Is In-Vivo laparoscopic simulation learning a step forward in the Undergraduate Surgical Education?

A 3-D interactive microbiology laboratory via virtual reality for enhancing practical skills

Virtual Reality (VR) laboratories are a new pedagogical approach to support psychomotor skills development in undergraduate programmes to achieve practical competency. VR laboratories are successfully used to carry out virtual experiments in science courses and for clinical skills training in professional courses. This paper describes the development and evaluation of a VR-based microbiology laboratory on Head-Mounted Display (HMD) for undergraduate students. Student and faculty perceptions and expectations were collected to incorporate into the laboratory design. An interactive 3-dimensional VR laboratory with a 360° view was developed simulating our physical laboratory setup. The laboratory environment was created using Unity with the (created) necessary assets and 3D models. The virtual laboratory was designed to replicate the physical laboratory environment as suggested by the students and faculty. In this VR laboratory, six microbiology experiments on Gram staining, bacterial streaking, bacterial motility, catalase test, oxidase test and biochemical tests were placed on the virtual platform. First-year biomedical science students were recruited to evaluate the VR laboratory. Students' perception of the virtual laboratory was positive and encouraging. About 70% of the students expressed they felt safe using the VR laboratory and that it was engaging. They felt that the VR laboratory provided an immersive learning experience. They appreciated that they could repeat each experiment multiple times without worrying about mistakes or mishaps. They could personalise their learning by concentrating on the specific experiments. Our in-house VR-based microbiology laboratory was later extended to other health professions programmes teaching microbiology.

In vivo Simulation-Based Learning for Undergraduate Medical Students: Teaching and Assessment

An increasing emphasis on simulation has become evident in the last three decades following fundamental shifts in the medical profession. Simulation-based learning (SBL) is a wide term that encompasses several means for imitating a skill, attitude, or procedure to train personnel in a safe and adaptive environment. A classic example has been the use of live animal tissue, named in vivo SBL. We aimed to review all published evidence on in vivo SBL for undergraduate medical students; this includes both teaching concepts as well as focused assessment of students on those concepts. We performed a systematic review of published evidence on MEDLINE. We also incorporated evidence from a series of systematic reviews (eviCORE) focused on undergraduate education which have been outputs from our dedicated research network (eMERG). In vivo SBL has been shown to be valuable at undergraduate level and should be considered as a potential educational tool. Strict adherence to 3R (Reduce, Refine, Replace) principles in order to reduce animal tissue usage, should always be the basis of any curriculum. In vivo SBL could potentially grant an extra mile towards medical students' inspiration and aspiration to become safe surgeons; however, it should be optimised and supported by a well-designed curriculum which enhances learning via multi-level fidelity SBL.

Student Views on a Novel Holistic Surgical Education Curriculum (iG4): A Multi-national Survey in a Changing Landscape

AIM

Essential Skills in the Management of Surgical Cases (ESMSC Marathon Course™₎ Integrated Generation 4 (iG4) is the first reported multifaceted undergraduate surgical course aiming to provide holistic surgical teaching. In this prospective observational study, we explored students' views on the iG4 curriculum, and identified how it can potentially address modern challenges in surgical training.

MATERIAL AND METHODS

Medical students were invited to apply to the course online and were screened against pre-defined criteria. A multi-national structured questionnaire incorporating five domains related to the course curriculum and our dedicated research network, was designed and distributed to participants after successful completion of the course.

RESULTS

Forty-one students from European and Asian medical schools completed the course and filled in the survey. The median overall evaluation score of the course was 4.73 out of 5 (interquartile range=4.21-4.72) and all students found that iG4 served the vision of holistic surgical education. ESMSC had a positive motivational effect towards following a career in surgery (p=0.012) and 92.7% of students declared that it should be an essential part of a future medical school curriculum. There was no statistically significant difference (p>0.05) in results between participants of different countries of study, year of studies or age group.

CONCLUSION

The ESMSC Marathon Course™ is perceived as a unique course model, with an established educational value and a positive motivational effect towards surgery. It might potentially be implemented in future medical school curricula as an essential element of undergraduate surgical education. The iG4 curriculum has opened a new exciting horizon of opportunities for advancing undergraduate holistic surgical education.

Evidence in surgical training - a review

The first residency programs for surgical training were introduced in Germany in the late 1880s and adopted in 1889 by William Halsted in the United States [Cameron JL. William Stewart Halsted. Our surgical heritage. Ann Surg 1997;225:445-58.]. Since then, surgical education has evolved from a sheer volume of exposure to structured curricula, and at the moment, due to work time restrictions, surgical education is discussed on an international level. The reported effect of limited working hours on operative case volume has been variable [McKendy KM, Watanabe Y, Lee L, Bilgic E, Enani G, Feldman LS, et al. Perioperative feedback in surgical training: a systematic review. Am J Surg 2017;214:117-26.]. Experienced surgeons fear that residents do not have sufficient exposure to standard procedures. This may reduce the residents' responsibility for the treatment of the patient and even lead to a reduced autonomy at the end of the residency. Surgical education does not only require learning the technical skills but also human factors as well as interdisciplinary and interprofessional handling. When analyzing international surgical curricula, major differences even between countries of the European Union with more or less strict curricula can be found. Thus far, there is no study that analyzes the educational program of different countries, so there is no evidence which educational system is superior. There is also little evidence to distinguish the good from the average surgeon or the junior surgeons' progress during his residency training. Although some evaluation tools are already available, the lack of resources of most teaching hospitals often results in not using these tools as long it is not mandatory by a governmental program. Because of decreased working hours, increasing hospital costs, and increasing jurisdictional restrictions, teaching hospitals and teachers will have to change their sentiments and focus on their way of surgical education before governmental regulations will emerge leading to more regulation in surgical education. Some learning tools such as simulation, electronic learning, augmented reality, or virtual reality for a timely, sufficient and up to date surgical education. However, research and evidence for existing and novel learning tools will have to increase in the next years to allow surgical education for the future generation of surgeons around the world.

Hands train the brain-what is the role of hand tremor and anxiety in undergraduate microsurgical skills?

Introduction

Physiological hand tremor occurs naturally, due to oscillations of the upper extremities. Tremor can be exacerbated by stress and anxiety, interfering with fine motor tasks and potentially impact on surgical performance, particularly in microsurgery. We investigated the link between tremor, anxiety and performance in a neurosurgical module as part of an international surgical course.

Methods

Essential Skills in the Management of Surgical Cases (ESMSC) course recruits medical students from European Union (EU) medical schools. Students are asked to suture the dura mater in an ex vivo swine model, of which the first suture completed was assessed. Questionnaires were distributed before and after the module, eliciting tremor risk factors, self-perception of tremor and anxiety. Johnson O’Connor dexterity pad was used to objectively measure dexterity. Direct Observation of Procedural Skills (DOPS) was used to assess skills-based performance. Anxiety was assessed using the Westside Test Anxiety Scale (WTAS). Tremor was evaluated by four qualified neurosurgeons.

Results

Forty delegates participated in the study. Overall performance decreased with greater subjective perception of anxiety (p = 0.032, rho = − 0.392). Although increasing scores for tremor at rest and overall WTAS score were associated with decreased performance, this was not statistically significant (p > 0.05). Tremor at rest did not affect dexterity (p = 0.876, rho = − 0.027).

Conclusions

Physiological tremor did not affect student performance and microsurgical dexterity in a simulation-based environment. Self-perception of anxiety affected performance in this module, suggesting that more confident students perform better in a simulated neurosurgical setting.

Increasing motivation and engagement in neurosurgery for medical students through practical simulation-based learning

Background

Simulation-based learning (SBL) is an essential adjunct to modern surgical education. Our study aimed to evaluate the educational benefit and motivational impact of a pilot practical neurosurgical module.

Materials and methods

38 clinical medical students from several EU Medical Schools attended an international surgical course focused on teaching and learning basic surgical skills. We designed a pilot neurosurgical workshop instructing students to insert an intracranial pressure bolt using an ex vivo pig model. Each delegate was assessed by two consultant neurosurgeons using a validated assessment tool. Structured questionnaires were distributed on completion of the module.

Results

Delegate performance increased (p < 0.001) with no difference in performance improvement across year of study (p = 0.676) or medical school (p = 0.647). All delegates perceived this workshop as a potential addition to their education (median 5/5, IQR = 0), and indicated that the course provided motivational value towards a neurosurgical career (median 4/5, IQR = 1), with no difference seen between year of study or medical school (p > 0.05).

Conclusion

Our pilot neurosurgical workshop demonstrated the educational value of practical SBL learning for motivating students towards a surgical career. Homogeneous views across year of study and medical school underline the value of developing a unified strategy to develop and standardise undergraduate surgical teaching with a practical focus.

Optimizing engagement of undergraduate students in medical education research: The eMERG training network

Background

The practice of evidence-based medicine and critical appraisal are essential for the modern doctor. Early engagement of medical students in research methodology is considered as a rising need for most medical school curricula; however, few peer-reviewed initiatives have been reported so far. We developed a Medical Education Research Group (eMERG) as part of a novel undergraduate surgical masterclass, which aimed to train undergraduate students on basic research methodology, as well as to motivate them to pursue a clinical and academic career in surgical specialties.

Methods: eMERG consists of an international structured network of senior academics, consultant-level clinicians, senior and junior trainees who support undergraduate trainees. Students are selected from a competitive pool of applicants. Several small prospective studies in skills-based education, as well as systematic reviews on similar topics, have run under the umbrella of this framework, in the form of scholarship awards. Structured feedback questionnaires were distributed to evaluate the experience of the first three years.

Results

12 students have participated in this pilot initiative. 11 manuscripts have been submitted for publication and 8 were accepted following peer-review in MEDLINE-indexed journals. Delegates perceived this experience as an excellent training opportunity which improved their research productivity. Delegates also stated engagement in research developed interest in the relevant surgical speciality, impacting their career aspirations.

Conclusions

eMERG is one of the first reported European educational research networks for undergraduates. Research outcomes and students' perceptions conclude that eMERG enhances engagement with research methodology and motivation towards a career in surgery.

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eMERG is a pilot international research training network where medical students receive support to conduct research in Medical Education.

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eMERG structure can serve as a novel model to convey research experience from one generation to another, and in the same time, motivate and aspire students to develop leadership skills.

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eMERG was developed in a financial crisis environment with promising research outputs and positive students' feedback.

Developing a novel international undergraduate surgical masterclass during a financial crisis: our 4-year experience

BACKGROUND

Essential Skills in the Management of Surgical Cases (ESMSC) is a novel 3-day international undergraduate surgical masterclass. Its current curriculum (Cores integrated for Research-Ci4R) is built on a tetracore, multiclustered architecture combining high-fidelity and low-fidelity simulation-based learning (SBL), with applied and basic science case-based workshops, and non-technical skills modules. We aimed to report our experience in setting up ESMSC during the global financial crisis.

METHODS

We report the evolution of our curriculum's methodology and summarised the research outcomes related to the objective performance improvement of delegates, the educational environment of the course and the use of mixed-fidelity SBL. Feedback from the last three series of the course was prospectively collected and analysed using univariate statistics on IBM SPSS V.23.

RESULTS

311 medical students across the European Union (EU) were selected from a competitive pool of 1280 applicants during seven series of the course between 2014 and 2017. During this period, curriculum 14 s evolved to the final Ci4R version, which integrates a tetracore structure combining 32 stations of in vivo, ex vivo and dry lab SBL with small group teaching workshops. Ci4R was positively perceived across different educational background students (p>0.05 for any comparison).

CONCLUSIONS

ESMSC is considered an innovative and effective multidisciplinary teaching model by delegates, where it improves delegates objective performance in basic surgical skills. Our experience demonstrates provision of high-quality and free surgical education during a financial crisis, which evolved through a dynamic feedback mechanism. The prospective recording and subsequent analysis of curriculum evolution provides a blueprint to direct development of effective surgical education courses that can be adapted to local needs.

The Role of Anxiety in Simulation-Based Dexterity and Overall Performance: Does It Really Matter?

BACKGROUND

Essential Skills in the Management of Surgical Cases (ESMSC) is an international undergraduate surgical masterclass which combines ex vivo, dry lab and high fidelity in vivo simulation-based learning (SBL). It consists of 32 stations of skills-based learning, including open reduction internal fixation (ORIF) of fractures. Current literature suggests early involvement in skills-based learning at the undergraduate level is vital.

AIMS

To compare students' dexterity and skills-based performance with demographic and educational background parameters.

METHODS

112 medical students from European Union countries including the United Kingdom, Germany, Greece, Cyprus, Germany, and Bulgaria were selected from a competitive pool of candidates to attend the course. Students undertook ORIF in an ex vivo swine model, and in a simulated fracture on a bamboo rod. Skills-based performance was assessed by two consultant surgeons with validated direct observation of procedural skills (DOPS) forms. Anxiety was self-assessed using the Westside Anxiety Scale prior to the ORIF stations. Dexterity was measured with the O'Connor tweezer dexterity test.

RESULTS

Female students had significantly higher dexterity scores (median difference 7, p =.003). Right-handed students achieved higher dexterity than left-handed students (median difference 7, p =.043). There was no difference in students' performance across different medical schools, and across year groups (p <.05 for any correlation). Self-reported anxiety was not correlated with high fidelity skills-based performance (r = 0.032, p =.74).

CONCLUSION

Anxiety does not seem to play a significant role in Simulation Skills-Based learning. Undergraduate surgical curricula should incorporate SBL-based modules to enhance practical skills learning and motivate future orthopedic surgeons.