Zachary Husband OMS III, Matthew McDonald OMS III, Glynnis Page OMS IV
RVUCOM

DOI: 10.70709/qevsjl3h51

ABSTRACT

The current medical education model involves two years of primarily didactic coursework as well as two years of clinical integration and rotations before applying to residency programs. Medicine is an extremely hands-on career. Surgeons will need to master technical skills in their residency years of training as they have little exposure to hands-on surgical training in the current medical education model. For medical students that are interested in the surgical specialties, this calls into question whether or not there are modalities available to begin this training earlier on in their medical training. The ACOS (American College of Osteopathic Surgeons) Spring Conference held April 29- April 30, 2023, offered a state of the art surgical simulation experience that gave medical students interested in surgery the ability to explore these passions. In order to assess the benefits of such surgical simulations, the opinions of the medical students were assessed via survey. Respondents provided insight as to whether or not surgical simulations may be a useful addition to the didactic years of medical education, as well as continued training afterward. Resulting data suggests that medical students may benefit greatly from simulation experiences alongside attending physicians, whereupon they can ask questions as well as perform new skills under the guidance of an expert. Practicing in front of fellow students and attending physicians before encountering these same situations on rotations and in hospital may prove to be greatly beneficial to students seeking surgical careers. Medical students that engaged in the simulation training and answered the survey expressed opinions that highlighted benefits both in technical aspects as well as communication (non- technical) aspects of surgery. This study highlights simulation training as a potential solution to bridge the gap between the didactic and clinical years of medicine for aspiring surgeons.

Keywords: Simulation, Surgery, Surgical Simulation, Training

INTRODUCTION
The need for hands-on training as well as leadership training in medical education is well evidenced. Medical students currently are not required to undergo any formal hands-on training as they progress through their didactic years and so incorporating simulation training in medical education training has been proposed as a potential answer towards developing some of the crucial hands on as well as communication skills that medical students will need entering rotations, as well as in residency. The more exposure that medical students have with experiences that mimic the actual medical environment in hospital, the more seamlessly they will be able to transition into the clinical years and into actual practice. There have been many instances of medical schools providing simulation training as an adjunct to their education. The benefits of simulation-based training have also been well evidenced in the hospital environment to train teams, in acute trauma scenarios, as well as in mock operating room creations.

The American College of Osteopathic Surgeons offers spring and fall conferences to medical students interested in pursuing surgery. This includes students interested in any surgical subspecialty or general surgery. The annual spring conference in 2023 was held at Rocky Vista University in Parker, CO. Medical students that attended the conference were placed in groups that rotated through mock trauma scenarios as well as simulation training in operating rooms. In the operating rooms, students worked alongside career trauma surgeons and were able to perform incisions, as well as laparoscopy exploration in fake human models fitted with cut suits. Ten medical students attending the event were surveyed on their experience in the surgical simulation. Questions in the survey ranged from confidence levels performing the operation, to whether they felt as though communication with the attending physician was strong or weak. The resulting data provided intriguing trends in the opinions of the medical students after performing the mock operations with the attendings. Opinions the medical students had about attending similar future simulation training events were also investigated.

In order to establish an improved system for hands-on medical training in early medical education, efforts will need to be made in the medical education community as well as by students to participate in prepare events for other students to participate in. There are many benefits to “walking the walk” before entering the hospital environment. Many residency programs and program directors specifically focus on students’ experiences before medical school, including leadership roles, military service, work experience, etc., as it is well understood that these experiences will all be more representative of the hospital environment than didactic medical education can provide. Simulation training offers a method by which to get students involved in the hands-on aspects of medicine so they are more familiar with and have more realistic expectations of what they will face as practicing physicians. Providing training events such as the surgical simulation event at ACOS Spring Conference 2023 afforded medical students the opportunity to begin gaining realistic medical experiences in addition to their didactic coursework.

METHODS
Students that participated in the ACOS Spring Conference Simulations in Surgery event were put to the test by board certified trauma surgeons in mock operating rooms with realistic model patients and “cut suits” resembling actual anatomy. Three cohorts of medical students were separated and dispersed evenly in three mock operating rooms. The operating rooms had continuous vitals being played for the mock patients as well as proper draping for sterile technique. Sterile areas were established by blue markings and draped as they would be in any real hospital operating room. The students were gowned and gloved upon entry to the operating room and then proceeded to the operating table, whereupon they began to work alongside an actual surgical technician as well as an attending surgeon.

Operating rooms were staffed with a surgical technician as well as a board-certified trauma surgeon who guided the medical students through the operation in whichever classical method of operation they decided to teach the students. The students would then cut, suture, and operate on the mock patients as they would during an actual surgery. Cut suits with realistic organs were provided, which allowed the students the opportunity to explore the fake anatomy in a realistic way. Open laparoscopy was performed in each of the three operating rooms which allowed the students to explore gastrointestinal contents before making incisions on the appendix and performing the cholecystectomy.

Each cohort was given a 10-question survey after leaving the surgical simulation training on their experiences throughout the course of the mock operation. Ten responses were collected which entailed the opinions of the medical students participating in the simulation. Survey questions were focused on communication between them and their attending surgeon, their confidence levels operating on the mock patients, the knowledge they gained from working with the attendings, the chance they would participate in similar future events, their confidence being gowned and gloved, whether or not they had participated in similar events in the past, and their ideas with regards to incorporating more simulation training in medical education during the didactic years.

RESULTS
Thirty percent of respondents reported that they felt “very confident” entering a real OR in the future after having attended the surgical simulation. Fifty percent of the students reported that they felt “somewhat confident” entering a real OR in the future. Twenty percent of the students reported feeling unsure. When polled on their comfortability in asking attending physicians questions while working on patients in the simulated operating rooms, 30% percent of students reported feeling very confident, 40% reported that they felt somewhat confident, and 30% reported feeling unsure. Fifty percent of participants felt confident being gowned and gloved before entering an operating room. Sixty percent of students felt somewhat confident asking for help when they needed assistance in the OR. This was an encouraging statistic because it sheds light on the fact that there were positive avenues of communication in place during the event and that students felt comfortable asking for help from attendings or fellow students if they were confused about any part of the procedure.

When asked whether or not the students felt more confident in their knowledge of surgical techniques and instruments after their simulation experience the students reported mixed opinions. Twenty percent of the students reported feeling very confident, 40% of students somewhat confident, and 40% of students were unsure. Communication was somewhat efficient during the study and so when students were polled as to whether or not communication was transparent between the OR attending and the team they were working with, 55.56% reported feeling somewhat confident and 44.44% reported feeling very confident. This suggests that a majority of the students believed there was transparent communication throughout the procedure.

When polled on whether or not the students felt as though they knew more about assisting in surgeries after participating in the simulated operating room, 50% reported that they felt very confident. These numbers were encouraging as this will be the main focus of their activities on rotations and at the beginning of residency training. Most notably, 80% of the respondents believed that medical simulations should be more integrated into standard medical education before clinical rotations. This brings to the fore the idea that surgical simulations are not only well known to provide benefits toward clinical growth throughout medical school, but that it is also what the students desire.

Many of the participants in the study had not participated in mock OR training in the past. Seventy percent of the students responded that they had not attended a similar mock training exercise at another conference or in general. Eighty percent of students stated they would participate in similar training like this if offered in this format again. This gave encouragement towards the idea that future training simulations such as the surgical simulation at ACOS could be an integral component of future medical education and training.

REVIEW OF THE LITERATURE
See one, teach one, do one is a common adage that many medical students and medical professionals have probably encountered at some point but how often is this put into practice in the training of medical professionals? It is well noted that without deliberate practice and spaced repetition, skills one worked so hard to acquire in the first place, could atrophy when requested to demonstrate in the future.

In this literature review we will demonstrate the importance of deliberate practice and its effectiveness in training future and current physicians. We will also discuss notable pros and cons towards increased simulation training in medical curriculum at the medical school, residency, and attending level. Ultimately we will try to discern if the current literature supports increased simulation-based training (SBT) and several expectations and hurdles that might be encountered moving forward.

Initially, we found a common trend in the literature that deliberate practice is critical to learning and in the case of SBT as well. In a study utilizing VR simulators at the resident level, it was found that despite each group having comparable technical acumen before the training, the residents who completed deliberate practice showed a notably better performance compared to the non-VR group (Palter et al). Continually, with the prospect of increased SBT, it was noted that this could help residents get more “Hands-On” training without the increased risk to the patient or time constraints as would be involved in an actual case in the OR. This study highlighted a transition from the standard training protocol of residents working in a similar capacity to apprentices to a hybrid model that utilized SBT in the residency (Brandao et. al). An interesting takeaway from this model was the recognition that SBT could serve as an avenue for training on highly complex procedures thus decreasing the risk to patients and giving trainees the opportunity to learn from their mistakes without placing a patient at increased risk. Lastly, this study noted the ability to tailor the simulations to the unique nuances of a given program (Brandao et. al)¹.

Adding to our discussion of the potential for more use of SBT at the resident level, the impact of the COVID-19 pandemic posed threats to ophthalmology residents completing the required training which included 350 cataract surgeries through the traditional Halstedian training model of an apprenticeship tailored training program. Of pertinent concern to the patient is the noted risk of a posterior capsule rupture (PCR) of 5-9% for the initial 100 surgeries done by a resident ophthalmologist. The study noted that residents who underwent SBT before performing cataract surgery demonstrated a significantly lower threat for PCR (Wood et. Al²). Continually, this study made a nice parallel with how pilots are trained with simulations being a necessary component to their curriculum. This allows pilots to undergo training in a safe environment via a simulation and complete deliberate practice with spaced repetition through continued simulations beyond their initial training. Continually, one of the proposed barriers to increased utilization of SBT is the concern that with more data and tangible feedback, surgeons’ demonstrated ability could be highlighted to the point where their discrepancies are more apparent. Just like how it would be unsafe for a pilot to fly in the real world if they are not sufficient in SBT, this appears to be a concern to surgeons. On the other hand though, having more data and immediate feedback could be a strong tool for surgeons to grow and develop as they can see more tangibly their strengths and weaknesses. Lastly, the researchers noted a barrier of the cost to SBT in making sure that the ophthalmology simulations truly do represent a real-life scenario as it does for pilots (Wood et. Al²).

In contrast to the noted financial barrier to further simulation integration, a study focused on individual deliberate practice via utilization of cadaveric hands was studied in a cohort of orthopedic surgery residents. The goal was to determine how confident the residents felt about performing three separate procedures to include: distal radius open reduction internal fixation, flexor tendon repair, and ulnar shortening osteotomy. The results demonstrated that this SBT gave the resident the opportunity to practice in a low-stakes environment where they could get insight from faculty and be able to quickly and efficiently make improvements in their surgical ability. Overall, many of the residents were able to take aspects from the simulation and apply it to how they practiced medicine thus improving the potential outcomes of patients (James et. al). Compared to the orthopedic residents, a different study we looked at sought to investigate the long-term retention of skills that medical students had learned in SBT. Of note, it was found that from the 51 medical students who participated in the study, 55% of them were considered deficient in at least three of the skills they had previously learned via SBT 18 months prior when tested without being informed prior. It was also noted that a large number of the students did not practice the skill they learned after a given SBT experience. The researchers came to the conclusion that deliberate practice is a crucial aspect to learning even in a simulation-based approach to help increase the effectiveness of using SBT (Offiah et. Al³).

Moving beyond the proposed benefits and challenges at the resident and attending level, we found some key takeaways at the medical student level. A study was conducted that focused on the potential benefits of using SBT for medical students in performing a lumbar puncture (LP). The study was unique in choosing LP as the procedure of interest in how it is not directly related to just one given specialty but can be performed by physicians with many different areas of expertise. This further aided the discussion of considering SBT being more integrated into the curriculum. In this study a group of 115 students partook in SBT that consisted of a pre and post-test to assess their knowledge of an LP pre and post-training along with their level of confidence to do an LP pre and post-training. The data showed significance for both the student’s knowledge of LP and confidence along with the students demonstrating a high amount of satisfaction from the training experience. Continually, not only did their knowledge and confidence increase, but the students were more successful in performing an LP on a real patient. Moving forward, the study commented that further studies should be done to see the effectiveness of SBT in how it applies to all medical specialties (Gaubert et. Al⁴).

Continuing with the discussion on SBT in medical students, a study was performed to see the outcome of having medical students play the role of a surgical assistant in a congenital heart surgery simulation. One note of interest was that the study stated that medical students in the past 10 years have shown a lower desire to enter a surgical specialty. They noted that the use of hands-on simulation during medical school seemed to help intrigue medical students in considering becoming a surgeon. The study involved medical students playing the role of surgical assistants to congenital heart surgeons. They completed a pre-survey and information session followed by the simulation. Overall, the medical students were impressed with the 3D-printed models used in the simulation and that the experience increased their desire to attend future simulations along with the possibility of making SBT in the curriculum. Lastly, the students noted a change from 33% to 87% for their consideration to become a congenital heart surgeon after the training (Hon et. Al⁵).

CONCLUSION
This review illustrates the importance of SBT in preparing medical students for clinical rotations and residency, notably those interested in surgical residencies. SBT gives students an idea of how operating rooms function, and how to succeed as a medical student. Medical students are often timid in the operating room, and have little to no prior experience before clinical rotations begin in the third year. By engaging in simulation, students are able to practice important skills in a safe place with direct feedback from mentors, thus increasing confidence, competence, and success when transitioning from didactic to clinical years. The use of simulation based training may be an effective next step towards developing future surgical residency candidates.

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