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Cited by 17Surgical Simulation and TrainingInnovations in Medical EducationSimulation-Based Education in Healthcare

Neurosurgery resident training using blended learning concepts: Course development and participant evaluation

Open access
Hickmann, Anne-Katrin, Ferrari, Andrea, Bozinov, Oliver, Stienen, Martin N., Ostendorp, Carsten·2022·Neurosurgical Focus
DOI 10.3171/2022.5.focus22193
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Abstract

OBJECTIVE: Restrictions on working time and healthcare expenditures, as well as increasing subspecialization with caseload requirements per surgeon and increased quality-of-care expectations, provide limited opportunities for surgical residents to be trained in the operating room. Yet, surgical training requires goal-oriented and focused practice. As a result, training simulators are increasingly utilized. The authors designed a two-step blended course consisting of a personalized adaptive electronic learning (e-learning) module followed by simulator training. This paper reports on course development and the evaluation by the first participants. METHODS: Adaptive e-learning was curated by learning engineers based on theoretical information provided by clinicians (subject matter experts). A lumbar spine model for image-guided spinal injections was used for the simulator training. Residents were assigned to the e-learning module first; after its completion, they participated in the simulator training. Performance data were recorded for each participant’s e-learning module, which was necessary to personalize the learning experience to each individual’s knowledge and needs. Simulator training was organized in small groups with a 1-to-4 instructor-to-participant ratio. Structured assessments were undertaken, adapted from the Student Evaluation of Educational Quality. RESULTS: The adaptive e-learning module was curated, reviewed, and approved within 10 weeks. Eight participants have taken the course to date. The overall rating of the course is very good (4.8/5). Adaptive e-learning is well received compared with other e-learning types (8/10), but scores lower regarding usefulness, efficiency, and fun compared with the simulator training, despite improved conscious competency (32.6% ± 15.1%) and decreased subconscious incompetency (22.8% ± 10.2%). The subjective skill level improved by 20%. Asked about the estimated impact of the course, participants indicated that they had either learned something new that they plan to use in their practice (71.4%) or felt reassured in their practice (28.6%). CONCLUSIONS: The development of a blended training course combining adaptive e-learning and simulator training in a rapid manner is feasible and leads to improved skills. Simulator training is rated more valuable by surgical trainees than theoretical e-learning; the impact of this type of training on patient care needs to be further investigated.

AI snapshot

Written from the paper’s full text.

TL;DR

This paper describes the development of a two-step blended neurosurgery training course combining a personalized adaptive e-learning module with simulator training for image-guided spinal injections, and reports evaluation by the first 8 participants. The course was rated very good overall (4.8/5), though simulator training was rated significantly more useful, efficient, and fun than the e-learning.

Key findings

  • The adaptive e-learning module was curated, reviewed, and approved within 10 weeks (total working time 332 hours; 94 probes for 94 learning objectives with 87 learning resources).
  • Eight participants (7 neurosurgery, 1 orthopedic) took the course; 5 (62.5%) completed the entire e-learning, and hands-on attendance was 100%.
  • Overall course rating was 4.8 ± 0.25 of 5; adaptive e-learning scored 8 ± 2.45 of 10 versus other e-learning programs, but rated lower than simulator training on usefulness (4.9 ± 2.04 vs 9.7 ± 0.49, p = 0.001), fun (3.9 ± 2.41 vs 10.0 ± 0.0, p = 0.001), and efficiency (3.9 ± 1.77 vs 10.0 ± 0.0, p < 0.0001).
  • E-learning improved conscious competency by 32.6% ± 15.1% and decreased subconscious incompetency by 22.8% ± 10.2%; subjective skill level improved by 21.4% ± 9.8% (mean score 4.5 ± 1.7 before to 6.5 ± 1.1 after).
  • Of participants, 71.4% (n = 5) learned something new they plan to use in practice and 28.6% (n = 2) felt reassured; all would recommend the course.

Methods

  • Course development: two clinician subject matter experts defined learning goals and prepared background information over 12 weeks, guided by a teaching psychologist; learning engineers transformed content into an adaptive e-learning format (Area9 Lyceum platform).
  • Simulator training: a 3-hour session using a lumbar spine model (3B Scientific GmbH) for image-guided spinal injections in a typical clinical setting (C-arm, injection equipment, sterile material), with a 1-to-4 instructor-to-participant ratio; each participant performed transforaminal epidural/periradicular, intraarticular facet joint, medial branch block, and caudal epidural injections at least once.
  • Assessment: e-learning performance data collected automatically (progress, time, competency categories); post-course evaluation adapted from the Student Evaluation of Educational Quality (SEEQ) questionnaire plus 10-point ratings of e-learning and simulator training; descriptive statistics in SPSS v27, Kolmogorov-Smirnov test, paired-sample t-test (significance p < 0.05).

Limitations

  • Stated: only a small number of participants so far, so results need to be interpreted with caution; with greater numbers the differences in ratings between adaptive e-learning and simulation training may vanish, and the difference may also disappear if the course is given at a more appropriate time during clinical training.
  • Stated: the effect of the training on objective clinical outcomes is currently unknown (Kirkpatrick level 3 not yet evaluated).
  • Evident from the text: only 5 of 8 participants (62.5%) completed the entire e-learning, and course evaluation was completed by 7 (87.5%), so evaluation data are incomplete; 9 of 94 probes (9.6%) were identified as too difficult and need revision.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.3171/2022.5.focus22193

Cites

18 of 18 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 31 cited sources checked · 0 supported · 0 flagged

  • Findingown data
    § RESULTS

    The overall rating of the two-step course is very good (4.8 ± 0.25 of 5).

    “The overall rating of the course is very good (4.8/5).”
    • Also stated in: § Results · plain
      “The two-step course received a high overall rating (4.8 ± 0.25 of 5)”
    Quote in the paperNot a substantial claim
  • Findingown data
    § RESULTS

    Participants indicated they learned something new that they plan to use in their practice (71.4%).

    “participants indicated that they had either learned something new that they plan to use in their practice (71.4%)”
    • Also stated in: § Results · plain
      “the majority (n = 5, 71.4%) learned something new, which they plan to use in their daily practice.”
    Quote in the paperSubstantial claim
  • Findingown data
    § RESULTS

    Adaptive e-learning scores lower than simulator training on efficiency.

    “but scores lower regarding usefulness, efficiency, and fun compared with the simulator training”
    • Also stated in: § Results · plain
      “The simulator training was believed to be more useful, efficient, and fun compared with the adaptive e-learning (p < 0.05)”
    Quote in the paperNot a substantial claim
  • Findingown data
    § RESULTS

    Adaptive e-learning scores lower than simulator training on fun.

    “but scores lower regarding usefulness, efficiency, and fun compared with the simulator training”
    • Also stated in: § Results · plain
      “The simulator training was believed to be more useful, efficient, and fun compared with the adaptive e-learning (p < 0.05)”
    Quote in the paperNot a substantial claim
  • Findingown data
    § RESULTS

    Adaptive e-learning is well received compared with other e-learning types (8 ± 2.45 of 10).

    “Adaptive e-learning is well received compared with other e-learning types (8/10)”
    • Also stated in: § Results · plain
      “Compared with other e-learning courses that participants had experienced in the past, it scored above average (8 ± 2.45 of 10).”
    Quote in the paperNot a substantial claim
  • Classified as probably not a substantial claim. 29
  • May combine two claims. 9

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    Findingown data
    § RESULTS

    Eight participants have taken the course to date.

    “Eight participants have taken the course to date.”
    • Also stated in: § Results · plain
      “To date, 8 participants with mediocre skill levels (4.5 ± 1.7 of 10) have been assigned to take the course”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data
    § RESULTS

    The adaptive e-learning module was curated, reviewed, and approved within 10 weeks.

    “The adaptive e-learning module was curated, reviewed, and approved within 10 weeks.”
    • Also stated in: § Results · plain
      “After establishing the course objectives and preparing the medical background information (12 weeks), the e-learning course was designed and reviewed in a 4-step process over 10 weeks.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingreasoning
    § Discussion

    Clinicians were able to focus on what they wanted their trainees to learn, without needing to worry about how to transport the knowledge in a meaningful manner from a learning-psychology point of view.

    “Clinicians were able to focus on what they wanted their trainees to learn, without needing to worry about how to transport the knowledge in a meaningful manner from a learning-psychology point of view.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data
    § Discussion

    In our e-learning course, 9 learning probes were identified as being too difficult, because the average rate of correct answers was too low and participants spent more time than expected on the tasks.

    “In our e-learning course, 9 learning probes were identified as being too difficult, because the average rate of correct answers was too low and participants spent more time than expected on the tasks.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data
    § Discussion

    Feedback comments from multiple participants indicated that a greater variability for open-ended questions and use of common abbreviations would be preferred.

    “In addition, feedback comments from multiple participants indicated that a greater variability for open-ended questions and use of common abbreviations would be preferred”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given
    § Discussion

    Preparing the background information for nonmedical personnel required a thorough understanding of the specific task with all its steps, possible pitfalls, and how to manage them.

    “Yet, preparing the background information for nonmedical personnel required a thorough understanding of the specific task with all its steps, possible pitfalls, and how to manage them.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data
    § Discussion

    Aspects of the practical training including the enthusiasm of the instructor, group interaction, and individual rapport were rated as good or very good.

    “Aspects of the practical training including the enthusiasm of the instructor, group interaction, and individual rapport were rated as good or very good”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingnone given
    § Discussion

    Collaboration through an online platform allowed for timely development of the course over a period of 22 weeks, including 12 weeks of content preparation.

    “Collaboration through an online platform allowed for timely development of the course over a period of 22 weeks, including 12 weeks of content preparation.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data
    § Discussion

    The length of the e-learning was only criticized by one trainee.

    “while the length of the e-learning was only criticized by one trainee.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data
    § Discussion

    Participants responded that they had either learned something new that they plan to use in their daily routine (71.4%) or felt reassured in their clinical practice (28.6%).

    “participants responded that they had either learned something new that they plan to use in their daily routine (71.4%) or felt reassured in their clinical practice (28.6%).”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation
    § Discussion

    The reorganization of brain activity from whole-brain activation in novices to focal activation of areas needed for specialized processing in experts remains unchanged.

    “While the reorganization of brain activity from whole-brain activation in novices to the focal activation of areas needed for specialized processing in experts15 remains unchanged”
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    Premisecitation
    § Discussion

    Encephalographic and MRI studies show different utilization of brain areas between novices and experts in sports.

    “Encephalographic and MRI studies show different utilization of brain areas between novices and experts in sports”
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    Premisecitation
    § CONCLUSIONS

    The level of expertise is directly related to time spent practicing and is associated with measurable outcome.

    “In fact, the level of expertise is directly related to time spent practicing and is associated with measurable outcome.3”
    Quote in the paperSubstantial claim0 of 1 sources checked
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    Premisecitation
    § CONCLUSIONS

    Both the quality and type of practice matter more than how often one practices.

    “While how often one practices matters, it is both the quality and type of practice that matter even more.4–6”
    Quote in the paperSubstantial claim0 of 3 sources checked
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  • Classified as probably not a substantial claim.

    Premisecitation
    § Discussion

    These simulation-based trainings account for the greater expectations of residents' surgical skills when treating patients.

    “These trainings account for the greater expectations of residents’ surgical skills when treating patients.1,7–9”
    Quote in the paperSubstantial claim0 of 4 sources checked
    • cites [1] [1] John, Tina, 2026, Computer Supported Education Vol. 2882, pp 235, 978-3-032-21997-8 Crossref Metrics All Time Past Year Past 30 Days Abstract Views 0 0 0 Full Text Views 2782 341 249 PDF Downloads 2097 70 16 EPUB Downloads 0 0 0 PubMed Citation Articles by Anne-Katrin Hickmann Articles by Andrea Ferrari Articles by Oliver Bozinov Articles by Martin N. Stienen Articles by Carsten Ostendorp Similar articles in PubMed Article by Anne-Katrin Hickmann Article by Andrea Ferrari Article by Oliver Bozinov Article by Martin N. Stienen Article by Carsten Ostendorp Similar articles in Google Scholar

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites [7]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

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    Study design and conductown data
    § Discussion

    With only a small number of participants so far, results need to be interpreted with caution.

    “With only a small number of participants so far, results need to be interpreted with caution.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation
    § Discussion

    Adaptive learning is a form of deliberate practice as defined by Ericsson and Harwell, which has a high predictive power in terms of expertise.

    “In this sense, adaptive learning is a form of deliberate practice as defined by Ericsson and Harwell,6 which has a high predictive power in terms of expertise.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
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    Premisecitation
    § Discussion

    Individual growth only takes place within the ZPD.

    “Individual growth only takes place within the ZPD.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [16]

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    Interpretationnone given
    § Discussion

    Some probes may have been too easy.

    “while others may have been too easy.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation
    § Discussion

    Course evaluation using questionnaires and assessment of participant satisfaction are level 1 criteria of Kirkpatrick's evaluation model of training programs (subjective evaluation).

    “Course evaluation using questionnaires and assessment of participant satisfaction are level 1 criteria of Kirkpatrick’s evaluation model of training programs (subjective evaluation).”
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    Interpretationreasoning
    § Discussion

    Instructors can assume comparable theoretical knowledge among all trainees when starting the course.

    “Instructors can assume comparable theoretical knowledge among all trainees when starting the course.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Interpretationreasoning
    § Discussion

    It remains to be evaluated whether these skills will be transferred actively into clinical practice where they can have an impact on patient outcome (level 3).

    “it remains to be evaluated whether these skills will be transferred actively into clinical practice where they can have an impact on patient outcome (level 3).18”
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  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Premisenone given
    § Discussion

    The adaption in adaptive e-learning results from systematic data analysis, learner interaction with the learning system, and intelligent technologies in real time to provide an optimal learning experience.

    “The adaption in adaptive e-learning results from systematic data analysis, learner interaction with the learning system, and intelligent technologies in real time to provide an optimal learning experience.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Premisecitation
    § Discussion

    In the other two areas outside of the ZPD, the challenge is either too high or too low.

    “In the other two areas outside of the ZPD, the challenge is either too high or too low.”
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    Premisecitation
    § Discussion

    Outside of their comfort zone, learners need specific support from a teacher.

    “Outside of their comfort zone, learners need specific support from a teacher.”
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    Interpretationreasoning
    § Discussion

    ZPD is the key concept on which all forms of adaptive learning are based.

    “Ultimately, ZPD is the key concept on which all forms of adaptive learning are based.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Premisereasoning
    § Discussion

    The learner receives the appropriate next learning content, which supports him or her precisely where it is needed.

    “The learner receives the appropriate next learning content, which supports him or her precisely where it is needed (Fig. 2).”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Premisecitation
    § Discussion

    Learning is most efficient and effective when the support matches the learner's personality and specific needs.

    “Learning is most efficient and effective when the support matches the learner’s personality and specific needs.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
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    Premisecitation
    § Discussion

    Compliance with theoretical learning can be enhanced among trainees with customized sessions, supporting individual learning styles accessible anywhere and anytime compared with conventional lectures.

    “Additionally, compliance with theoretical learning can be enhanced among trainees with customized sessions, supporting individual learning styles accessible anywhere and anytime17 compared with conventional lectures.”
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    Interpretationreasoning
    § Discussion

    During simulator training, more time can be spent on skills training because no time is needed for introductory lectures.

    “During simulator training, more time can be spent on skills training as no time is needed for introductory lectures.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Blended learning (combining e-learning with practical hands-on training) allows better use of resources.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation
    § Discussion

    Modern adaptive learning systems enable trainees to individually study theoretical content based on their respective preferences, needs, and prior knowledge.

    “These systems enable trainees to individually study theoretical content based on their respective preferences, needs, and prior knowledge.17”
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    Interpretationreasoning
    § Discussion

    Participants stepped out of their comfort zone for the most part.

    “it can be assumed that participants stepped out of their comfort zone for the most part”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Interpretationreasoning
    § Discussion

    An adaptive learning system replicates a teacher who supports the learner in a needs-based, focused, and goal-oriented manner within the ZPD.

    “An adaptive learning system thus replicates a teacher who supports the learner in a needs-based, focused, and goal-oriented manner within the ZPD.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data
    § Discussion

    Assessments for this two-part course are favorable and can improve residents' skills.

    “Assessments for this two-part course are favorable and can improve residents’ skills.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation
    § Discussion

    Analysis of objective, automated measures of the e-learning account for level 2.

    “Analysis of objective, automated measures of the e-learning account for level 2.”
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    Premisecitation
    § Discussion

    Learners cannot acquire all knowledge independently.

    “According to Vygotsky, learners cannot acquire all knowledge independently.”
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36 of 36

  • The paper relies on this without support.

    Restrictions on working time and healthcare expenditures, as well as increasing subspecialization with caseload requirements per surgeon and increased quality-of-care expectations, provide limited opportunities for surgical residents to be trained in the operating room.

    “Restrictions on working time and healthcare expenditures, as well as increasing subspecialization with caseload requirements per surgeon and increased quality-of-care expectations, provide limited opportunities for surgical residents to be trained in the operating room.”

  • The paper relies on this without support.

    Surgical training requires goal-oriented and focused practice.

    “Yet, surgical training requires goal-oriented and focused practice.”

  • The paper relies on this without support.

    Training simulators are increasingly utilized.

    “As a result, training simulators are increasingly utilized.”

  • The paper relies on this without support.

    Adaptive learning strategies improve adherence and learning outcomes when conveying background information based on an individual's prior knowledge.

    “Improved adherence and learning outcomes can be achieved by using adaptive learning strategies to convey background information on specific tasks based on an individual’s prior knowledge.”

  • The paper relies on this without support.

    Combining adaptive e-learning with practical hands-on training allows better use of resources (i.e., blended learning).

    “Combining adaptive e-learning with practical hands-on training allows better use of resources (i.e., blended learning).”

  • The paper relies on this without support.

    Learning results will improve if personal factors are optimally combined with effective teaching and learning strategies.

    “Learning results will improve if personal factors are optimally combined with effective teaching and learning strategies.”

  • The paper relies on this without support.

    Personal factors such as learning history, skills, abilities, and prior knowledge are closely intertwined with learning factors, and both affect learning success.

    “Personal factors such as learning history, skills, abilities, and prior knowledge are closely intertwined with learning factors, and both affect learning success.”

  • The paper relies on this without support.

    Blended learning (combining e-learning with practical hands-on training) allows better use of resources.

    “with practical hands-on training allows better use of resources (i.e., blended learning).”

  • The paper relies on this without support.

    Manual skills cannot be trained through theoretical courses.

    “manual skills cannot be trained through theoretical courses.”
9 of 9

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Subconscious-incompetency decrease differs from Table 2

    Major

    Table 2 reports a decrease from 23.5% to 1.3%, or 22.2 percentage points, rather than the stated 22.8. This is one of the paper's principal reported improvements.

    Reported 22.8 · recomputed 22.2

  • SEEQ score range conflicts with the stated response scale

    Minor

    Table 3 labels the SEEQ items as ranging from 0 to 5, but the methods describe a five-point scale whose scored responses range from 1 to 5; the sixth option is not applicable.

  • Conscious-incompetency decrease differs from Table 2

    Minor

    Table 2 reports a decrease from 11.4% to 1.1%, or 10.3 percentage points, rather than the stated 10.9.

    Reported 10.9 · recomputed 10.3

3 of 3

Cites

Flagged first, then by citations

Research works printed but not linked: 18

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  3. Birkmeyer JD, Finks JF, O’Reilly A, Surgical skill and complication rates after bariatric surgery. N Engl J Med. 2013;369(15):1434–1442.10.1056/NEJMsa1300625 · DOI · Paper page
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  5. Ericsson KA. Acquisition and maintenance of medical expertise: a perspective from the expert-performance approach with deliberate practice. Acad Med. 2015;90(11):1471–1486.10.1097/ACM.0000000000000939 · DOI · Paper page
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Related

Authors
Hickmann, A.-K., Ferrari, A., Bozinov, O., Stienen, M. N., & Ostendorp, C.
Affiliations
Kantonsspital St. Gallen (CH)
ORCID
Venue
Neurosurgical Focus
Publisher
Journal of Neurosurgery Publishing Group (JNSPG)
Published
2022-08
Volume
53
Issue
2
Pages
E13
ISSN
1092-0684 (ISSN-L)
DOI
10.3171/2022.5.focus22193
OpenAlex
W4289341483
Semantic Scholar
9557b0616fb1ca1c10410929dc76d82233f20044
Cited by
17
References
18
Citations by year
2026: 2 · 2025: 7 · 2024: 4 · 2023: 4
FWCI
3.60
Type
journal article
Language
en
Open access
Locations
  • Neurosurgical FOCUS (publishedVersion)
  • PubMed (publishedVersion)
Topics
  • Health Sciences › Medicine › Surgery › Surgical Simulation and Training
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Innovations in Medical Education
  • Health Sciences › Medicine › Physiology › Simulation-Based Education in Healthcare
Keywords
neurosurgery residency, blended learning, adaptive e-learning, surgical simulator, course development, resident satisfaction, skill acquisition, competency assessment
MeSH terms
Clinical Competence, Curriculum, Humans, Internship and Residency, Neurosurgery, Neurosurgical Procedures

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-09.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-09.

Statistics and arithmetic are recomputed, not judged.

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