The Laryngoscope C 2015 The American Laryngological, V
Rhinological and Otological Society, Inc.
Evaluation of an Otoscopy Simulator to Teach Otoscopy and Normative Anatomy to First Year Medical Students Daniel J. Lee, BHSc; Terence S. Fu, MBA; Brian Carrillo, PhD; Paolo Campisi, MD; Vito Forte, MD; Albino Chiodo, MD Objective/Hypothesis: Our study evaluates the effectiveness of the OtoSim as an educational tool for teaching otoscopy and normal middle ear anatomy to first-year medical students. Study Design: Cross-sectional survey design. Methods: A large group otoscopy simulator teaching session was held in January 2014 for 29 first-year medical students at the University of Toronto. Following the training session, survey questions were administered to assess the student experience. Results: A total of 29 students completed the survey. All respondents rated the overall quality of the event as very good or excellent. Ninety-three percent of respondents indicated that the simulator increased their confidence in otoscopy. Students also commented that they were able to learn normal middle ear anatomy without causing discomfort to patients. Conclusions: The use of otoscopy simulation is a novel addition to traditional learning methods for undergraduate medical students. Students can effectively learn normal external and middle ear anatomy and improve their confidence in performing otoscopy examination. Key Words: Otoscopy, medical education, simulation. Level of Evidence: NA Laryngoscope, 125:2159–2162, 2015
INTRODUCTION Otolaryngology disorders are common in the primary care setting, comprising 10% to 30% of presenting complaints to primary care providers.1,2 In pediatric populations, this number rises to approximately 50%.3 Despite the prevalence of ear, nose, and throat problems in primary care, recent studies have demonstrated inadequate exposure to otolaryngology–head and neck surgery during undergraduate and postgraduate medical education.4–8 Medical schools in North America have been under mounting pressure to restructure their curricula in response to rising enrollment and a tidal increase in medical knowledge. These factors have created the challenging task of developing a curriculum that provides students with optimal exposure to various medical specialties.9,10 There is a risk that exposure to otolaryngol-
From the Faculty of Medicine (D.J.L., T.S.F.), and the Department of Otolaryngology–Head and Neck Surgery (B.C., P.C., V.F., A.C.), University of Toronto, Toronto, Ontario, Canada. Editor’s Note: This Manuscript was accepted for publication December 4, 2014. The otoscopy simulator (OtoSim) described in this study was developed by a team that included two of the authors, Drs. Paolo Campisi and Vito Forte. The authors have no other funding, financial relationships, or conflicts of interest to disclose. Daniel J. Lee, BHSc, and Terence S. Fu, MBA, contributed equally to this study. Send correspondence to Albino Chiodo, MD, Department of Otolaryngology–Head & Neck Surgery, University of Toronto, Toronto East General Hospital, 840 Coxwell Avenue, Toronto, ON, Canada M4C 5T2. E-mail: [email protected] DOI: 10.1002/lary.25135
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ogy–head and neck surgery may be further compromised, as this field has been traditionally underrepresented in the undergraduate medical curriculum.4 Learning to identify normative anatomy and diagnose conditions of the middle ear is particularly challenging for medical trainees. In fact, only 5% of medical students at the end of their third year of training are confident in their ability to consistently perform a reasonable otoscopic examination.2 Furthermore, inexperienced clinicians often misdiagnose middle ear pathology due to inadequate training and evaluation.11,12 Given that otologic pathologies are among the most common presenting ear, nose, and throat complaints in primary care, educators have recognized the need to implement novel learning formats to improve the diagnosis and management of common ear conditions.4,12 Increasingly, educators have turned to the use of simulation-based models to teach practical skills such as otoscopic examination.13 OtoSim (OtoSim Inc., Toronto, Ontario, Canada) is an innovative educational tool that allows students to practice otoscopy on a realistic model ear while viewing over 200 high-fidelity images of normative and pathological ear anatomy. Previous studies showed that OtoSim significantly increased the diagnostic accuracy of students in small-group settings and improved students’ confidence levels in diagnosing ear pathologies in a large group session.14,15 The purpose of this study was to evaluate the effectiveness of otoscopy simulation as an educational tool to aid in teaching normative ear anatomy and otoscopy skills to first year medical students. Lee et al.: Simulation-Based Otoscopy Training
2159
MATERIALS AND METHODS
Data Collection and Statistical Analysis
Organization of the OtoSim Session The Department of Otolaryngology–Head and Neck Surgery held an otoscopy simulator (OtoSim) teaching session for 29 first-year medical students at the University of Toronto in January 2014. The training session was optional and scheduled outside of the official curriculum. Prior to the OtoSim session, students had been introduced to otoscopy during head and neck clinical sessions as part of the preclerkship curriculum. There were four instructors at the otoscopy simulator teaching session, optimizing the ratio of instructor to student to 1:7.25. During the OtoSim session, students maneuvered through model ear canals (OtoSim) with otoscopes to view 30 highresolution images of normal and abnormal tympanic membranes and various external and middle ear pathologies. A systematic review of important landmarks, such as the annulus, pars tensa, pars flaccida, ossicles, cone of light, and chorda tympani, was used to highlight differences between normal and abnormal images. A lead instructor at the front of the classroom used the land-marking functionality of the software to point out critical structures or areas, which were concurrently displayed on the students’ OtoSim devices and on the large screen in the classroom. Other faculty members served as facilitators to answer questions and assist students with identifying structures.
Cross-sectional Survey To evaluate the utility of the OtoSim session, participants were surveyed at the completion of the training session. The survey consisted of nine questions, both quantitative and qualitative, to assess the student’s experience with the training session and the OtoSim in comparison to traditional clinical skills sessions. The first five questions of the survey were scored on a five-point Likert scale. The remaining four questions were qualitative and designed to capture open feedback from students. The questions were as follows: 1. 2. 3. 4. 5. 6. 7. 8. 9.
Overall quality of the event. Organization of the event. Degree to which staff at the event were helpful. Degree to which the event improved confidence in using an otoscope to diagnose pathologies of the ear. Degree to which the event stimulated interest in otolaryngology–head and neck surgery. How would you compare learning otoscopy with the OtoSim to the traditional style of learning otoscopy? What did you like most? What was least useful? Do you have any recommendations for improving the event?
Microsoft Excel (Microsoft Corp., Redmond, WA) and SPSS Statistics version 19 for Windows (IBM, Armonk, NY) were used to collect and analyze data from the survey. Thematic analysis was performed to explore key themes among student responses to open-ended survey questions. Two authors (D.L. and T.F.) reviewed responses independently to identify recurring comments, which were categorized as either constructive or critical. Both investigators independently performed the analysis, and the level of agreement was >95%. The Health Sciences Research Ethics Board (REB) of the Faculty of Medicine, University of Toronto granted approval to the research protocol under the REB’s delegated review process.
RESULTS The response rate in this study was 100% (29/29). The results of all 29 completed surveys are summarized in Table I. Student responses to open-ended survey questions are presented by category and frequency in Tables II and III.
Rating of the OtoSim Session All of the respondents (100%) rated the overall quality of the event as “very good” or “excellent” (Table I). The majority (93%) of respondents either agreed or strongly agreed that the event was well organized and improved their confidence in otoscopy. All of the participants agreed or strongly agreed that the faculty members at the event were helpful for the OtoSim session. A smaller proportion of students (65%) indicated that the event stimulated interest in otolaryngology–head and neck surgery as a potential career direction.
Open Feedback From Students Comments from all four qualitative questions (questions 6–9) were used for analysis. More than half of the respondents (55%) commented that the OtoSim was useful and helpful in learning normal anatomy of the external and middle ear (Table II). Thirteen students (45%) noted that they appreciated the opportunity to repeatedly view many variations of normal ear structures in a single session. Twelve participants (41%) mentioned that the ability to concurrently view images under the guidance of a lead instructor contributed to a positive learning experience. Six students (21%) indicated that OtoSim allowed them to practice their otoscopy skills for
TABLE I. Student Responses to Survey Questions (N 5 29). Student Responses Very Poor
Overall quality of the event Organization of the event Helpfulness of the staff
Poor
0
0
Strongly Disagree
Disagree
0 0
0 0
Neutral
0 Neutral 2 (7%) 0
Very Good
9 (31%) Agree
Excellent
20 (69%) Strongly Agree
10 (34%) 6 (21%)
17 (59%) 23 (79%)
Improved confidence in diagnosis using otoscope
0
0
0
17 (59%)
12 (41%)
Stimulation of interest in otolaryngology–head and neck surgery
0
0
12 (41%)
13 (45%)
4 (14%)
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TABLE II. Major Constructive Themes and Representative Quotes in Response to Open-Ended Survey Questions. Theme
Frequency (N 5 29)
Opportunity to practice otoscopy without causing discomfort to a real patient.
6 (21%)
Useful for learning middle ear anatomy.
16 (55%)
Educational to receive real-time advice and guidance of knowledgeable instructor.
12 (41%)
Students’ Perspective
“I felt like it was less intimidating to use the OtoSim since I wasn’t worried about hurting a patient.” (Student 2) “Very helpful; able to take time to look around without worrying about causing someone discomfort.” (Student 16) “Easier to see anatomy and understand differences between normal and abnormal ears.” (Student 29) “Allowed me to better appreciate landmarks.” (Student 27)
Helpful to view a large number of high-resolution images of normal ear anatomy.
13 (45%)
“I liked being able to have the presenter outline features with the mouse.” (Student 8) “Helpful to follow along with structures using mouse pointer.” (Student 21) “Learning how to recognize normal anatomy in many different images.” (Student 20) “I liked the diversity of slides that expose you to many different ways the ear drum can present.” (Student 13)
OtoSim should be implemented into the undergraduate medical education curriculum.
3 (10%)
“Should be an integral part of medical education.” (Student 5) “May be useful as supplement to the anatomy curriculum.” (Student 29)
an extended period of time without causing discomfort to patients. Three students (10%) mentioned that the OtoSim should be incorporated into the first-year undergraduate medical education curriculum. In addition to positive responses, students provided critical suggestions to improve future sessions (Table III). The most common critique (33%) concerned administrative issues, such as the lack of e-mail confirmation for session enrollment, minimal advertisement, and poor timing of the session (days before an exam). Six students (21%) commented that the straight ear canal of OtoSim did not accurately simulate the varied and tortuous structure of a real ear canal. Three students (10%) mentioned that it would be helpful to have a more thorough introduction to otoscopy and OtoSim prior to viewing images. Additionally, five students (17%) suggested that the session would benefit from further promotion of the specialty of otolaryngology– head and neck surgery.
DISCUSSION Otoscopy is an important skill for physicians and medical trainees due to the high prevalence of middle ear pathology in primary care and general otolaryngology–head and neck surgery practice. Although clinical guidelines emphasize the diagnostic value of pneumatic otoscopy for common middle ear pathologies such as otitis media, the accuracy of otoscopy may be less than ideal due to varying levels of training and experience.16 Correct use of otoscopy has been shown to improve the accuracy of diagnosing ear pathology, quality of patient care, and patterns of antibiotic prescription.11,12 However, otoscopic examination is a difficult skill to learn, and is often used suboptimally in clinical practice. In one study, 75% of emergency medicine residents felt that they had not received enough education in otolaryngology.7 With the lack of adequate training, it is no surprise that many providers are not utilizing otoscopy to its full diagnostic capability.17 Given the dual challenge of
TABLE III. Major Critical Themes and Representative Quotes in Response to Open-Ended Survey Questions. Theme
Model does not simulate some features of a normal ear.
Frequency (n529)
Students’ Perspective
6 (21%)
“OtoSim doesn’t simulate the need to pull pinna/straighten the ear canal.” (Student 9) “OtoSim has a very straight ear canal, which may not be as practical.” (Student 13) “Not just before exam.” (Student 26)
Administrative problems (i.e., e-mail confirmation, scheduling).
9 (31%)
More thorough introduction to OtoSim and otoscopy.
3 (10%)
“Start off with an introduction on how to hold and maneuver otoscope.” (Student 3)
More promotion and illustration of the specialty of otolaryngology.
5 (17%)
“More good stories about ENT to hype up the specialty!” (Student 1) “Advertise the event more so more students know to take advantage of a great learning opportunity.” (Student 15)
“It would be nice to receive a confirmation after registering.” (Student 15)
ENT 5ear, nose, and throat.
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increased enrollment and an overburdened curriculum, it is clear that novel teaching methods are needed to promote confidence and competence among students in performing otoscopy. The present study explores the value of using an innovative simulation-based tool to teach otoscopy and normative external and middle ear anatomy to first year medical students. Traditional methods of learning otoscopy can be arduous for trainees due to the challenge of identifying structures of the middle ear without causing physical discomfort to patients. The presence of cerumen and the tortuous ear canal may also prevent students from fully accessing and exploring the middle ear. Our study shows that OtoSim is an effective method of teaching the skills of otoscopy, as demonstrated by favorable student responses regarding improved confidence in performing otoscopy. The use of a simulated model such as the OtoSim also allowed students to explore the external auditory canal for an extended period of time without experiencing the anxiety of causing patient discomfort. The large number of high-resolution images of the middle ear further allowed students to appreciate the variable nature of normal anatomy. Additionally, high ratings for the organization of our session highlight an important advantage of OtoSim: the ability of students to view images concurrently while an instructor emphasizes key learning objectives. The use of the software’s ability to show landmark structures on each individual simulator unit screen and on the large screen, enabled students to appreciate anatomic features in each slide. The presence of other faculty members further reinforced the positive learning environment by addressing student concerns during the session. Unlike a previous OtoSim session, the present study focused on normative anatomy and was organized to coincide with head and neck clinical sessions.15 This may explain the higher ratings for improved confidence levels observed in the present study (100% vs. 71%), despite the lower faculty-to-student ratio in this study. The relatively low rating for interest stimulation in otolaryngology–head and neck surgery suggests that future sessions should incorporate a more detailed description of the specialty and faculty experiences to generate interest in the field. This study is subject to several limitations. First, our study is based on a small sample size of 29 medical students. Second, due to the survey structure, we were unable to quantitatively evaluate the improvement in otoscopy skills and instead relied on subjective measures. Despite these caveats, our study demonstrates that OtoSim is an effective otoscopy teaching tool from the student perspective. Furthermore, our findings are generalizable to similar simulation-based teaching tools, which may be used to train students in other important but challenging clinical skills.
CONCLUSION OtoSim is an innovative and effective teaching tool that allows students to build foundational skills in otos-
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copy. Students are able to clearly view variations of normal middle ear anatomy without causing discomfort to patients. Moreover, Otosim promotes interaction among students and instructors through concurrent viewing of images. This study demonstrates the utility of incorporating simulation-based teaching tools such as OtoSim in medical education and highlights the need for further evaluation of these educational tools.
Acknowledgments The authors acknowledge OtoSim (MaRS Innovation Center, Toronto, Canada) and the faculty of the Department of Otolaryngology–Head and Neck Surgery, University of Toronto for their support of this innovation. We would also like to thank the Center for Image Guided Innovation and Therapeutic Intervention, biomedical engineering at the Hospital for Sick Children, and support received from educational leaders in the Faculty of Medicine, University of Toronto.
BIBLIOGRAPHY 1. Griffiths E. Incidence of ENT problems in general practice. J R Soc Med 1979;72:740–742. 2. Jones WS, Johnson C, Longacre J. How well are we teaching otoscopy? Medical students perspectives. Pediatr Res 2003;53(suppl):95A. 3. Donnelly MJ, Quraishi MS, McShane DP. ENT and general practice: a study of paediatric ENT problems seen in general practice and recommendations for general practitioner training in ENT in Ireland. Ir J Med Sci 1995;164:209–211. 4. Campisi P, Asaria J, Brown D. Undergraduate otolaryngology education in Canadian medical schools. Laryngoscope 2008;118:1941–1950. 5. Carr MM, Brown DH, Reznick RK. Needs assessment for an undergraduate otolaryngology curriculum. Otolaryngol Head Neck Surg 1999;120: 865–868. 6. Chawdhary G, Ho EC, Minhas SS. Undergraduate ENT education: what students want. Clin Otolaryngol 2009;34:584–585. 7. Sharma A, Machen K, Clarke B, Howard D. Is undergraduate otorhinolaryngology teaching relevant to junior doctors working in accident and emergency departments? J Laryngol Otol 2006;120:949–951. 8. Glicksman JT, Brandt MG, Parr J, Fung K. Needs assessment of undergraduate education in otolaryngology among family medicine residents. J Otolaryngol Head Neck Surg 2008;37:668–675. 9. The revitalization of undergraduate education in Canada. A report on the AUCC workshop on undergraduate education in Halifax, March 6–8, 2011. Ottawa, Canada: Association of Universities and Colleges of Canada; 2011. 10. Skochelak SE. A decade of reports calling for change in medical education: what do they say? Acad Med 2010;85:S26–S33. 11. Steinbach WJ, Sectish TC, Benjamin DK Jr, Chang KW, Messner AH. Pediatric residents’ clinical diagnostic accuracy of otitis media. Pediatrics 2002;109:993–998. 12. Varrasso DA. Otitis media: the need for a new paradigm in medical education. Pediatrics 2006;118:1731–1733. 13. Morris E, Kesser BW, Peirce-Cottler S, Keeley M. Development and validation of a novel ear simulator to teach pneumatic otoscopy. Simul Healthc 2012;7:22–26. 14. Campisi P, Tirado Y, Chadha N, Abdulkader D, Forte V. Otoscopy simulation: a new paradigm in undergraduate medical education. Paper presented at: Annual Combined Otolaryngology Spring Meeting of the Triological Society; April 2011; Chicago, IL. 15. Davies J, Djelic L, Campisi P, Forte V, Chiodo A. Otoscopy simulation training in a classroom setting: a novel approach to teaching otoscopy to medical students. Laryngoscope 2014;124:2594–2597. 16. Rosenfeld RM, Culpepper L, Doyle KJ, et al. Clinical practice guideline: otitis media with effusion. Otolaryngol Head Neck Surg 2004;130:S95– S118. 17. Oyewumi M, Isaac K, Schreiber M, Campisi P. Undergraduate otolaryngology education at the University of Toronto: a review using a curriculum mapping system. J Otolaryngol Head Neck Surg 2012;41:71–75.
Lee et al.: Simulation-Based Otoscopy Training
Rhinological and Otological Society, Inc.
Evaluation of an Otoscopy Simulator to Teach Otoscopy and Normative Anatomy to First Year Medical Students Daniel J. Lee, BHSc; Terence S. Fu, MBA; Brian Carrillo, PhD; Paolo Campisi, MD; Vito Forte, MD; Albino Chiodo, MD Objective/Hypothesis: Our study evaluates the effectiveness of the OtoSim as an educational tool for teaching otoscopy and normal middle ear anatomy to first-year medical students. Study Design: Cross-sectional survey design. Methods: A large group otoscopy simulator teaching session was held in January 2014 for 29 first-year medical students at the University of Toronto. Following the training session, survey questions were administered to assess the student experience. Results: A total of 29 students completed the survey. All respondents rated the overall quality of the event as very good or excellent. Ninety-three percent of respondents indicated that the simulator increased their confidence in otoscopy. Students also commented that they were able to learn normal middle ear anatomy without causing discomfort to patients. Conclusions: The use of otoscopy simulation is a novel addition to traditional learning methods for undergraduate medical students. Students can effectively learn normal external and middle ear anatomy and improve their confidence in performing otoscopy examination. Key Words: Otoscopy, medical education, simulation. Level of Evidence: NA Laryngoscope, 125:2159–2162, 2015
INTRODUCTION Otolaryngology disorders are common in the primary care setting, comprising 10% to 30% of presenting complaints to primary care providers.1,2 In pediatric populations, this number rises to approximately 50%.3 Despite the prevalence of ear, nose, and throat problems in primary care, recent studies have demonstrated inadequate exposure to otolaryngology–head and neck surgery during undergraduate and postgraduate medical education.4–8 Medical schools in North America have been under mounting pressure to restructure their curricula in response to rising enrollment and a tidal increase in medical knowledge. These factors have created the challenging task of developing a curriculum that provides students with optimal exposure to various medical specialties.9,10 There is a risk that exposure to otolaryngol-
From the Faculty of Medicine (D.J.L., T.S.F.), and the Department of Otolaryngology–Head and Neck Surgery (B.C., P.C., V.F., A.C.), University of Toronto, Toronto, Ontario, Canada. Editor’s Note: This Manuscript was accepted for publication December 4, 2014. The otoscopy simulator (OtoSim) described in this study was developed by a team that included two of the authors, Drs. Paolo Campisi and Vito Forte. The authors have no other funding, financial relationships, or conflicts of interest to disclose. Daniel J. Lee, BHSc, and Terence S. Fu, MBA, contributed equally to this study. Send correspondence to Albino Chiodo, MD, Department of Otolaryngology–Head & Neck Surgery, University of Toronto, Toronto East General Hospital, 840 Coxwell Avenue, Toronto, ON, Canada M4C 5T2. E-mail: [email protected] DOI: 10.1002/lary.25135
Laryngoscope 125: September 2015
ogy–head and neck surgery may be further compromised, as this field has been traditionally underrepresented in the undergraduate medical curriculum.4 Learning to identify normative anatomy and diagnose conditions of the middle ear is particularly challenging for medical trainees. In fact, only 5% of medical students at the end of their third year of training are confident in their ability to consistently perform a reasonable otoscopic examination.2 Furthermore, inexperienced clinicians often misdiagnose middle ear pathology due to inadequate training and evaluation.11,12 Given that otologic pathologies are among the most common presenting ear, nose, and throat complaints in primary care, educators have recognized the need to implement novel learning formats to improve the diagnosis and management of common ear conditions.4,12 Increasingly, educators have turned to the use of simulation-based models to teach practical skills such as otoscopic examination.13 OtoSim (OtoSim Inc., Toronto, Ontario, Canada) is an innovative educational tool that allows students to practice otoscopy on a realistic model ear while viewing over 200 high-fidelity images of normative and pathological ear anatomy. Previous studies showed that OtoSim significantly increased the diagnostic accuracy of students in small-group settings and improved students’ confidence levels in diagnosing ear pathologies in a large group session.14,15 The purpose of this study was to evaluate the effectiveness of otoscopy simulation as an educational tool to aid in teaching normative ear anatomy and otoscopy skills to first year medical students. Lee et al.: Simulation-Based Otoscopy Training
2159
MATERIALS AND METHODS
Data Collection and Statistical Analysis
Organization of the OtoSim Session The Department of Otolaryngology–Head and Neck Surgery held an otoscopy simulator (OtoSim) teaching session for 29 first-year medical students at the University of Toronto in January 2014. The training session was optional and scheduled outside of the official curriculum. Prior to the OtoSim session, students had been introduced to otoscopy during head and neck clinical sessions as part of the preclerkship curriculum. There were four instructors at the otoscopy simulator teaching session, optimizing the ratio of instructor to student to 1:7.25. During the OtoSim session, students maneuvered through model ear canals (OtoSim) with otoscopes to view 30 highresolution images of normal and abnormal tympanic membranes and various external and middle ear pathologies. A systematic review of important landmarks, such as the annulus, pars tensa, pars flaccida, ossicles, cone of light, and chorda tympani, was used to highlight differences between normal and abnormal images. A lead instructor at the front of the classroom used the land-marking functionality of the software to point out critical structures or areas, which were concurrently displayed on the students’ OtoSim devices and on the large screen in the classroom. Other faculty members served as facilitators to answer questions and assist students with identifying structures.
Cross-sectional Survey To evaluate the utility of the OtoSim session, participants were surveyed at the completion of the training session. The survey consisted of nine questions, both quantitative and qualitative, to assess the student’s experience with the training session and the OtoSim in comparison to traditional clinical skills sessions. The first five questions of the survey were scored on a five-point Likert scale. The remaining four questions were qualitative and designed to capture open feedback from students. The questions were as follows: 1. 2. 3. 4. 5. 6. 7. 8. 9.
Overall quality of the event. Organization of the event. Degree to which staff at the event were helpful. Degree to which the event improved confidence in using an otoscope to diagnose pathologies of the ear. Degree to which the event stimulated interest in otolaryngology–head and neck surgery. How would you compare learning otoscopy with the OtoSim to the traditional style of learning otoscopy? What did you like most? What was least useful? Do you have any recommendations for improving the event?
Microsoft Excel (Microsoft Corp., Redmond, WA) and SPSS Statistics version 19 for Windows (IBM, Armonk, NY) were used to collect and analyze data from the survey. Thematic analysis was performed to explore key themes among student responses to open-ended survey questions. Two authors (D.L. and T.F.) reviewed responses independently to identify recurring comments, which were categorized as either constructive or critical. Both investigators independently performed the analysis, and the level of agreement was >95%. The Health Sciences Research Ethics Board (REB) of the Faculty of Medicine, University of Toronto granted approval to the research protocol under the REB’s delegated review process.
RESULTS The response rate in this study was 100% (29/29). The results of all 29 completed surveys are summarized in Table I. Student responses to open-ended survey questions are presented by category and frequency in Tables II and III.
Rating of the OtoSim Session All of the respondents (100%) rated the overall quality of the event as “very good” or “excellent” (Table I). The majority (93%) of respondents either agreed or strongly agreed that the event was well organized and improved their confidence in otoscopy. All of the participants agreed or strongly agreed that the faculty members at the event were helpful for the OtoSim session. A smaller proportion of students (65%) indicated that the event stimulated interest in otolaryngology–head and neck surgery as a potential career direction.
Open Feedback From Students Comments from all four qualitative questions (questions 6–9) were used for analysis. More than half of the respondents (55%) commented that the OtoSim was useful and helpful in learning normal anatomy of the external and middle ear (Table II). Thirteen students (45%) noted that they appreciated the opportunity to repeatedly view many variations of normal ear structures in a single session. Twelve participants (41%) mentioned that the ability to concurrently view images under the guidance of a lead instructor contributed to a positive learning experience. Six students (21%) indicated that OtoSim allowed them to practice their otoscopy skills for
TABLE I. Student Responses to Survey Questions (N 5 29). Student Responses Very Poor
Overall quality of the event Organization of the event Helpfulness of the staff
Poor
0
0
Strongly Disagree
Disagree
0 0
0 0
Neutral
0 Neutral 2 (7%) 0
Very Good
9 (31%) Agree
Excellent
20 (69%) Strongly Agree
10 (34%) 6 (21%)
17 (59%) 23 (79%)
Improved confidence in diagnosis using otoscope
0
0
0
17 (59%)
12 (41%)
Stimulation of interest in otolaryngology–head and neck surgery
0
0
12 (41%)
13 (45%)
4 (14%)
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TABLE II. Major Constructive Themes and Representative Quotes in Response to Open-Ended Survey Questions. Theme
Frequency (N 5 29)
Opportunity to practice otoscopy without causing discomfort to a real patient.
6 (21%)
Useful for learning middle ear anatomy.
16 (55%)
Educational to receive real-time advice and guidance of knowledgeable instructor.
12 (41%)
Students’ Perspective
“I felt like it was less intimidating to use the OtoSim since I wasn’t worried about hurting a patient.” (Student 2) “Very helpful; able to take time to look around without worrying about causing someone discomfort.” (Student 16) “Easier to see anatomy and understand differences between normal and abnormal ears.” (Student 29) “Allowed me to better appreciate landmarks.” (Student 27)
Helpful to view a large number of high-resolution images of normal ear anatomy.
13 (45%)
“I liked being able to have the presenter outline features with the mouse.” (Student 8) “Helpful to follow along with structures using mouse pointer.” (Student 21) “Learning how to recognize normal anatomy in many different images.” (Student 20) “I liked the diversity of slides that expose you to many different ways the ear drum can present.” (Student 13)
OtoSim should be implemented into the undergraduate medical education curriculum.
3 (10%)
“Should be an integral part of medical education.” (Student 5) “May be useful as supplement to the anatomy curriculum.” (Student 29)
an extended period of time without causing discomfort to patients. Three students (10%) mentioned that the OtoSim should be incorporated into the first-year undergraduate medical education curriculum. In addition to positive responses, students provided critical suggestions to improve future sessions (Table III). The most common critique (33%) concerned administrative issues, such as the lack of e-mail confirmation for session enrollment, minimal advertisement, and poor timing of the session (days before an exam). Six students (21%) commented that the straight ear canal of OtoSim did not accurately simulate the varied and tortuous structure of a real ear canal. Three students (10%) mentioned that it would be helpful to have a more thorough introduction to otoscopy and OtoSim prior to viewing images. Additionally, five students (17%) suggested that the session would benefit from further promotion of the specialty of otolaryngology– head and neck surgery.
DISCUSSION Otoscopy is an important skill for physicians and medical trainees due to the high prevalence of middle ear pathology in primary care and general otolaryngology–head and neck surgery practice. Although clinical guidelines emphasize the diagnostic value of pneumatic otoscopy for common middle ear pathologies such as otitis media, the accuracy of otoscopy may be less than ideal due to varying levels of training and experience.16 Correct use of otoscopy has been shown to improve the accuracy of diagnosing ear pathology, quality of patient care, and patterns of antibiotic prescription.11,12 However, otoscopic examination is a difficult skill to learn, and is often used suboptimally in clinical practice. In one study, 75% of emergency medicine residents felt that they had not received enough education in otolaryngology.7 With the lack of adequate training, it is no surprise that many providers are not utilizing otoscopy to its full diagnostic capability.17 Given the dual challenge of
TABLE III. Major Critical Themes and Representative Quotes in Response to Open-Ended Survey Questions. Theme
Model does not simulate some features of a normal ear.
Frequency (n529)
Students’ Perspective
6 (21%)
“OtoSim doesn’t simulate the need to pull pinna/straighten the ear canal.” (Student 9) “OtoSim has a very straight ear canal, which may not be as practical.” (Student 13) “Not just before exam.” (Student 26)
Administrative problems (i.e., e-mail confirmation, scheduling).
9 (31%)
More thorough introduction to OtoSim and otoscopy.
3 (10%)
“Start off with an introduction on how to hold and maneuver otoscope.” (Student 3)
More promotion and illustration of the specialty of otolaryngology.
5 (17%)
“More good stories about ENT to hype up the specialty!” (Student 1) “Advertise the event more so more students know to take advantage of a great learning opportunity.” (Student 15)
“It would be nice to receive a confirmation after registering.” (Student 15)
ENT 5ear, nose, and throat.
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increased enrollment and an overburdened curriculum, it is clear that novel teaching methods are needed to promote confidence and competence among students in performing otoscopy. The present study explores the value of using an innovative simulation-based tool to teach otoscopy and normative external and middle ear anatomy to first year medical students. Traditional methods of learning otoscopy can be arduous for trainees due to the challenge of identifying structures of the middle ear without causing physical discomfort to patients. The presence of cerumen and the tortuous ear canal may also prevent students from fully accessing and exploring the middle ear. Our study shows that OtoSim is an effective method of teaching the skills of otoscopy, as demonstrated by favorable student responses regarding improved confidence in performing otoscopy. The use of a simulated model such as the OtoSim also allowed students to explore the external auditory canal for an extended period of time without experiencing the anxiety of causing patient discomfort. The large number of high-resolution images of the middle ear further allowed students to appreciate the variable nature of normal anatomy. Additionally, high ratings for the organization of our session highlight an important advantage of OtoSim: the ability of students to view images concurrently while an instructor emphasizes key learning objectives. The use of the software’s ability to show landmark structures on each individual simulator unit screen and on the large screen, enabled students to appreciate anatomic features in each slide. The presence of other faculty members further reinforced the positive learning environment by addressing student concerns during the session. Unlike a previous OtoSim session, the present study focused on normative anatomy and was organized to coincide with head and neck clinical sessions.15 This may explain the higher ratings for improved confidence levels observed in the present study (100% vs. 71%), despite the lower faculty-to-student ratio in this study. The relatively low rating for interest stimulation in otolaryngology–head and neck surgery suggests that future sessions should incorporate a more detailed description of the specialty and faculty experiences to generate interest in the field. This study is subject to several limitations. First, our study is based on a small sample size of 29 medical students. Second, due to the survey structure, we were unable to quantitatively evaluate the improvement in otoscopy skills and instead relied on subjective measures. Despite these caveats, our study demonstrates that OtoSim is an effective otoscopy teaching tool from the student perspective. Furthermore, our findings are generalizable to similar simulation-based teaching tools, which may be used to train students in other important but challenging clinical skills.
CONCLUSION OtoSim is an innovative and effective teaching tool that allows students to build foundational skills in otos-
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copy. Students are able to clearly view variations of normal middle ear anatomy without causing discomfort to patients. Moreover, Otosim promotes interaction among students and instructors through concurrent viewing of images. This study demonstrates the utility of incorporating simulation-based teaching tools such as OtoSim in medical education and highlights the need for further evaluation of these educational tools.
Acknowledgments The authors acknowledge OtoSim (MaRS Innovation Center, Toronto, Canada) and the faculty of the Department of Otolaryngology–Head and Neck Surgery, University of Toronto for their support of this innovation. We would also like to thank the Center for Image Guided Innovation and Therapeutic Intervention, biomedical engineering at the Hospital for Sick Children, and support received from educational leaders in the Faculty of Medicine, University of Toronto.
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