A pilot study of new approaches to teaching anatomy and pathology

Immersive Live Streaming of Surgery Using 360-Degree Video to Head-Mounted Virtual Reality Devices: A New Paradigm in Surgical Education

BACKGROUND

Prior studies have demonstrated the value of live streamed surgical procedures in surgical education and that learning is further enhanced with the use of 360-degree video. Emerging virtual reality (VR) technology now offers yet another advancement by placing learners in an immersive environment, which can improve both engagement and procedural learning.

AIMS

The aim here is to test the feasibility of live streaming surgery in immersive virtual reality using consumer-level technology, including stream stability and impacts on case duration.

METHODOLOGY

Ten laparoscopic procedures were live-streamed in a 360-degree immersive VR format over a 3-week period for viewing by surgical residents in a remote location wearing a head-mounted display. Stream quality, stability and latency were monitored, and operating room time was compared to non-streamed surgeries to quantify impacts on procedure times.

CONCLUSIONS

This novel live streaming configuration was able to deliver high-quality, low-latency video directly to a VR platform, allowing complete immersion into the learning environment by remote learners. Live streaming surgical procedures in an immersive VR format provides an efficient, cost-effective, and reproducible way to teleport remote learners from any location directly into the operating room.

Guided discovery learning: A follow-up study of try-it-yourself surgery and subsequent video-assisted teaching for oral surgical skills training

INTRODUCTION

The purpose of this follow-up study was to assess the effects of discovery learning and subsequent standardised teaching on students' advanced dental surgical skills.

MATERIALS AND METHODS

A total of 29 dental students who had no theoretical education on the Rehrmann flap were included in the skills training programme. Without prior teaching, the students were initially asked to perform a discovery surgery with a subsequent multiple-choice test (MCT) on the first day. This was followed by a video-assisted teaching lecture. On the same day and after 122 days, the surgery and MCT were repeated. Aside from the practical and theoretical assessment forms, the training was evaluated by the students themselves.

RESULTS

Regarding the evaluation of surgery (EOS), significant improvements were measured between the first surgery and the second and third surgeries (p > .001). In addition, the theoretical test scores showed significant improvements after the first test when compared with the second (p = .004) and third tests (p < .001). For both assessments, no significant difference was found between the second and third attempts. The MCT and EOS in the second and third attempts strongly correlated (r = .77 and r = .71 respectively).

CONCLUSION

The dental students in this study successfully learned a complex oral surgical procedure, the Rehrmann flap technique, for closing oro-antral communications. The participants indicated their high satisfaction with the teaching approach. After 122 days of follow-up, their practical and theoretical test scores remained high and presented no significant difference, which suggests that the newly learnt individual skills were retained.

Evidence-based Guidelines on the Use of Virtual Surgical Education Pertaining to the Domains of Cognition and Curriculum, Psychomotor Skills Training, and Faculty Development and Mentorship

OBJECTIVE

To identify, categorize, and evaluate the quality of literature, and to provide evidence-based guidelines on virtual surgical education within the cognitive and curricula, psychomotor, and faculty development and mentorship domains.

SUMMARY OF BACKGROUND DATA

During the coronavirus disease 2019 pandemic, utilizing virtual learning modalities is expanding rapidly. Although the innovative methods must be considered to bridge the surgical education gap, a framework is needed to avoid expansion of virtual education without proper supporting evidence in some areas.

METHODS

The Association for Surgical Education formed an ad-hoc research group to evaluate the quality and methodology of the current literature on virtual education and to build evidence-based guidelines by utilizing the SiGN methodology. We identified patient/problem-intervention-comparison-outcome-style questions, conducted systematic literature reviews using PubMed, EMBASE, and Education Resources information Center databases. Then we formulated evidence-based recommendations, assessed the quality of evidence using Grading of Recommendations, Assessment, Development, and Evaluation, Newcastle-Ottawa Scale for Education, and Kirkpatrick ratings, and conducted Delphi consensus to validate the recommendations.

RESULTS

Eleven patient/problem-intervention-comparison-outcome-style questions were designed by the expert committees. After screening 4723 articles by the review committee, 241 articles met inclusion criteria for full article reviews, and 166 studies were included and categorized into 3 domains: cognition and curricula (n = 92), psychomotor, (n = 119), and faculty development and mentorship (n = 119). Sixteen evidence-based recommendations were formulated and validated by an external expert panel.

CONCLUSION

The evidence-based guidelines developed using SiGN methodology, provide a set of recommendations for surgical training societies, training programs, and educators on utilizing virtual surgical education and highlights the area of needs for further investigation.

Live surgery outcomes in cataract surgery

PURPOSE

To evaluate and compare the outcomes of live surgery (LS) and no-live surgery (NLS) on cataract surgery with implantation of different types of intraocular lenses (IOLs).

METHODS

Retrospective, contralateral eye, case series of patients that underwent cataract surgery in live or non-live view during two consecutive editions of national meetings. Both eyes of the same patients were implanted with the same IOL, one in LS and the other in NLS.

RESULTS

108 eyes of 54 patients, aged between 50 and 82 (72 ± 8.2) and implanted with different types of IOLs, were reviewed. Both eyes in each patient were well matched at baseline in terms of intraocular biometric characteristics, corneal curvature and endothelial cell density (ECD) (p > 0.05). There are no statistically significant differences between the biometric and topographic parameters, aberrometric data and the loss of ECD in the post-operative outcomes (p > 0.05). However, comparing the different types of IOLs, there is a significant loss of ECD in eyes implanted with a toric IOL during LS (p = 0.0014 and p = 0.04, in 2017 and 2018 edition respectively).

CONCLUSIONS

In this series of live cataract surgery, eyes operated in LS or NLS have comparable outcomes, underlying the importance and the benefits of live view in terms of medical education and the low-risk of complications. Nevertheless, we have found a significant increase in ECD loss in patients implanted with toric IOLs during LS.

Real-time Cadaveric Laparoscopy and Laparoscopic Video Demonstrations in Gross Anatomy: An Observation of Impact on Learning and Career Choice

Medical curricula are continually evolving and increasing clinical relevance. Gross anatomy educators have tested innovations to improve the clinical potency of anatomic dissection and found that clinical correlations are an effective method to accomplish this goal. Recently, surgical educators defined a role for laparoscopy in teaching anatomy. We aimed to expand this role by using surgical educators to create clinical correlates between gross anatomy and clinical surgery. We held supplements to traditional anatomy open dissection for medical students, including viewing prerecorded operative footage and live laparoscopic dissection performed on cadavers. The main outcome measures were assessed through pre- and postsession surveys. Greater than 75 per cent of students found the demonstrations highly valuable, and students perceived a significant increase in their understanding of abdominopelvic anatomy ( P < 0.01). Additionally, 62 per cent of students with previous interest in surgery and 10 per cent of students without previous interest in surgery reported increased interest in pursuing surgical careers. Our demonstrations advance the use of minimally invasive surgical technology to teach gross anatomy. Live laparoscopic demonstrations augment traditional anatomic instruction by reinforcing the clinical relevance of abdominopelvic anatomy. Additionally, laparoscopic demonstrations generate interest in surgery that would otherwise be absent in the preclinical years.

Does learning in clinical context in anatomical sciences improve examination results, learning motivation, or learning orientation?

The preclinical compulsory elective course "Ready for the Operating Room (OR)!?" [in German]: "Fit für den OP (FOP)"] was implemented for students in their second year, who were simultaneously enrolled in the gross anatomy course. The objective of the study was to determine whether the direct practical application of anatomical knowledge within the surgical context of the course led to any improvement in learning motivation, learning orientation, and ultimately examination results in the gross anatomy course, as compared with a control group. Within the scope of five teaching sessions, the students learned surgical hand disinfection, suturing techniques, and the identification of commonly used surgical instruments. In addition, the students attended five surgical demonstrations performed by surgical colleagues on cadavers. Successful learning of these basic skills was then assessed based on an Objectively Structured Practical Examination. Learning motivation and learning orientation in both subgroups was determined using the SELLMO-ST motivation test and the Approaches and Study Skills Inventory test. While a significant increase in work avoidance was identified in the control group, this was not the case for FOP participants. Similarly, an increase in the "deep approach" to learning, as well as a decrease in the "surface approach," was able to be documented among the FOP participants following completion of the course. The results suggest that students enrolled in the gross anatomy course, who were simultaneously provided with the opportunity to learn in clinical context, were more likely to be successful at maintaining learning motivation and learning orientation required for the learning process, than students who attended the gross anatomy course alone.

Students' perception of anatomy education at a Korean medical college with respect to time and contents

Among medical education institutions worldwide, the time allotted for anatomy instruction has decreased without any reasonable time optimization suggestions. In addition, the utility of cadaver dissection has long been debated. Herein, we surveyed students' perceptions of anatomy education with respect to time and hands-on cadaver dissection, at Seoul National University College of Medicine. With the help of a questionnaire, we surveyed third- and fourth-year students at our institute who had completed the anatomy module as freshmen as well as their clinical clerkship. At our institute, students complete 50 hours of anatomy lectures and 120 hours of dissection laboratory during their first year. According to the survey responses, they generally considered these durations to be adequate for achieving their anatomy education goals. Almost all the students regarded the dissection laboratory as an essential and most helpful modality. Thus, we suggest that these ranges of time along with cadaver dissection could be useful guidelines for optimized anatomy education. The survey data also indicated that a more clinically oriented anatomy education could improve students' results.

Live surgery in neurosurgical training courses: essential infrastructure and technical set-up

BACKGROUND

Training courses in neurosurgery are essential educational elements of residency. Teaching methods vary due to cultural differences, monetary restrictions and infrastructure conditions. Anatomical dissection courses combined with annotated live surgeries performed by senior surgeons have proved to be best accepted by students.

OBJECTIVE

In this technical note, we provide detailed information about the necessary requirements, resources and optimal performance of live surgeries in neurosurgical training courses.

METHODS AND RESULTS

From 2007 to 2012, 12 neurosurgical training courses with live surgeries were organised at the Department of Neurosurgery. Here, we share our experience and report the essential set-up for these courses. Our department organised seven skull base, four cervical spine and one spinal cord stimulation hands-on dissection course with live surgeries. The course structure included lectures, cadaver dissections and live surgeries. The technical set-up included video transmission via an IP-based network with fibreglass backbone between the operating theatre (OR) and lecture room. During surgery, bidirectional discussions offered the participants the ability to interject and ask questions. Important issues included the careful selection of live operated patients with clearly presented pathology for the didactic cases used to demonstrate the technique. A live surgery should include the entire procedure: intraoperative set-up, positioning, anaesthesiological procedures and handling of intraoperative situations.

CONCLUSION

A professionally prepared step-by-step educational program including surgical anatomy, cadaver dissection and live surgeries with online discussion offers a high level of training and enriches both the participants and instructors.

Acquisition of fundamental laparoscopic skills: is a box really as good as a virtual reality trainer?

BACKGROUND

Laparoscopic surgery requires working in a three-dimensional environment with a two-dimensional view. Skills such as depth perception, hand to eye co-ordination and bimanual manipulation are crucial to its efficacy.

AIM

To compare the efficiency of training in laparoscopic skills on a VR simulator with a traditional box trainer.

METHOD

Twenty medical students were recruited. An initial training session on the relevant anatomy and steps of a laparoscopic cholecystectomy was given. Baseline skills were recorded using a pre-training laparoscopic cholecystectomy on the VR trainer. Parameters measured were: (1) total time taken (mins); (2) number of movements right and left instrument; (3) path length (cms) of right and left instrument was recorded. Ten students trained on a VR simulator, and ten on a box trainer, for three hours each. The box trainer group exercises were based on the Royal College of Surgeons core laparoscopic skills course, and the VR trainer exercises were based on the Simbionix LapMentor basic skills tasks. Following this both groups were reassessed by a laparoscopic cholecystectomy on the VR trainer.

RESULTS

Both groups showed improvement in all measured parameters. A student T-test at 95% confidence interval showed no statistically significant difference between the two groups pre and post training.

CONCLUSION

Both the VR and box trainer are effective in the acquisition of laparoscopic skills.

Ready for the OR? - Clinical anatomy and basic surgical skills for students in their preclinical education

Medical students’ first experience in the operating theatre often takes place during their electives and is therefore separated from the university’s medical curriculum. In the winter term 2009/10, the Institute of Anatomy and Cell Biology at the University of Ulm implemented an elective called “Ready for the OR” for 2nd year medical students participating in the dissection course. We attempted to improve learning motivation and examination results by transferring anatomical knowledge into a surgical setting and teaching basic surgical skills in preparation of the students’ first participation in the OR. Out of 69 online applicants, 50 students were randomly assigned to the Intervention Group (FOP) or the Control Group. In 5 teaching session students learned skills like scrubbing, stitching or the identification of frequently used surgical instruments. Furthermore, students visited five surgical interventions which were demonstrated by surgical colleagues on donated bodies that have been embalmed using the Thiel technique. The teaching sessions took place in the institute’s newly built “Theatrum Anatomicum” for an ideal simulation of a surgical setting. The learning outcomes were verified by OSPE. In a pilot study, an intervention group and a control group were compared concerning their examination results in the dissection course and their learning motivation through standardized SELLMO-test for students. Participants gained OSPE results between 60.5 and 92% of the maximum score. “Ready for the OR” was successfully implemented and judged an excellent add-on to anatomy teaching by the participants. However, we could not prove a significant difference in learning motivation or examination results. Future studies should focus on the learning orientation, the course’s long-term learning effects and the participants’ behavior in a real surgery setting.

Properties of publications on anatomy in medical education literature

Publications on anatomy in medical education appear to be largely anecdotal. To explore this, we investigated the literature on anatomy in medical education, aiming first to evaluate the contribution of the literature on anatomy in medical education to "best evidence medical education" (BEME) and second to evaluate the development of this literature toward more "best evidence" between 1985 and 2009. Four databases were searched for publications on anatomy in medical education published between 1985 and 2009, resulting in 525 references. Hundred publications were characterized by five variables (journal category, paper subject, paper category, author perspective, and paper perspective). Statements from these publications were characterized by two variables (category and foundation). The publications contained 797 statements that involved the words "anatomy," "anatomical," or "anatomist." Forty-five percent of the publications contained no explicit research question. Forty percent of the statements made were about "teaching methods" and 17% about "teaching content," 8% referred to "practical value," and 10% to "side effects" of anatomy education. Ten percent of the statements were "positional," five percent "traditional," four percent "self-evident," and two percent referred to "quality of care." Fifty-six percent of the statements had no foundation, 17% were founded on empirical data, and 27% by references. These results substantiated the critical comments about the anecdotal nature of the literature. However, it is encouraging to see that between 1985 and 2009 the number of publications is rising that these publications increasingly focus on teaching methods and that an academic writing style is developing. This suggests a growing body of empirical literature about anatomy education.

Perspective: the case for subspecialty clinical learning in early medical education-moving from case-based to patient-based learning

The subspecialty departments are greatly underutilized for teaching during the first two years of medical school. While second-year students are spending most of their time behind closed doors in the laboratory, lectures, and small groups, the clinical environment is teeming with actual patients whose cases are often directly analogous to the material being learned. Moreover, even in today's environment of increased emphasis on quality of medical care and medical education reform, many U.S. medical students still lack essential exposure to common technologies, tests, and procedures performed within several subspecialties. To remedy this situation, the authors propose that educators develop a system of subspecialty clinical learning for first- and/or second-year students correlated to the classroom study of the pathophysiology of the various organ systems. For example, the second-year cardiology course could be augmented with self-directed, patient-centered learning assignments in the cardiac unit, the pathology lab, the echo lab, and other areas. The authors explain the several advantages of comprehensive subspecialty clinical learning (e.g., it will help prepare physicians to practice distributed care, aid development of competencies within the behavioral and social sciences, foster students' professional development, and encourage creative approaches to issues of health care quality). The authors acknowledge the multiple difficulties of implementing such an approach, and present evidence supporting their argument that with the appropriate vision and leadership, such a living curriculum is important and achievable.

Anatomy: the future teaching of undergraduates

The time devoted to the teaching of anatomy to medical students has long been under pressure. Much work has been devoted to how best to teach anatomy in both a time-efficient and cost-effective manner. This article discusses the main methods of teaching anatomy and their respective advantages and disadvantages as evidenced in the literature. Suggestions are made as to how best to teach anatomy to medical students in the future.

Using fresh tissue dissection to teach human anatomy in the clinical years

PURPOSE

Gross anatomy is taught in medical school with textbooks, cadaver dissection, plastic models, and multimedia illustration, but all lack the reality of color and texture that is possible with fresh tissue dissection. The authors studied the use of fresh tissue dissection of the thorax and abdomen of the rat to teach human anatomy.

METHOD

In a half-day exercise, 52 fourth-year medical students paired off and completed an exercise to dissect in less than three hours the thorax and abdomen of a euthanized rat. Observation of organs was augmented by active manipulation such as passing a tube down the esophagus, cannulating the trachea and inflating the lungs, injecting dye in the kidney to trace the ureter and bladder, and pulling the testis through the inguinal canal. Comparison of the rat and human was emphasized to enhance the education. The exercise ended with practice suturing fresh tissue.

RESULTS

Students rated the exercise to teach anatomy as 4.9 positive on a 5.0 (high) scale. The significant positive structures (p <.05) for texture were heart, liver, lungs and trachea; for color they were lungs and spleen; for location and size they were adrenal gland and urinary bladder; and for function they were adrenal gland and esophagus.

CONCLUSION

Fresh tissue dissection of the thorax and abdomen of the rat is a valuable tool for human anatomy education. The dissonances in human and rat anatomy enhance abstraction and transfer of knowledge. Active manipulation of organs promotes retention of knowledge, and suturing provides a "clinical" context. Fresh tissue dissection is an efficient innovative method to provide a global review of anatomy of the thorax and abdomen during the busy clinical years of medical education.