British Journal of Neurosurgery, October 2014; 28(5): 680–684 © 2014 The Neurosurgical Foundation ISSN: 0268-8697 print / ISSN 1360-046X online DOI: 10.3109/02688697.2014.896873
ORIGINAL ARTICLE
Evaluation of the contribution of theatre attendance to medical undergraduate neuroscience teaching – A pilot study Thomas Flannery1 & Gerry Gormley2 1Department of Neurosurgery, Belfast Health & Social Care Trust, Belfast, UK, and 2Queen’s University Belfast, Belfast, UK
designing an undergraduate curriculum that will produce graduates who will deliver a safe and modern medical care for the next generation.1 To deliver an increasingly efficient and effective curriculum, medical schools need to optimize all their available resources for undergraduate teaching. In addition to lectures, ward-based teaching and outpatient clinics, this ‘maximizing the student experience’, may involve teaching in the operating theatre. There is emerging evidence to suggest that theatre-based learning, when delivered in a structured way, can be a useful forum for student teaching.2–5 Not only does theatre-based learning integrate with other aspects of the student’s curriculum, but it may also widen the cultural learning experiences espoused by ‘Tomorrow’s Doctor’s, 2009’ such as teamwork and communication. Indeed, this complementary integrated approach may be particularly suited to neurosurgery and the clinical neurosciences given the well-documented difficulties that the students have with this aspect of their curriculum.6–9 The aim of this study was to evaluate the contribution of neurosurgical theatre attendance to clinical neuroscience teaching among third-year medical students studying at Queen’s University Belfast (QUB). This two-week attachment is the only formal clinical neurosciences teaching QUB medical students get and is likely to reflect the experiences of medical students elsewhere at other UK universities.
Abstract Introduction. Medical students often attend the neurosurgical theatre during their clinical neurosciences attachment. However, few studies have been performed to objectively assess the value of this theatre-based learning experience. The main aim of this study was to explore student perceptions on the contribution of neurosurgical theatre attendance to clinical neuroscience teaching. Materials and methods. Third-year medical students undergoing their 2-week clinical neurosciences rotation at the Royal Hospitals Belfast were invited to participate in this study. A multi-method strategy was employed using a survey questionnaire comprising of closed and open-ended questions followed by semi-structured interviews to gain a greater ‘in-depth’ analysis of the potential contribution of neurosurgical theatre attendance to neuroscience teaching. Results. Based on the completed survey responses of 22 students, the overall experience of neurosurgical theatre-based learning was a positive one. ‘In-depth’ analysis from semi-structured interviews indicated that students felt that some aspects of their neurosurgical theatre attendance could be improved. Better preparation such as reading up on the case in hand and an introduction to simple theatre etiquette to put the student at ease (in particular, for students who had never attended theatre previously), would improve the learning experience. In addition, having an expectation of what students are expected to learn in theatre making it more learning outcomes-based would probably make it feel a more positive experience by the student. Conclusions. The vast majority of students acknowledged the positive learning outcomes of neurosurgical theatre attendance and felt that it should be made a mandatory component of the curriculum.
Materials and methods Study population The participants for this study were third-year medical students from QUB undertaking their clinical neurosciences attachment at the Royal Victoria Hospital Belfast from September 2011 to December 2012. Ethical approval for this study was obtained from the School of Medicine, Dentistry & Biomedical Sciences, QUB.
Keywords: medical students; neurosurgery theatre-based learning
Introduction
Evaluation questionnaire
With advances in scientific knowledge and technology in medicine, medical schools are facing the difficult task of
All students were sent an e-mail at the start of their neurosciences inviting them to participate in the study
Correspondence: Thomas Flannery, Department of Neurosurgery, Belfast Health & Social Care Trust, Belfast BT12 6BA, UK. Tel: ⫹ 44 028-90632474. Fax: ⫹ 44 028-90237733. E-mail: [email protected] Received for publication 17 June 2013; accepted 16 February 2014
680
Undergraduate neurosurgery theatre-based teaching 681 in addition to an information sheet, consent form and questionnaire. The questionnaire layout was broadly similar to a survey conducted for medical student evaluation of ENT theatre-based learning used by Lee et al. (2005).4 The questionnaire included open-ended and closed questions in addition to questions with a range of responses using a Likert scale of extremely important to not important at all. Questions included student demographics, perceived learning objectives and importance of neurosurgical theatre attendance. Participants were asked to indicate who provided the bulk of teaching, if they were able to ‘follow’ the procedure, whether it was a beneficial experience and if they considered a career in neurosurgery. The final question was open-ended inviting any additional comments not covered in the questionnaire.
Semi-structured interview To gain a more ‘in-depth’ analysis of the student learning experience in theatre, a cohort of students were also invited to participate in semi-structured interviews (SSI). Convenience sampling was used to select students for this aspect of the study because the principal investigator (TF) had access to the names of students who attended theatre through theatre staff who routinely record the names of visitors. The principal investigator also interviewed the students as he was intimately aware of the theatre environment and how this may impact on the student’s learning experience. On this basis, 10 students who attended neurosurgical theatre were sampled and were invited via e-mail to participate in the interview component of the study. The interview was guided by a topic guide developed by reference to questionnaire responses and discussion within the research team. The content of the interview relied largely on the interviewee and their responses with emphasis on the learning experience of attending neurosurgical theatre, areas for improvement, and whether it should be a compulsory component of the neurosciences curriculum. Within this framework of questioning, students were encouraged to articulate their perceptions and experiences freely and spontaneously. The sessions were recorded using a digital audio-recorder and recordings were then transcribed verbatim. Participants were assigned a code and their contributions were identified by these codes (i.e. Student 1, Student 2 etc). Following transcription, manual data organization techniques were used to organize, index, sort and retrieve qualitative data. Each researcher independently and systematically analyzed the transcripts line by line, annotating a descriptive code by the side of each piece of datum. Code abbreviations were used to help the researcher readily identify consistent themes emerging from each transcript. Constant comparative analysis was then performed, that is, transcripts were analyzed following each interview so that emergent themes and theories could be tested and included in subsequent interviews. This iterative process helped to refine identified categories based on coded responses. After 10 interviews, it was felt that data saturation had been reached and that no further interviews would be necessary. All analyses (identification of
themes and coding) were carried out independently by the research team (TF and GG). Finally, both researchers met to discuss and agree a final consensus on the main themes that emerged.
Results Questionnaires Out of a total number of 290 students, only 22 (8%) attended theatre and completed the questionnaire. At least one student was known to have attended theatre (with the PI) but did not complete the questionnaire. It is likely that there were additional students but this data was not recorded and the aspect of student apathy to the questionnaire was not included in the study protocol. Indeed, it is likely that this aspect may introduce a degree of bias in our results as perhaps only the most conscientious students were more likely to respond. Of the 22 questionnaire participants, 13 were male, 19 were native students and 4 were of postgraduate entry. The majority of participants (n ⫽ 19) were in the age range 20–25 years. Of the students who did not attend theatre, seven students expressed an interest in attending the operating theatre but were unable to do so due to a clash with their timetabled teaching sessions. The majority of participants felt that learning clinically relevant neuroanatomy (21/22) and neuropathology (21/22) were important learning objectives from neurosurgical theatre attendance (Fig. 1). All participants felt it was important to be aware of the risks and complications of a neurosurgical procedure while a majority of participants felt it was important to gain an insight into the dynamics of a neurosurgical theatre in terms of team-working (20/22) and differences with other surgical specialties (19/22). Finally, 20/22 participants felt it was important to be aware of the peri-operative management of a neurosurgical patient – ‘the patient journey’. In terms of the neurosurgical procedures observed, 22 participants observed a total of 29 procedures (Table I). Nine procedures were for a brain tumour resection/biopsy, nine were spinal procedures and two were for shunt placement. The remaining cases were craniotomy for intracerebral haematoma evacuation, craniotomy for other pathologies and replacement of a bone flap. The consultant neurosurgeon provided the bulk of the teaching, although in three cases there was an equal contribution made by the anaesthetic and junior medical staff. The majority of participants agreed that they could satisfactorily see the surgical procedure (20/22) (Fig. 2). In conjunction with these visual aids, 17/22 participants felt they were able to ‘follow’ the procedure more easily although two participants had no strong view and three participants felt they were unable to follow the procedure at all. Although 19 participants felt that the operating theatre was an important component of the neurosciences attachment, only 15/22 participants felt that their educational needs were met. Four procedures observed by this student cohort were spinal procedures (for decompression and tumour resection), while three were craniotomies
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Fig. 1. Student perceived importance of learning objectives from attending neurosurgical theatre. Uniqueness ⫽ uniqueness of learning in neurosurgery theatre compared with other surgical disciplines.
for intracranial pathologies. Three students cited a lack of interest on the part of the surgeon to teach as a major factor in their unmet educational need. One student felt that their educational needs would have been met by a more integrated and better organized approach, that is, given more notice to prepare by reading around the topic and seeing the patient pre-operatively. Three students did not supply any additional information in the free text box to indicate reasons for unmet educational need. Although the majority of the free text comments were positive (‘the opportunity to attend theatre was much appreciated’), a minority of participants felt ‘lost’ and unable to ‘follow’ the procedure. Some students felt that the experience could have been improved if some preparative tips were given to students, for example, where to access theatre lists, a brief induction and the opportunity to read up in advance on the case in hand.
1. Teamwork Study participants were generally impressed by the level of communication between all staff members and how ‘everything just seemed to happen so smoothly’ (Student 2). For some ‘it was interesting to see how much preparation goes on apart from just opening the patient up’ (Student 6) and how the scrub nurse and surgeon ‘worked together well’ (Student 3).
2. Live anatomy and pathology Another theme was the value of seeing ‘live’ anatomy and pathology (‘anatomy in a living patient is very different’, Student 3) complemented by ‘the surgeon talking us through the anatomical structures he was going through’ (Student 1). Indeed, some students commented on how seeing ‘live’ anatomy was ‘useful to consolidate what you learn in a book’ (Student 3) and ‘was helpful for review of anatomy’ (Student 2).
SSIs The 10 SSI transcripts (obtained from seven female and three male students) were analyzed independently by the authors. Six prominent consensus themes emerged from the data (with full student extracts available in a Supplementary materials available online at http://informahealthcare.com/ doi/abs/10.3109/02688697.2014.896873):
Table I. Summary of neurosurgical procedures observed by study participants. Number of cases Operative procedure observed observed per group Craniotomy for tumour resection Craniotomy for intracranial haematoma Craniotomy for infection Craniotomy for other pathologies Shunt insertion Cervical disc surgery Lumbar disc surgery Spinal surgery for tumour removal Other procedures (cranioplasty, burr hole for tumour biopsy) Total number of procedures
8 1 2 3 2 4 3 2 2 29
3. Imaging and visual aids in surgery Participants found the operative microscope monitor very helpful – ‘placing everything in view’ (Student 3). Students also found the intra-operative ultrasound and neuronavigation software extremely helpful – ‘there was quite a lot of visual imagery’ (Student 4).
4. Theatre etiquette for students Unlike other work environments, there is a certain code of behaviour or etiquette expected in the operating room, that is, awareness of sterile operative field. This may create difficulties for ‘first-time’ students who may benefit from an induction in theatre ‘etiquette, of what to do’ as they ‘may feel just a bit too scared to say anything in case they interrupt the surgeon’ (Student 3).
5. Demystifying neurosurgery It is clear from a layperson perspective that neurosurgery is different from many other aspects of medicine. Medical students are no different and this was evident by some of
Undergraduate neurosurgery theatre-based teaching 683
Fig. 2. Participant actual experiences of neurosurgical theatre attendance.
the comments – ‘I was very excited about the whole thing as I never had any experience with neurosurgery apart from watching it on the television’ (Student 4). The experience of neurosurgery seemed to fulfil some students’ expectations – ‘it was one of those things I think just to say that you saw it even and the experience of it was great’ (Student 3).
6. The patient journey Aside from the surgical aspect of attending neurosurgery theatre, students found other aspects of the patient journey ‘through theatre’ a useful learning experience. Observing anaesthetic techniques, the intra-operative physiological monitoring and the immediate post-operative period were issues regularly mentioned by participants: ‘the anaesthetist was very helpful in telling us what was happening and keen to let us see the initial anaesthesia and preparation’ (Student 1).
Discussion Medical students expect their educational needs to be met and coupled with their increased number and evolving syllabus mandates continual improvements in undergraduate curriculum design, organization and delivery.10,11 To the best of our knowledge, this is the first study to explore student perceptions of the learning opportunities in the neurosurgical operating theatre. Although the neurosurgical operating theatre can be an intimidating environment to the medical student, it can also provide a wealth of learning opportunities. Furthermore, student access to neurosurgical theatre in our institution is limited to two students at any one time (for infection control and health and safety purposes). This ‘exclusive’ access allows an almost one-to-one interaction between the student and the theatre staff and may positively influence the learning experiences of the student. Our study found that technology, in particular visual aids integral to modern-day neurosurgery, lends itself to an improved learning experience for the student – something also reported by a significant proportion (74%) of students surveyed in an Australian study.5
Each stage in the patient’s journey through theatre affords the student has a unique learning experience and the opportunity to see ‘teamwork in action’. The prominence of this theme in our study appears to be lacking in other reports on theatre-based learning. Fernando et al (2007a) reported that only 11% of student respondents considered staff roles and interactions, theatre etiquette, familiarity with theatre layout and environment, principles of patient management, patient pathway, anaesthetic considerations and fitness for surgery and principles of sterility and asepsis. Active participation of the student in the ‘theatre team’ by scrubbing in was only mentioned by one student. This lack of opportunity to ‘scrub-in’ may account for the unmet educational need cited by some students in our study. A student’s perception of their learning experience is also likely to be influenced by the respect they gain from theatre staff. The two extremes of this feeling of respect in our study were experienced by the participant who got the opportunity to ‘scrub in’ and the participant who was mistaken for a nursing student. Lyon (2003) indicates that establishing credibility, negotiating a role to play, participating in the team and having that participation supported and acknowledged as legitimate are crucial to student learning in theatre.5 Indeed, it was traditional for medical students to routinely ‘scrub-in’ for cases – a practice that appears (at least in our department) to have waned over time. It is likely that student acknowledgement and an opportunity to actively engage with the operating team leads to increased student self-esteem and improved learning experiences. Two significant weaknesses of this study are the small sample size and study bias. Although the study was initially ‘rolled-out’ for an entire year, the participation rate was extremely low, requiring an extension to recruit a reasonable cohort of students for meaningful analysis. In order to obtain sufficient number of cases and based on our accrual rate and likely low level of interest among medical undergraduates in a neurosurgical career, it is likely that a future study over a number of years would be required to study this concept in more detail.
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Another aspect of this study which requires further analysis is the potential bias of the principal investigator as the interviewer. It is well recognized that students take on a sycophantic attitude to senior medical colleagues as they know that they may come across them later in their careers as students or junior doctors. With ongoing investment in medical educational research in our institute (QUB), we hope to compare these results with that of an independent interviewer in the future to minimize the bias from our findings. A future study will also enable us to review improvements which will be made to the undergraduate neurosurgery curriculum, that is, logbook of useful procedures that students should see, for example, craniotomy for intrinsic tumour, trauma, shunt, spinal decompression rather than very rare or complex procedures.
Conclusions Although there are significant perceived benefits to neurosurgical theatre-based learning, significant improvements can be made in terms of student preparation and perhaps induction on theatre etiquette.
Acknowledgements Ethical approval for this study was obtained from the School of Medicine, Dentistry & Biomedical Sciences QUB School Ethics Committee. I would like to acknowledge the support of my clinical colleagues and also theatre staff in the Department of Neurosurgery Belfast Health and Social
Supplementary material available online Supplementary materials.
Care Trust for contributing to the teaching of students in theatre. Declaration of interest: The authors report no declarations of interest. The authors alone are responsible for the content and writing of the paper.
References 1. General Medical Council. Tomorrow’s doctors: Outcomes and standards for undergraduate medical education, 2009. 2. Fernando N, McAdam T, Youngson G, et al. Undergraduate medical students’ perceptions and expectations of theatre-based learning: how can we improve the student learning experience? Surgeon 2007;5:271–4. 3. Fernando N, McAdam T, Cleland J, et al. How can we prepare medical students for theatre-based learning? Med Educ 2007; 41:968–74. 4. Lee MSW, Montague ML, Hussain SSM. Student-perceived benefit from otolaryngology theatre attendance. J Laryngol Otol 2005;119:293–8. 5. Lyon PMA . 2003. Making the most of learning in the operating theatre: student strategies and curricular initiatives. Med Educ 37:680–8. 6. Flanagan E, Walsh C, Tubridy N. “Neurophobia” – attitudes of medical students and doctors in Ireland to neurological teaching. Eur J Neurol 2007;14:1109–12. 7. Lim E, Seet R. Demystifying neurology: preventing “neurophobia” among students. Nat Clin Pract Neurol 2008;4:461–2. 8. Menken M. Demystifying neurology. BMJ 2002;324:1469–70. 9. Schon F, Hart P, Fernandez C. 2002. Is clinical neurology really so difficult? J Neurol Neurosurg Psychiatry 72:557–9. 10. Brice J, Corrigan O. 2010. The changing landscape of medical education in the UK . Med Teach 32:727–32. 11. Bligh J. More medical students, more stress in the medical education system. Med Educ 2004;38:460–2.
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ORIGINAL ARTICLE
Evaluation of the contribution of theatre attendance to medical undergraduate neuroscience teaching – A pilot study Thomas Flannery1 & Gerry Gormley2 1Department of Neurosurgery, Belfast Health & Social Care Trust, Belfast, UK, and 2Queen’s University Belfast, Belfast, UK
designing an undergraduate curriculum that will produce graduates who will deliver a safe and modern medical care for the next generation.1 To deliver an increasingly efficient and effective curriculum, medical schools need to optimize all their available resources for undergraduate teaching. In addition to lectures, ward-based teaching and outpatient clinics, this ‘maximizing the student experience’, may involve teaching in the operating theatre. There is emerging evidence to suggest that theatre-based learning, when delivered in a structured way, can be a useful forum for student teaching.2–5 Not only does theatre-based learning integrate with other aspects of the student’s curriculum, but it may also widen the cultural learning experiences espoused by ‘Tomorrow’s Doctor’s, 2009’ such as teamwork and communication. Indeed, this complementary integrated approach may be particularly suited to neurosurgery and the clinical neurosciences given the well-documented difficulties that the students have with this aspect of their curriculum.6–9 The aim of this study was to evaluate the contribution of neurosurgical theatre attendance to clinical neuroscience teaching among third-year medical students studying at Queen’s University Belfast (QUB). This two-week attachment is the only formal clinical neurosciences teaching QUB medical students get and is likely to reflect the experiences of medical students elsewhere at other UK universities.
Abstract Introduction. Medical students often attend the neurosurgical theatre during their clinical neurosciences attachment. However, few studies have been performed to objectively assess the value of this theatre-based learning experience. The main aim of this study was to explore student perceptions on the contribution of neurosurgical theatre attendance to clinical neuroscience teaching. Materials and methods. Third-year medical students undergoing their 2-week clinical neurosciences rotation at the Royal Hospitals Belfast were invited to participate in this study. A multi-method strategy was employed using a survey questionnaire comprising of closed and open-ended questions followed by semi-structured interviews to gain a greater ‘in-depth’ analysis of the potential contribution of neurosurgical theatre attendance to neuroscience teaching. Results. Based on the completed survey responses of 22 students, the overall experience of neurosurgical theatre-based learning was a positive one. ‘In-depth’ analysis from semi-structured interviews indicated that students felt that some aspects of their neurosurgical theatre attendance could be improved. Better preparation such as reading up on the case in hand and an introduction to simple theatre etiquette to put the student at ease (in particular, for students who had never attended theatre previously), would improve the learning experience. In addition, having an expectation of what students are expected to learn in theatre making it more learning outcomes-based would probably make it feel a more positive experience by the student. Conclusions. The vast majority of students acknowledged the positive learning outcomes of neurosurgical theatre attendance and felt that it should be made a mandatory component of the curriculum.
Materials and methods Study population The participants for this study were third-year medical students from QUB undertaking their clinical neurosciences attachment at the Royal Victoria Hospital Belfast from September 2011 to December 2012. Ethical approval for this study was obtained from the School of Medicine, Dentistry & Biomedical Sciences, QUB.
Keywords: medical students; neurosurgery theatre-based learning
Introduction
Evaluation questionnaire
With advances in scientific knowledge and technology in medicine, medical schools are facing the difficult task of
All students were sent an e-mail at the start of their neurosciences inviting them to participate in the study
Correspondence: Thomas Flannery, Department of Neurosurgery, Belfast Health & Social Care Trust, Belfast BT12 6BA, UK. Tel: ⫹ 44 028-90632474. Fax: ⫹ 44 028-90237733. E-mail: [email protected] Received for publication 17 June 2013; accepted 16 February 2014
680
Undergraduate neurosurgery theatre-based teaching 681 in addition to an information sheet, consent form and questionnaire. The questionnaire layout was broadly similar to a survey conducted for medical student evaluation of ENT theatre-based learning used by Lee et al. (2005).4 The questionnaire included open-ended and closed questions in addition to questions with a range of responses using a Likert scale of extremely important to not important at all. Questions included student demographics, perceived learning objectives and importance of neurosurgical theatre attendance. Participants were asked to indicate who provided the bulk of teaching, if they were able to ‘follow’ the procedure, whether it was a beneficial experience and if they considered a career in neurosurgery. The final question was open-ended inviting any additional comments not covered in the questionnaire.
Semi-structured interview To gain a more ‘in-depth’ analysis of the student learning experience in theatre, a cohort of students were also invited to participate in semi-structured interviews (SSI). Convenience sampling was used to select students for this aspect of the study because the principal investigator (TF) had access to the names of students who attended theatre through theatre staff who routinely record the names of visitors. The principal investigator also interviewed the students as he was intimately aware of the theatre environment and how this may impact on the student’s learning experience. On this basis, 10 students who attended neurosurgical theatre were sampled and were invited via e-mail to participate in the interview component of the study. The interview was guided by a topic guide developed by reference to questionnaire responses and discussion within the research team. The content of the interview relied largely on the interviewee and their responses with emphasis on the learning experience of attending neurosurgical theatre, areas for improvement, and whether it should be a compulsory component of the neurosciences curriculum. Within this framework of questioning, students were encouraged to articulate their perceptions and experiences freely and spontaneously. The sessions were recorded using a digital audio-recorder and recordings were then transcribed verbatim. Participants were assigned a code and their contributions were identified by these codes (i.e. Student 1, Student 2 etc). Following transcription, manual data organization techniques were used to organize, index, sort and retrieve qualitative data. Each researcher independently and systematically analyzed the transcripts line by line, annotating a descriptive code by the side of each piece of datum. Code abbreviations were used to help the researcher readily identify consistent themes emerging from each transcript. Constant comparative analysis was then performed, that is, transcripts were analyzed following each interview so that emergent themes and theories could be tested and included in subsequent interviews. This iterative process helped to refine identified categories based on coded responses. After 10 interviews, it was felt that data saturation had been reached and that no further interviews would be necessary. All analyses (identification of
themes and coding) were carried out independently by the research team (TF and GG). Finally, both researchers met to discuss and agree a final consensus on the main themes that emerged.
Results Questionnaires Out of a total number of 290 students, only 22 (8%) attended theatre and completed the questionnaire. At least one student was known to have attended theatre (with the PI) but did not complete the questionnaire. It is likely that there were additional students but this data was not recorded and the aspect of student apathy to the questionnaire was not included in the study protocol. Indeed, it is likely that this aspect may introduce a degree of bias in our results as perhaps only the most conscientious students were more likely to respond. Of the 22 questionnaire participants, 13 were male, 19 were native students and 4 were of postgraduate entry. The majority of participants (n ⫽ 19) were in the age range 20–25 years. Of the students who did not attend theatre, seven students expressed an interest in attending the operating theatre but were unable to do so due to a clash with their timetabled teaching sessions. The majority of participants felt that learning clinically relevant neuroanatomy (21/22) and neuropathology (21/22) were important learning objectives from neurosurgical theatre attendance (Fig. 1). All participants felt it was important to be aware of the risks and complications of a neurosurgical procedure while a majority of participants felt it was important to gain an insight into the dynamics of a neurosurgical theatre in terms of team-working (20/22) and differences with other surgical specialties (19/22). Finally, 20/22 participants felt it was important to be aware of the peri-operative management of a neurosurgical patient – ‘the patient journey’. In terms of the neurosurgical procedures observed, 22 participants observed a total of 29 procedures (Table I). Nine procedures were for a brain tumour resection/biopsy, nine were spinal procedures and two were for shunt placement. The remaining cases were craniotomy for intracerebral haematoma evacuation, craniotomy for other pathologies and replacement of a bone flap. The consultant neurosurgeon provided the bulk of the teaching, although in three cases there was an equal contribution made by the anaesthetic and junior medical staff. The majority of participants agreed that they could satisfactorily see the surgical procedure (20/22) (Fig. 2). In conjunction with these visual aids, 17/22 participants felt they were able to ‘follow’ the procedure more easily although two participants had no strong view and three participants felt they were unable to follow the procedure at all. Although 19 participants felt that the operating theatre was an important component of the neurosciences attachment, only 15/22 participants felt that their educational needs were met. Four procedures observed by this student cohort were spinal procedures (for decompression and tumour resection), while three were craniotomies
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Fig. 1. Student perceived importance of learning objectives from attending neurosurgical theatre. Uniqueness ⫽ uniqueness of learning in neurosurgery theatre compared with other surgical disciplines.
for intracranial pathologies. Three students cited a lack of interest on the part of the surgeon to teach as a major factor in their unmet educational need. One student felt that their educational needs would have been met by a more integrated and better organized approach, that is, given more notice to prepare by reading around the topic and seeing the patient pre-operatively. Three students did not supply any additional information in the free text box to indicate reasons for unmet educational need. Although the majority of the free text comments were positive (‘the opportunity to attend theatre was much appreciated’), a minority of participants felt ‘lost’ and unable to ‘follow’ the procedure. Some students felt that the experience could have been improved if some preparative tips were given to students, for example, where to access theatre lists, a brief induction and the opportunity to read up in advance on the case in hand.
1. Teamwork Study participants were generally impressed by the level of communication between all staff members and how ‘everything just seemed to happen so smoothly’ (Student 2). For some ‘it was interesting to see how much preparation goes on apart from just opening the patient up’ (Student 6) and how the scrub nurse and surgeon ‘worked together well’ (Student 3).
2. Live anatomy and pathology Another theme was the value of seeing ‘live’ anatomy and pathology (‘anatomy in a living patient is very different’, Student 3) complemented by ‘the surgeon talking us through the anatomical structures he was going through’ (Student 1). Indeed, some students commented on how seeing ‘live’ anatomy was ‘useful to consolidate what you learn in a book’ (Student 3) and ‘was helpful for review of anatomy’ (Student 2).
SSIs The 10 SSI transcripts (obtained from seven female and three male students) were analyzed independently by the authors. Six prominent consensus themes emerged from the data (with full student extracts available in a Supplementary materials available online at http://informahealthcare.com/ doi/abs/10.3109/02688697.2014.896873):
Table I. Summary of neurosurgical procedures observed by study participants. Number of cases Operative procedure observed observed per group Craniotomy for tumour resection Craniotomy for intracranial haematoma Craniotomy for infection Craniotomy for other pathologies Shunt insertion Cervical disc surgery Lumbar disc surgery Spinal surgery for tumour removal Other procedures (cranioplasty, burr hole for tumour biopsy) Total number of procedures
8 1 2 3 2 4 3 2 2 29
3. Imaging and visual aids in surgery Participants found the operative microscope monitor very helpful – ‘placing everything in view’ (Student 3). Students also found the intra-operative ultrasound and neuronavigation software extremely helpful – ‘there was quite a lot of visual imagery’ (Student 4).
4. Theatre etiquette for students Unlike other work environments, there is a certain code of behaviour or etiquette expected in the operating room, that is, awareness of sterile operative field. This may create difficulties for ‘first-time’ students who may benefit from an induction in theatre ‘etiquette, of what to do’ as they ‘may feel just a bit too scared to say anything in case they interrupt the surgeon’ (Student 3).
5. Demystifying neurosurgery It is clear from a layperson perspective that neurosurgery is different from many other aspects of medicine. Medical students are no different and this was evident by some of
Undergraduate neurosurgery theatre-based teaching 683
Fig. 2. Participant actual experiences of neurosurgical theatre attendance.
the comments – ‘I was very excited about the whole thing as I never had any experience with neurosurgery apart from watching it on the television’ (Student 4). The experience of neurosurgery seemed to fulfil some students’ expectations – ‘it was one of those things I think just to say that you saw it even and the experience of it was great’ (Student 3).
6. The patient journey Aside from the surgical aspect of attending neurosurgery theatre, students found other aspects of the patient journey ‘through theatre’ a useful learning experience. Observing anaesthetic techniques, the intra-operative physiological monitoring and the immediate post-operative period were issues regularly mentioned by participants: ‘the anaesthetist was very helpful in telling us what was happening and keen to let us see the initial anaesthesia and preparation’ (Student 1).
Discussion Medical students expect their educational needs to be met and coupled with their increased number and evolving syllabus mandates continual improvements in undergraduate curriculum design, organization and delivery.10,11 To the best of our knowledge, this is the first study to explore student perceptions of the learning opportunities in the neurosurgical operating theatre. Although the neurosurgical operating theatre can be an intimidating environment to the medical student, it can also provide a wealth of learning opportunities. Furthermore, student access to neurosurgical theatre in our institution is limited to two students at any one time (for infection control and health and safety purposes). This ‘exclusive’ access allows an almost one-to-one interaction between the student and the theatre staff and may positively influence the learning experiences of the student. Our study found that technology, in particular visual aids integral to modern-day neurosurgery, lends itself to an improved learning experience for the student – something also reported by a significant proportion (74%) of students surveyed in an Australian study.5
Each stage in the patient’s journey through theatre affords the student has a unique learning experience and the opportunity to see ‘teamwork in action’. The prominence of this theme in our study appears to be lacking in other reports on theatre-based learning. Fernando et al (2007a) reported that only 11% of student respondents considered staff roles and interactions, theatre etiquette, familiarity with theatre layout and environment, principles of patient management, patient pathway, anaesthetic considerations and fitness for surgery and principles of sterility and asepsis. Active participation of the student in the ‘theatre team’ by scrubbing in was only mentioned by one student. This lack of opportunity to ‘scrub-in’ may account for the unmet educational need cited by some students in our study. A student’s perception of their learning experience is also likely to be influenced by the respect they gain from theatre staff. The two extremes of this feeling of respect in our study were experienced by the participant who got the opportunity to ‘scrub in’ and the participant who was mistaken for a nursing student. Lyon (2003) indicates that establishing credibility, negotiating a role to play, participating in the team and having that participation supported and acknowledged as legitimate are crucial to student learning in theatre.5 Indeed, it was traditional for medical students to routinely ‘scrub-in’ for cases – a practice that appears (at least in our department) to have waned over time. It is likely that student acknowledgement and an opportunity to actively engage with the operating team leads to increased student self-esteem and improved learning experiences. Two significant weaknesses of this study are the small sample size and study bias. Although the study was initially ‘rolled-out’ for an entire year, the participation rate was extremely low, requiring an extension to recruit a reasonable cohort of students for meaningful analysis. In order to obtain sufficient number of cases and based on our accrual rate and likely low level of interest among medical undergraduates in a neurosurgical career, it is likely that a future study over a number of years would be required to study this concept in more detail.
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Another aspect of this study which requires further analysis is the potential bias of the principal investigator as the interviewer. It is well recognized that students take on a sycophantic attitude to senior medical colleagues as they know that they may come across them later in their careers as students or junior doctors. With ongoing investment in medical educational research in our institute (QUB), we hope to compare these results with that of an independent interviewer in the future to minimize the bias from our findings. A future study will also enable us to review improvements which will be made to the undergraduate neurosurgery curriculum, that is, logbook of useful procedures that students should see, for example, craniotomy for intrinsic tumour, trauma, shunt, spinal decompression rather than very rare or complex procedures.
Conclusions Although there are significant perceived benefits to neurosurgical theatre-based learning, significant improvements can be made in terms of student preparation and perhaps induction on theatre etiquette.
Acknowledgements Ethical approval for this study was obtained from the School of Medicine, Dentistry & Biomedical Sciences QUB School Ethics Committee. I would like to acknowledge the support of my clinical colleagues and also theatre staff in the Department of Neurosurgery Belfast Health and Social
Supplementary material available online Supplementary materials.
Care Trust for contributing to the teaching of students in theatre. Declaration of interest: The authors report no declarations of interest. The authors alone are responsible for the content and writing of the paper.
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