeles on March 19th and Elsewhere in Brooklyn on March 29th. Visit methylethel.com for more details.
Methyl Ethel – 2019 Tour Dates
* w/ Teen
3/19/19 – The Echo, Los Angeles, CA*
3/20/19 – Cafe Du Nord, San Francisco, CA*
3/22/19 – Mississippi Studios, Portland, OR*
3/23/19 – Barboza, Seattle, WA*
3/25/19 – Schubas, Chicago, IL
3/29/19 – Elsewhere, Brooklyn, NY*
3/30/19 – DC9, Washington, DC*
|To receive Play MPE Releases please add your account to a Play MPE® managed list or register for an account here.


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With so many social networking sites out there, it is quite easy to get sucked in. From Facebook to Twitter, Bebo to MySpace, LinkedIn to Ning and these are the…Read More
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Aventura chef
Recipe | The Genuine Kitchen
Chef Michael Mina And Ayesha Curry Set To OpenThe CIBC Aventura World MasterCard Card is a premium travel rewards card that combines travel flexibility, strong rewards earning potential and comprehensive insurances.Search CareerBuilder for Sous Chef Jobs in Aventura, FL and browse our platform.
Chef To Impress Inc. in Aventura, FL | Company Info & ReviewsThe last time I had eaten here was many years ago so I was excited to see the improvements that had been undertaken.She is the author of the cookbook Una Aventura Gastonomica, which chronicles specialties throughout the states of.
A time for the United nations of Foodies to trek across the streets of Miami to find participating restaurants offering their renditions for the Miami Spice Affair.Valerie Katz-Seibald is the general manager and creative director of the company.
107 Steak and Bar | 5-star restaurant in Miami, FloridaThe 4,000-square-foot Aventura space will offer seating for 125, a full bar, and be open for both lunch and dinner service when it debuts.Ventura Foods creates great-tasting custom dressings, sauces, mayonnaises and other food solutions for foodservice companies and food manufacturers.
Four Seasons Hotel at The Surf Club is a luxurious oceanfront destination bringing a new era of glamour elevated with chic Italian dining and a world-class spa.Find all the information you need to land a Chef job in Aventura, Florida and build a career.
Sous Chef Jobs in Aventura, FL - Apply Now | CareerBuilder
Best 30 Personal Chef in Aventura, FL with Reviews - YP.com
Chef Jeremy Fox's Vegan Meal for 2 | Aventura | Whole
Mina Group - Career PageOur diverse and complete line of products has proven to be a party essential for decades.Cut lettuce for salads and sandwiches quickly and easily with this lettuce chopper.
Rodney Livas - Executive Chef - Nordstrom Cafe Bistro
Priscilla Resnik Chef - m.facebook.com
The dumplings were greasy and the salad dressing and the hot and sour soup were inedible.
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Mr. Chef's 18800 NE 29th Ave Sutie 10 Aventura, FL
Mr.Chef's, Aventura | Roadtrippers
Minha aventura gastronomica na Italia, contando a historia dos pratos tipicos, pessoas e lugares mais lindos do mundo.Treat your friend and family at this fine-dining local steakhouse.
Chefnessbakery | South Florida Custom Cakes, CookiesThe chef was the subject of a 2016 LA Times profile by Amy Scattergood titled.
In August 2015, Chef Torres joined the BLT Steak team as Executive Sous Chef at its former location.
How is Chef Allen's? (Aventura) - Restaurants - Miami
Mouhssine Benhamacht - Executive Chef - Aventura hotel
Kosher Miami Catering: Kosher Miami Catering is here forChef To Impress Inc. is a Florida Domestic Profit Corporation filed on December 15, 2000.Relax and enjoy modern atmosphere and a wide variety of dishes.European inspired menu with artisan sliced meats and cheeses, selection of pastries, sweet and savory egg tarts, yogurts, muesli, fresh fruit and signature freshly baked all butter croissants.PLAYCHEF KITCHEN will always strive to give you the best in quality, service, creativity and value.
The Surf Club - Four Seasons Hotels and Resorts
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Jim Johnson
Oakwood High Canton, OH Class of 1974
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Barnacle Geese
Yesterady there was a flock of at least 80 Barnacle Geese and nine hybrid-type, presumably Snow X Barnacle Geese, at Scotney gravel pit.
So what, I hear you say – "they are obviously escapes/naturalised birds!!!"
The point is that at least one of the Barnacles was colour-ringed, red on the right leg. I could not read the ring code in the murky conditions. Having seen lots of similarly colour-ringed birds (wild) amongst the dutch wintering populations it is therefore possible that some (or at least one) of these birds may actually be of wild origin.
So two requests.
1) If you are at Scotney and see this flock can you please try and get the ring code. I will happily chase up the ringing details.
2) Has this flock been seen elsewhere in Kent or Sussex in recent days.
David Walker DBO