TITLE PAGE ORIGINAL REPORT Otoscopy simulation training in a classroom setting: A novel approach to teaching otoscopy to medical students. J. DAVIES MSc,1 L. DJELIC BSc,1 P. CAMPISI MD,2 V . FORTE MD,2 AND A. CHIODO MD2. 1Faculty

of Medicine, University of Toronto, Toronto, Ontario, Canada

2Department

of Otolaryngology - Head and Neck Surgery, University of Toronto,

Toronto, Ontario, Canada Running Title: Simulation-based Otoscopy Training Financial Support: No source of financial support. Conflict of interest: The otoscopy simulator (OtoSim™) described in this study was developed by a team which included two of the authors, Drs. Paolo Campisi and Vito Forte. *Correspondence to: Al Chiodo, Department of Otolaryngology-Head & Neck Surgery, University of Toronto, University Office: University Health Network, Toronto General Hospital, RFE3S-438, 190 Elizabeth Street, Toronto, Ontario, M5G 2N2. Office: (416) 946-8743. Fax: (416) 946-8744. E-mail: [email protected]

This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1002/lary.24682 The American Laryngological, Rhinological and Otological Society, Inc.

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Abstract Objective: To determine the effectiveness of using of an otoscopy stimulator to teach medical students the primary principles of otoscopy in large group training sessions and improve their confidence in making otologic diagnoses. Study Design: Cross-sectional survey design. Methods: In March 2013, the Department of Otolaryngology - Head and Neck Surgery held a large-scale otoscopy simulator teaching session at the MaRS Innovation Center for 92 first and second year University of Toronto medical students. Following the training session, students were provided with an optional electronic nine question survey relating to their experience with learning otoscopy using the simulators alone, and in comparison to traditional methods of teaching. Results: Thirty-four medical students completed the survey. Ninety-one percent of the respondents indicated that the overall quality of the event was either very good or excellent. A total of 71% of respondents either agreed, or strongly agreed, that the otoscopy simulator training session improved their confidence in diagnosing pathologies of the ear. The majority (70%) of students indicated that the training session had stimulated their interest in otolaryngology - head and neck surgery as a medical specialty. Conclusion: Organizing large group otoscopy simulator training sessions is one method whereby students can become familiar with a wide variety of pathologies of the ear and improve both their diagnostic accuracy and their confidence in making otologic diagnoses. Key Words: Otoscopy; Medical education simulation. Level of Evidence: NA 2 The American Laryngological, Rhinological and Otological Society, Inc.

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Introduction In recent years, many Canadian medical schools have been under pressure to restructure their curriculum to meet the demands of increasing enrollment, advances in technology including simulation and a renewed focus on the merits of effective teaching.1,2 Medical educators are faced with the task of adapting to these demands by implementing innovative educational tools, which can optimize learning within the constraints of an already overburdened curriculum. The challenge of this task is of greater magnitude for those medical specialties, such as otolaryngology - head and neck surgery, which have traditionally been poorly represented within the undergraduate medical education curriculum.3 At the University of Toronto, the current undergraduate otolaryngology head and neck surgery pre-clerkship education consists of a mixture of didactic lectures and clinical skills sessions that are offered in the second year of medical training. Didactic lectures present the most common topics such as hearing loss, vertigo, otitis media, epistaxis, rhinosinusitis, head and neck malignancies and airway management.3 A single four hour clinical skills session covers the basics of an otolaryngology history, head and neck examination and introduction to the otoscopic examination.3 A recently developed Curriculum Mapping System, created by the University of Toronto, identified major gaps in otolaryngology education during the pre-clerkship years of medical school.4 While the formal objectives regarding the teaching of primary principles of otolaryngology set out by the Medical Council of Canada and the University of Toronto are met through the current medical school curriculum, the majority (>90%) of teaching occurs during 3 The American Laryngological, Rhinological and Otological Society, Inc.

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the first year of clerkship.4 At a national level, most (62.5%) of Canadian medical schools do not have a mandatory clinical rotation in otolaryngology.3 Therefore, it is no surprise that only 5% of medical students feel confident in consistently performing a reasonable otoscopic examination at the end of their third year of training.5 Considering that otolaryngology-related disorders comprise a sizeable number of encounters in family practice and pediatrics, it is imperative that novel learning formats, that can improve the diagnosis of common conditions affecting the ear, are implemented within the undergraduate medical education curriculum.3,6,7 In recent years, medical educators have increasingly turned to simulation based approaches to teach students practical skills which are difficult to acquire in the classroom. While otoscopy simulators such as the Ear Examination Simulator™ (Limbs and Things, United Kingdom) and Life/form® Pneumatic Otoscopy (Nasco, USA) provide students with hands on otoscopy simulation and limited exposure to pathologies of the ear, no simulator in production was capable of demonstrating hundreds of high resolution images of pathologies to multiple learners simultaneously and encourage interaction between students and instructors through viewing images concurrently. To this effect, the Department of Otolaryngology, in collaboration with MaRS Innovation Center (Toronto, Canada), developed an innovative otoscopy teaching tool, the OtoSim™, which is capable of accurately simulating the manual techniques of otoscopy and illustrating images of normal and pathological anatomy of the ear through the otoscope. While the otoscopy simulator has been proven to be a powerful tool for improving the 4 The American Laryngological, Rhinological and Otological Society, Inc.

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diagnostic accuracy of medical students when used in small group settings, it has not yet been evaluated in a large scale training session.8 The purpose of this study is to examine student perceptions of the use of an otoscopy simulator alone, and in comparison to traditional methods of teaching, during a large scale training session offered to medical students in their first or second year of training.

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Materials and Methods In March 2013, the Department of Otolaryngology - Head and Neck Surgery held a large-scale otoscopy simulator (OtoSimTM) teaching session for 92 first and second year University of Toronto medical students at the MaRS Innovation Center. Participation in the training session was optional and the session was scheduled outside of the official curriculum. Due to an overwhelming interest, the OtoSimTM teaching was divided into two one-hour sessions consisting of 46 students in each session. This distribution of students optimized the ratio of instructor to student to approximately 1:6. A total of 92 medical students (39 first year and 53 second year) took part in the two OtoSimTM teaching sessions. During the OtoSimTM teaching sessions, students were provided with a review of the basic technical skills of otoscopy and subsequently introduced to the normal anatomy of the ear and to over 50 high resolution images of various pathologies of the ear through the OtoSimTM simulation devices (Fig. 1). Images included commonly encountered pathologies such as cerumen, foreign bodies, otitis externa, otitis media as well as less frequently encountered pathologies such as osteoma, epidermal inclusion cysts, temporal bone fractures, tube granulomas and many others. A 1cm wide image of the tympanic membrane displayed each pathology at the distal end of the synthetic ear canal. Students were able to view each image with a handheld otoscope once they had maneuvered through the realistic ear canal. One instructor led the session at the head of the classroom with projected images while each of the smaller groups had their own facilitator to further explain what students were examining and stimulate discussion amongst the 6 The American Laryngological, Rhinological and Otological Society, Inc.

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group (Fig. 2). At each table, six OtoSimTM units were connected to a laptop where images could be viewed and edited by the facilitator. The facilitators used the landmarking functionality of the software to point out critical structures or areas that were highlighted by the instructor on the image projected at the front of the classroom. This enabled the facilitator to discuss with students the various pertinent features of the images and review the differences between normal anatomy and pathology. At the completion of the OtoSimTM training sessions, students were provided with an optional electronic nine question survey. The survey assessed the learners’ experience with the OtoSimTM device in comparison to traditional methods of didactic teaching. The first five questions of the survey were scored on a five point Likert scale. The remaining four questions provided students an opportunity to give open feedback regarding the session. Students answered by rating the following: 1) Overall quality of the event. 2) Organization of the event. 3) Degree to which staff at the event were helpful. 4) Degree to which the event improved confidence in using an otoscope to diagnose pathologies of the ear. 5) Degree to which the event stimulated interest in otolaryngology - head and neck surgery. 6) How would you compare learning otoscopy with the OtoSim™ to the traditional style of learning otoscopy? 7) What did you like most? 7 The American Laryngological, Rhinological and Otological Society, Inc.

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8) What was least useful? 9) Do you have any recommendations for improving the event? In this study, a cross-sectional survey design was employed. Data were collected from the survey given to medical students after their OtoSimTM teaching sessions. Descriptive statistics were calculated for all data using SPSS Statistics 19 for Windows (IBM®). The authors V.F. and P.C. were not involved in the writing of survey questions, data collection or analysis of the data.

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Results The initial response rate to the post-session survey was 26% (24/92). After a second request, an additional 10 students responded to the survey giving a total of 34 respondents or 37%. All 34 of the completed surveys were included in the analysis. Overall, the responses to the first five questions indicated a ‘very good’ or ‘excellent’ learning experience (Table 1). The majority of students rated the quality and organization of the event highly and perceived faculty recruited for the event as valuable. A total of 71% of respondents either agreed, or strongly agreed, that the OtoSimTM training session improved their confidence in diagnosing pathologies of the ear. The training session was also instrumental in stimulating interest in otolaryngology - head and neck surgery as a medical specialty. A total of 19 students provided comments when asked to compare learning otoscopy with the OtoSimTM to the traditional style of learning otoscopy (i.e. formal clinical skills teaching sessions, electives, observerships, etc.). One student wrote that the OtoSimTM “supplements otoscopy practice on real or standardized patients who may not have ear pathology”, while another wrote that “it was interesting to see so many different pathologies.” Overall, all of the comments were very positive and most stated that they thought implementing the OtoSimTM into the curriculum would be beneficial for students. Students were also asked what they liked most (20/34 commented) and least (17/34 commented) about the teaching session. The general consensus was that students appreciated being able to observe the same images as their peers and 9 The American Laryngological, Rhinological and Otological Society, Inc.

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facilitators throughout the training session, as this was often perceived as ambiguous in the clinical setting. Likewise, many students indicated that having a lead instructor present to review pathology as a group (Fig. 3A) and highlight the pertinent features in each image (Fig. 3B) was helpful to their learning. This was exemplified by comments such as "it was much easier to learn when the instructor and learner were both looking at the same image" and "it was helpful to have someone pointing out structures while [the lecturer] spoke about each pathology and structure." Other students commented that they appreciated being able to observe multiple different pathologies in one brief session. On the contrary, two students mentioned that too much information was introduced in such a short period of time and that more sessions would help for improving clarity and understanding. These comments may have been provided by first year medical students who, at the time of the session, had only minimal exposure to pathology of the ear.

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Discussion Traditionally, the primary principles and technical skills of otoscopy have been taught to medical students through didactic lectures or during clinical rotations. It has been assumed that these approaches have been effective. However, few graduates of medical programs are confident in properly performing an otoscopic examination.5 Likewise, with an increase in class sizes, reduced hours dedicated to teaching otolaryngology in the undergraduate curriculum, and low faculty to student ratios, it is clear that a novel approach to teaching otoscopy is necessary.3,5 In our study, a total of 92 students were instructed in the principles and skills of otoscopy using high-fidelity ear simulators. Despite accommodating a large number of participants, the overall quality and organization of the teaching session was rated highly (Table 1). This was possible as students were organized into small groups, each with a facilitator, as the lead instructor introduced the images. The role of the facilitator was to assist students in accurately identifying key features of the displayed images and in demonstrating the techniques of performing a proper otoscopic examination. This format ensured that students received immediate feedback regarding their technique and their ability to identify critical diagnostic features. The benefit of having facilitators to clarify important concepts and assist with technique was identified as a strength of the teaching session by many students. This is reflected in comments such as, "the staff to student ratio was great" and "I liked how each student was able to have their own... faculty member present to educate on what was observed". 11 The American Laryngological, Rhinological and Otological Society, Inc.

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A combined 71% of respondents either agreed, or strongly agreed, that the event improved their confidence in using an otoscope to diagnose pathologies of the ear (Table 1). This sentiment is borne out in data from a previous study assessing use of the OtoSimTM with third year clinical clerks which demonstrated a 44% improvement in diagnostic accuracy when using the simulator and standard curriculum versus the standard curriculum alone.8 Given that the OtoSim is capable of demonstrating over 200 hundred pathologic images, students can become comfortable with diagnosing a wide variety of pathologies that would be difficult to encounter in a typical outpatient clinic. Since around 10% of all patients present to primary care physicians with otolaryngic conditions that may require careful investigation with otoscopy, it is imperative that instruction in otoscopy is initiated at an early stage of medical training. 9 Without a strong foundation, lack of confidence in diagnosing common otologic conditions may perpetuate into residency training, and ultimately clinical practice. For example, a recently published Canadian study surveyed 68 family medicine residents and found that the majority felt uncomfortable with diagnosing and managing many common otologic conditions.10 Furthermore, high rates of antibiotic resistance and adverse events result from misdiagnosis of conditions such as otitis media with effusion.11 Hosting large group OtoSimTM sessions is one method whereby students can become familiar with a wide variety of pathologies of the ear and improve both their diagnostic accuracy and their confidence in making such diagnoses.

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Conclusion Otoscopy simulation is a novel addition to traditional didactic and clinical learning. Learners are exposed to a variety of common and rare pathologies in a short amount of time and in a safe setting. Moreover, students are able to discuss the various presentations with each other, group facilitators, and the lead instructor without time constraints. This report demonstrates that otoscopy simulation with very large groups of learners is technically possible and effective based on learner feedback. Acknowledgements The authors acknowledge OtoSimTM (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: Dr. Jay Rosenfeld, Dr. Martin Schreiber and Dr. Stacey Bernstein.

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References 1. Skochelak SE. A decade of reports calling for change in medical education: what do they say? Acad Med. 2010; 85(9): S26-33. 2. The revitalization of undergraduate education in Canada. Association of Universities and Colleges of Canada. Presented at AUCC workshop in Halifax, March 6-8, 2011. 3. Campisi P, Asaria J, Brown D. Undergraduate otolaryngology education in Canadian medical schools . Laryngoscope. 2008; 118: 1941-1950. 4. 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 and Neck Surg. 2012; 41(1): 71-75. 5. Jones WS, Johnson C, Longacre J. How well are we teaching otoscopy? Medical student perspectives. Pediatr Res. 2003; 53(suppl):95A. 6. Morris E, Kesser BW, Pierce-Cottler S, Keeley M. Development and validation of a novel ear simulator to teach pneumatic otoscopy. Sim Healthcare. 2012; 7: 22-26. 7. Varrasso DA. Otitis media: the need for a new paradigm in medical education. Pediatrics. 2006; 118: 1731-1733. 8. Campisi P, Tirado Y, Chadha NK, Forte V. Otoscopy simulation: a new paradigm in undergraduate medical education. Laryngoscope. 2011; 121 (suppl): S246. 9. Griffiths, E. Incidence of ENT problems in general practice. J R Soc Med. 1979; 72: 740-742. 10. 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(5): 668-75. 11. Pichichero ME. Diagnostic accuracy, tympanocentesis training performance, and antibiotic selection by pediatric residents in management of otitis media. Pediatrics. 2002; 110 (6): 1064-1070.

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Figure Legends Fig 1. The otoscopy simulator (OtoSim™) used during the training session to illustrate normal anatomy and various pathologies of the ear. Fig 2. Schematic of classroom during otoscopy simulator teaching session. Fig 3. A. Depiction of an otoscopic image projected on a large screen with descriptive text. B. Otoscopic image as viewed by students through each OtoSim™ station with key features highlighted by the instructor.

Table 1. Student responses to survey questions (n=34). Student Responses (%) Very Poor Neutral Very Poor Good Overall quality of the event. 0 0 9 50 Strongly Disagree Neutral Agree Disagree Organization of the event. 0 0 0 44 The staff at the event were helpful. 0 0 6 35 0 6 23 53 The event improved confidence in using an otoscope to diagnose pathologies of the ear. 0 6 24 46 The event stimulated interest in otolaryngology - head and neck surgery.

Excellent

41 Strongly Agree 56 59 18

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The otoscopy simulator (OtoSim™) used during the training session to illustrate normal anatomy and various pathologies of the ear. 67x63mm (240 x 240 DPI)

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Schematic of classroom during otoscopy simulator teaching session. 254x190mm (96 x 96 DPI)

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A. Depiction of an otoscopic image projected on a large screen with descriptive text. B. Otoscopic image as viewed by students through each OtoSim™ station with key features highlighted by the instructor. 146x57mm (96 x 96 DPI)

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Otoscopy simulation training in a classroom setting: a novel approach to teaching otoscopy to medical students.

To determine the effectiveness of using of an otoscopy stimulator to teach medical students the primary principles of otoscopy in large group training...
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