Arch Orthop Trauma Surg (2015) 135:795–803 DOI 10.1007/s00402-015-2217-7
ORTHOPAEDIC SURGERY
Teaching surgical exposures to undergraduate medical students: an integration concept for anatomical and surgical education Niels Hammer1 • Pierre Hepp2 • Sabine Lo¨ffler1 • Stefan Schleifenbaum2 Hanno Steinke1 • Stefan Klima2
•
Received: 30 October 2014 / Published online: 21 April 2015 Springer-Verlag Berlin Heidelberg 2015
Abstract Background Decreasing numbers of students are interested in starting a surgical career, posing substantial challenges to patient care in the next years. The anatomy course is one of the key subjects in medical training, especially in surgical disciplines. Innovative teaching concepts that integrate surgically relevant anatomy and manual dexterity might help boost student interest in surgery. Methods A preclinical workshop entitled ‘‘Surgical exposures’’ was developed. A team of anatomists and surgeons introduced the surgical exposures, demonstrating the procedures on Thiel-fixed body donors. Following this introduction, students practiced the exposures in an operating room-like manner. A six-point Likert scale was used to evaluate the workshop and to compare it to the first-year dissection course. Results The overall evaluation result for the surgical exposures was excellent, proving to be a significantly better result when compared to the first-year dissection course. The students were more satisfied with the teaching time invested by the peers and regarded the workshop as clinically highly relevant. Furthermore, they felt that questions were addressed better and that the overall atmosphere was better than in the gross anatomy course. Electronic supplementary material The online version of this article (doi:10.1007/s00402-015-2217-7) contains supplementary material, which is available to authorized users. & Niels Hammer [email protected] 1
Institute of Anatomy, University of Leipzig, Liebigstraße 13, 04103 Leipzig, Germany
2
Department of Orthopedic, Trauma and Reconstructive Surgery, University Clinic of Leipzig, Leipzig, Germany
Subject to criticism was the course size and practicing time in both cases. Discussion The surgical exposures workshop provides preclinical students with clinically relevant anatomy and manual dexterity. It may positively influence the decision to follow a surgical career. This course, however, requires extensive teaching resources. The given concept may help implement practical medical skills in the preclinical curriculum, strengthening the professional identity of surgeons and anatomists. Keywords Gross anatomy education Medical education German anatomy curriculum Surgical approach Orthopedic and trauma surgery Preclinical anatomy workshop Surgical exposure
Introduction Decreasing numbers of students are interested in starting a surgical career, posing substantial challenges to patient care in the next years in Germany [1, 2] and elsewhere in the western world [3–6]. The reasons for this inclining number are presumably the traditional role models of surgeons [7], changes in students’ attitudes regarding a worklife balance [1, 2, 7] or ‘‘poor lifestyle’’ [8]—and decreasing contact hours in the gross anatomy laboratory [9–11]. Students feel inadequately prepared to safely perform in clinical practice, particularly in surgery [10–12]. Clinicians akin feel that students’ limited exposure to anatomy causes a lack of knowledge in their future colleagues [12–14]. Though anatomy is considered one of the key subjects in medical training [14, 15], the dissection course is subject to on-going discussions regarding its suitability as part of the
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preclinical curriculum [13, 16–18]. Both surgeons and anatomists consider the gross anatomy course to be an unrecognized force in the decision making of medical students’ later field of expertise [3, 10, 19]. Innovative teaching concepts that integrate surgically relevant anatomy and surgical dexterity might therefore help to enhance students’ interest in surgery [10, 20–23]. Vice versa, concepts implementing practical medical skills in the preclinical curriculum may help to strengthen the professional identity of surgeons and anatomists, combining academic surgery and with clinically relevant anatomy [4, 20, 21, 24]. Taking into account this complex conviction especially in the German speaking countries, we established a workshop on surgical exposures in orthopedic and trauma surgery in the preclinical curriculum. The following objectives were defined for the workshop: To provide clinically relevant anatomy and manual skills from everyday situations in surgery to preclinical medical students: 1. 2.
To use and combine the strengths of anatomy and surgery in a teaching setting. To further increase the interest of students who consider starting a career in orthopedic and trauma surgery, and to potentially support their decision making to become or not to become a surgeon.
We describe our preliminary experiences in this workshop held to second-year undergraduate medical students and compare students’ survey data to the gross anatomy course held with first-year students.
Materials and methods Workshop design The surgical exposures workshop is offered as a compulsory elective subject. It consists of four teaching sessions in weekly intervals. A fifth session is used for a written examination, consisting of 30 multiple-choice questions. Two peers hold each of the courses, one anatomist and one trauma or orthopedic surgeon. Each of the teaching sessions takes place in a gross anatomy environment and consists of eight academic hours. The theory applying to the respective anatomical region and the surgical procedure are introduced in the first 3 h, followed by 5 h of surgical training. The theoretical part consists of on-screen presentations, videos, enhanced by subject literature [25–27], thin sliced specimens of the respective anatomical region [28, 29] and presected ethanol–glycerin-fixed specimens from the Institute of Anatomy, University of Leipzig
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[30, 31]. Three body donors are usually utilized to practice the surgical exposures of major anatomical regions in a freely selectable sequence: Session 1: shoulder and proximal humerus. Session 2: pelvis and hip joint (Fig. 1; Supplement figure 1). Session 3: spine. Session 4: femoral shaft (Supplement figure 2), knee joint (Supplement figure 3), proximal tibia and ankle. The donors are embalmed with the Thiel solution [32, 33] according to our house protocol [34]. The absence of any surgical implants in the regions of interest of the donors prior to the workshop is strongly recommended. Two of the three donors are used simultaneously in each of the sessions. The body donors are placed in an operating room-like manner, i.e. in a beach chair position in case of the shoulder exposures or in a lumbar kyphosis in case of lumbar spine exposures. Full surgery room equipment is provided by the Department of Orthopedics, Trauma and Reconstructive Surgery, University Clinic of Leipzig and by medical equipment manufacturers, including lighting, draping, instruments and implants. Each of the exposures is conducted by one or several students, guided by an experienced clinician in a manner as done in routine surgery. Time-consuming and complex exposures are presected in one of the body donors [35] for demonstration purposes prior to the course by the anatomist and surgeon and conducted again in another donor during the respective session by the students. If necessary, major landmarks, nerves and vessels that are most likely to become damaged are marked with surgical threads and fixing clamps. More details on the most commonly taught exposures can be found in Table 1. Estimated costs for the Thiel-fixed donors are 4000 € each, accounting for 540–600 € per student, provided by the Institute of Anatomy, University of Leipzig, Germany. The teaching philosophy is as follows: 1.
2. 3. 4.
5.
The anatomist and the surgeon demonstrate and teach simultaneously in parallel and as a well-integrated team, not successively. Lectures are held without fixed speaking times in a conversation-like manner. Students are regarded as young colleagues and discussions/explanations are always held on eye level. Students are engaged to interact and inquire as often as possible in the theory sessions and to act as surgeons in the practical sessions, supported by the peers from anatomy and surgery (Fig. 2) [36]. Mistakes during surgical training are tolerated explicitly but discussed subsequently, as known from pilot training using flight simulators [37, 38].
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Fig. 1 Ilio-inguinal [Letournel] exposure (85-year-old male donor). a The surgical site is shown with a skin incision ranging from the iliac crest (IC) to the pubic symphysis (PS). b The next step shows the surgical preparation of the external oblique muscle (EO) with its fascia before exploring the inguinal canal. c An islet of abdominal wall muscles consisting of internal (IO) and external oblique muscle attachments is tunneled manually. All structures passing below this islet, continuing to the muscular and vascular lacuna, are tunneled. The spermatic funiculus (FS) is retracted. cd caudal, cr cranial, l lateral, m medial
Table 1 List of surgical exposures demonstrated to and practiced by the students
Session
Anatomical region
Name of exposure
Presected
1
Shoulder and arm
Anterior approach to the clavicle
•
Delta split
•
Pelvis
Trans delta Ilio-inguinal (Letournel)
• 4
Stoppa
4
Hip joint
Extended anterior (Smith-Petersen)
4
Anterolateral (Watson-Jones)
4
Lateral transgluteal (Bauer, Hardinge)
4
Posterior (Kocher–Langenbeck)
4
Dorsal paraspinal (thoracolumbar spine)
•
Dorsal posterolateral (thoracal spine)
•
2
3
Spine
Anterior retroperitoneal approach (lumbar spine) 4
Posterior approach to lumbar spine
•
Femur shaft
Lateral access
•
Knee joint
Medial parapatellar approach
4
Midvastus approach
4
Subvastus approach
4
Anterolateral approach to the tibial plateau Posteromedial approach
4 4
Posterolateral approach
4
Lateral head of the tibia Ankle
Study setting and participants Twenty-two preclinical students were enrolled in the course of 2014, held in January and February. Informed consent was ratified from all students. An anonymized,
paper-based and voluntary survey consisting of 14 items (six-point Likert scale; 1 = I strongly agree/excellent/grade ‘‘A’’, 6 = I strongly disagree/failure/grade ‘‘F’’) was handed out at the end of session 4. The students were asked on the workshop design, how they believe the
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Fig. 2 Students practicing surgical exposures to the knee joint (84year-old female donor), guided by a peer team an anatomist and clinician
acquired knowledge will integrate in their future practice as medical doctors. The questions are given in Table 2. The students were asked to return the completed survey on the examination day after the multiple-choice examination to circumvent any biasing related to the examination or Hawthorne effects [39]. The results of this survey were compared to the data of the 2013 gross anatomy course, consisting of 346 undergraduate first-year students and a 12-item Likert scale. For statistical comparison of the survey data, SPSS version 20.0 (IVM Corp., Armonk, NY, USA) was used. Student’s t test was applied to compare the survey data. P values of 0.05 or less were considered as statistically significant.
Results Three Thiel-embalmed body donors were provided by the Institute of Anatomy, University of Leipzig for the preclinical surgical exposures workshop in January and February 2014, one female (84-year-old) and two males (75 and 85-year-old). The exposures demonstrated to and practiced by the students are given in Table 1. The faculty–student ratio was 2/22 (including the anatomist and the surgeon) and the male–female ratio was 10/12 in the surgical exposures workshop. In the gross anatomy course, the staff–student ratio was 1/22 (excluding Table 2 Baseline data including the staff–student ratio, the male–female ratio and student time required for preparing the course
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student assistants) and the male–female ratio was 58/101 (Table 2). Overall course time was 30 h for the workshop. Overall preparation and follow-up working time of one workshop accounts for 60, 40 and 30 h for the anatomist, the surgeon and the technical staff, respectively. The survey was returned by 91 % of the students (20/22) attending the surgical exposures workshop and by 45 % (159/346) of the students attending the gross anatomy course. Student preparation time was significantly shorter in case of the surgical exposures workshop than for the gross anatomy course (p \ 0.001; Table 2). The overall evaluations of the courses were ‘‘good’’ (1.6 ± 0.7) for the gross anatomy course and ‘‘excellent’’ (1.2 ± 0.4) for the surgical exposures workshop (Fig. 3a). Students were significantly more sufficed by the teaching time invested by the staff in the surgical exposures workshop (Fig. 3b) and they evaluated the clinical relevance of the surgical exposures to be significantly higher than the clinical relevance of the gross anatomy course (Fig. 3c). Applying the peer concept answer to students’ questions was rated as significantly better (1.0 ± 0.0, ‘‘excellent’’) than in the standard gross anatomy setting (1.6 ± 1.0, ‘‘good’’). The working atmosphere was evaluated as better in the surgical approaches workshop than in the gross anatomy course (Fig. 3d). The students felt that their learning achievements and in-depth knowledge after the course were ‘‘excellent’’ in both courses (Fig. 3e). The group size of the classes was evaluated as ‘‘satisfactory’’ in both courses and clearly a subject to criticism in both settings (Fig. 3b). A majority of the students felt that the group size should be smaller and that longer training times would increase their learning achievements (Table 3). Further student suggestions included providing live video transmissions from the surgery ward to the dissection room. In their free text responses the students emphasized that their interest to become a surgeon was raised by the surgical exposures workshop and that peer team of anatomists and surgeons contributed to the positive atmosphere of the class (Fig. 4).
Discussion The gross anatomy course may be regarded as the closest discipline to surgery in the preclinical curriculum. Shared values of anatomy and surgery go far beyond the use of scalpels and tweezers or topographical knowledge of the
Ratio Faculty/student
Preparation time (min) Male/female
\30
30–59
60–120
p value [120
Surgical exposures
2/22
10/12
5
15
–
–
Gross anatomy
1/22–1/20
58/101
4
10
10
135
\0.001
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Fig. 3 Summary and statistical comparison of the student survey from the surgical exposures workshop and the gross anatomy class. a General evaluation; b organization; c structuring; d practical part; e class benefit
site of intervention. The key to success in both disciplines is the ability to work in an interdisciplinary team [40]. Our workshop entitled ‘‘Surgical exposures’’ explicitly addresses this role of gross anatomy and promotes surgically relevant anatomy to second-year students in order to
increase their interest in orthopedic and trauma surgery. This workshop aimed at promoting students’ interest in surgery at a very early stage of their career in medicine based on personal experiences [3, 19]. We have started offering the workshop on surgical exposures in 2011.
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800 Table 3 Quotations from representative free text responses Quotations from representative free text responses Pros ‘‘I felt like a surgeon’’ ‘‘Nice workshop that raised my interest to become a surgeon’’ ‘‘The clinical relevance of anatomy was clearly emphasized’’ ‘‘Clinically relevant depth anatomy beyond standard student knowledge’’ ‘‘Highly motivated team of anatomists and clinicians, answering all questions in a great atmosphere’’ ‘‘Best workshop of the preclinical curriculum’’ Cons ‘‘A video transmission of real-live surgery would be desirable’’ ‘‘More specimens and longer training times would be great’’ ‘‘The group size was too large’’
Fig. 4 Grades of the lectures held by the anatomist and clinicians
Similar approaches to enhance students’ interest in surgery were recently demonstrated by Allen et al. [6] and Haggerty and coworkers [41]. In the surgical exposures workshop, students are encouraged to take over responsibility as acting surgeons [42–44], which is different from the students’ role as passive observers, e.g. in the ‘‘Theatrum anatomicum’’ concept with clinicians [45]. Students are presented a variety of surgical exposures to choose from, with the pros and cons of each of the exposures discussed in depth. Doing so helps enhance students’ knowledge of the site of surgery [46] and to gain an appreciation for a minimally invasive and tissue preserving approach. The subvastus approach may be regarded as one illustrative example of the 2014 workshop in this context. Though this approach is one of the least invasive ones in knee arthroplasty, it has certain limitations in contractures and varus deformities [47, 48]. Such deformity was presented by one of the donors used
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for the workshop, limiting the applicability of the subvastus approach (Fig. 2). Another aspect is the relatively short amount of time the students were given to complete each of the surgical exposures. This lack of time helped create a realistic atmosphere well known from the surgical ward, where time constraints are second only to patient safety [49]. Though the time issue was remarked critically by some of the students (Table 3), it may offer a straightforward and transparent glance into surgical everyday work [14]. In recent years, there has been an alarming decrease in applications to surgery especially in Germany [1, 2, 4, 5, 7, 41, 50–52] in spite of an increasing need for surgeons in future [1, 25]. Anatomy is a key subject in medical training [14, 15] and its impact is most evident especially in the surgical disciplines [13, 42, 53]. However, anatomy course contact hours have been consistently decreasing over the last decades [9]. Declining numbers of applications in surgery may be related to the decreasing emphasis of anatomy in the preclinical curriculum [10]. Though causation between decreasing anatomy contact hours and declining applicant numbers to surgery is most hypothetical, the majority of the teachers believe that surgery should play a greater role in undergraduate medical education [3, 4, 20, 21, 24, 46, 54] and the majority of the students would prefer to revisit dissection in a clinical context [10, 11, 37]. The survey data on our surgical exposures workshop confirm this standpoint. Students rated the surgical exposures workshop as highly relevant for a potential later career in the field of orthopedic or trauma surgery (Fig. 3). Furthermore, the students expressed their enthusiasm about the peer concept, consisting of anatomists and surgeons acting as a well-integrated team. The students reported that this approach created a great atmosphere for the students (Fig. 3; Table 3) and for the teaching staff. Highly qualified demonstrators, preferably from the respective medical field, have been shown to be more efficient than inexperienced or exclusively theoretical medical educators [53, 55]. Also, the peer concept proved to be highly efficient in our workshop (Fig. 3; Table 3) and elsewhere [4, 20, 21, 56, 57]. Another important aspect that needs to be taken into account is the skeptical stance of students toward the occupational image of surgeons. A majority of students consider surgeons as unapproachable [58]. Surgeons becoming part of the preclinical education may aid to resolve this issue [20–22, 44]. We expressively address the image of the surgeon as part of the teaching philosophy to the effect that all of the surveyed students rated the way the peer team answered their questions excellently and without exception (Fig. 3d). None of the students found the workshop to be too advanced, which might be related to the role of the anatomist in continuously connecting the mostly
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theoretical knowledge to the new clinically relevant information from the surgeon. The AOTrauma (AO Foundation, Davos, Switzerland) or Swemac Education (Swemac Orthopaedics, Linko¨ping, Sweden) offers similar surgical exposures workshops for clinical residents at prices of 1000 € (1400 US$) [59, 60]. These courses are mostly sponsored by the medical industry and specifically address colleagues that have already decided to work as surgeons. In contrast, we aim at getting young medical students interested in surgery. We provide the given workshop without any additional costs for the students, using Thiel-embalmed body donors with lifelike visual and haptic properties [32, 34]. Doing so was only possible with the support of medical product manufacturers that provided all necessary instruments and with the help of the Institute of Anatomy that provided the Thiel-embalmed donors as a surplus from previous workshops in anatomy provided for clinicians [34]. Consequently, the students commented on the relatively large group size and on the limited number of body donors (Fig. 3; Table 3). Though this criticism is valid, larger numbers of donors would necessarily involve high costs for the students or the faculty [34], which was not acceptable to the authors. As compared to the gross anatomy course presented in this study, the surgical exposures workshop was evaluated as better with the only exception of the impact on students’ later career and time issues. The workshop was rated as significantly better regarding the general evaluation, time spent by the teaching staff, clinical relevance, the way questions were addressed and the working atmosphere. These differences may likely be explained by the interdisciplinary approach and by the high faculty to student ratio in the surgical exposures workshop. The aim of this comparison was not, however, to show the superiority of one class over the other. Instead, the surgical exposures workshop serves as a repetition of clinically relevant anatomy on basis of the gross anatomy course, providing students with skills necessary for competent clinical practice [11, 23]. Another field of application of the course concept would be the use as a selection tool for future trainees who consider pursuing a career in surgery. Vice versa, the ‘‘Surgical exposures’’ concept could potentially be applied for assessing the technical skills of trainees or trainee applicants, as proposed by Martin et al. [61] and Van Hove and coworkers [62]. Furthermore, the concept may help enhance skills of candidates seeking for higher surgical training [63, 64]. The given study has a couple of limitations. First, the surgical approaches workshop was an elective course, whereas the gross anatomy course is mandatory for medical students. Therefore, the main participants of this elective course likely already have an interest and inclination to
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pursue a surgical career. Second, long-term data of our teaching concept are pending. Follow-up data of the preliminary results presented here will help determine the efficiency of this workshop to interest medical students to start their career in surgery.
Summary and outlook The surgical exposures workshop provides preclinical undergraduate students with clinically relevant anatomy and manual dexterity. The course concept combined clear and achievable learning objectives taught in an efficient way with relevant clinical correlates [23, 35]. Overall students’ rating was excellent with the exception of group size and practicing time. The course requires extensive teaching time and resources. Though the results of this study are preliminary, they clearly show that full-scale integration of surgical skills is possible in the preclinical curriculum, offering enjoyable anatomy in a surgical context. Further research is necessary to evaluate the effectiveness of anatomy and surgery taught as fellow disciplines. Acknowledgments The authors would like to thank Christine Auste for taking the pictures of the workshop. Matthias Henze helped with the student survey. Robert Mo¨bius performed the statistics. Gustav F. Preller proofread the paper as a native speaker. Conflict of interest
None.
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49.
50.
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52.
53.
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ORTHOPAEDIC SURGERY
Teaching surgical exposures to undergraduate medical students: an integration concept for anatomical and surgical education Niels Hammer1 • Pierre Hepp2 • Sabine Lo¨ffler1 • Stefan Schleifenbaum2 Hanno Steinke1 • Stefan Klima2
•
Received: 30 October 2014 / Published online: 21 April 2015 Springer-Verlag Berlin Heidelberg 2015
Abstract Background Decreasing numbers of students are interested in starting a surgical career, posing substantial challenges to patient care in the next years. The anatomy course is one of the key subjects in medical training, especially in surgical disciplines. Innovative teaching concepts that integrate surgically relevant anatomy and manual dexterity might help boost student interest in surgery. Methods A preclinical workshop entitled ‘‘Surgical exposures’’ was developed. A team of anatomists and surgeons introduced the surgical exposures, demonstrating the procedures on Thiel-fixed body donors. Following this introduction, students practiced the exposures in an operating room-like manner. A six-point Likert scale was used to evaluate the workshop and to compare it to the first-year dissection course. Results The overall evaluation result for the surgical exposures was excellent, proving to be a significantly better result when compared to the first-year dissection course. The students were more satisfied with the teaching time invested by the peers and regarded the workshop as clinically highly relevant. Furthermore, they felt that questions were addressed better and that the overall atmosphere was better than in the gross anatomy course. Electronic supplementary material The online version of this article (doi:10.1007/s00402-015-2217-7) contains supplementary material, which is available to authorized users. & Niels Hammer [email protected] 1
Institute of Anatomy, University of Leipzig, Liebigstraße 13, 04103 Leipzig, Germany
2
Department of Orthopedic, Trauma and Reconstructive Surgery, University Clinic of Leipzig, Leipzig, Germany
Subject to criticism was the course size and practicing time in both cases. Discussion The surgical exposures workshop provides preclinical students with clinically relevant anatomy and manual dexterity. It may positively influence the decision to follow a surgical career. This course, however, requires extensive teaching resources. The given concept may help implement practical medical skills in the preclinical curriculum, strengthening the professional identity of surgeons and anatomists. Keywords Gross anatomy education Medical education German anatomy curriculum Surgical approach Orthopedic and trauma surgery Preclinical anatomy workshop Surgical exposure
Introduction Decreasing numbers of students are interested in starting a surgical career, posing substantial challenges to patient care in the next years in Germany [1, 2] and elsewhere in the western world [3–6]. The reasons for this inclining number are presumably the traditional role models of surgeons [7], changes in students’ attitudes regarding a worklife balance [1, 2, 7] or ‘‘poor lifestyle’’ [8]—and decreasing contact hours in the gross anatomy laboratory [9–11]. Students feel inadequately prepared to safely perform in clinical practice, particularly in surgery [10–12]. Clinicians akin feel that students’ limited exposure to anatomy causes a lack of knowledge in their future colleagues [12–14]. Though anatomy is considered one of the key subjects in medical training [14, 15], the dissection course is subject to on-going discussions regarding its suitability as part of the
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preclinical curriculum [13, 16–18]. Both surgeons and anatomists consider the gross anatomy course to be an unrecognized force in the decision making of medical students’ later field of expertise [3, 10, 19]. Innovative teaching concepts that integrate surgically relevant anatomy and surgical dexterity might therefore help to enhance students’ interest in surgery [10, 20–23]. Vice versa, concepts implementing practical medical skills in the preclinical curriculum may help to strengthen the professional identity of surgeons and anatomists, combining academic surgery and with clinically relevant anatomy [4, 20, 21, 24]. Taking into account this complex conviction especially in the German speaking countries, we established a workshop on surgical exposures in orthopedic and trauma surgery in the preclinical curriculum. The following objectives were defined for the workshop: To provide clinically relevant anatomy and manual skills from everyday situations in surgery to preclinical medical students: 1. 2.
To use and combine the strengths of anatomy and surgery in a teaching setting. To further increase the interest of students who consider starting a career in orthopedic and trauma surgery, and to potentially support their decision making to become or not to become a surgeon.
We describe our preliminary experiences in this workshop held to second-year undergraduate medical students and compare students’ survey data to the gross anatomy course held with first-year students.
Materials and methods Workshop design The surgical exposures workshop is offered as a compulsory elective subject. It consists of four teaching sessions in weekly intervals. A fifth session is used for a written examination, consisting of 30 multiple-choice questions. Two peers hold each of the courses, one anatomist and one trauma or orthopedic surgeon. Each of the teaching sessions takes place in a gross anatomy environment and consists of eight academic hours. The theory applying to the respective anatomical region and the surgical procedure are introduced in the first 3 h, followed by 5 h of surgical training. The theoretical part consists of on-screen presentations, videos, enhanced by subject literature [25–27], thin sliced specimens of the respective anatomical region [28, 29] and presected ethanol–glycerin-fixed specimens from the Institute of Anatomy, University of Leipzig
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[30, 31]. Three body donors are usually utilized to practice the surgical exposures of major anatomical regions in a freely selectable sequence: Session 1: shoulder and proximal humerus. Session 2: pelvis and hip joint (Fig. 1; Supplement figure 1). Session 3: spine. Session 4: femoral shaft (Supplement figure 2), knee joint (Supplement figure 3), proximal tibia and ankle. The donors are embalmed with the Thiel solution [32, 33] according to our house protocol [34]. The absence of any surgical implants in the regions of interest of the donors prior to the workshop is strongly recommended. Two of the three donors are used simultaneously in each of the sessions. The body donors are placed in an operating room-like manner, i.e. in a beach chair position in case of the shoulder exposures or in a lumbar kyphosis in case of lumbar spine exposures. Full surgery room equipment is provided by the Department of Orthopedics, Trauma and Reconstructive Surgery, University Clinic of Leipzig and by medical equipment manufacturers, including lighting, draping, instruments and implants. Each of the exposures is conducted by one or several students, guided by an experienced clinician in a manner as done in routine surgery. Time-consuming and complex exposures are presected in one of the body donors [35] for demonstration purposes prior to the course by the anatomist and surgeon and conducted again in another donor during the respective session by the students. If necessary, major landmarks, nerves and vessels that are most likely to become damaged are marked with surgical threads and fixing clamps. More details on the most commonly taught exposures can be found in Table 1. Estimated costs for the Thiel-fixed donors are 4000 € each, accounting for 540–600 € per student, provided by the Institute of Anatomy, University of Leipzig, Germany. The teaching philosophy is as follows: 1.
2. 3. 4.
5.
The anatomist and the surgeon demonstrate and teach simultaneously in parallel and as a well-integrated team, not successively. Lectures are held without fixed speaking times in a conversation-like manner. Students are regarded as young colleagues and discussions/explanations are always held on eye level. Students are engaged to interact and inquire as often as possible in the theory sessions and to act as surgeons in the practical sessions, supported by the peers from anatomy and surgery (Fig. 2) [36]. Mistakes during surgical training are tolerated explicitly but discussed subsequently, as known from pilot training using flight simulators [37, 38].
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Fig. 1 Ilio-inguinal [Letournel] exposure (85-year-old male donor). a The surgical site is shown with a skin incision ranging from the iliac crest (IC) to the pubic symphysis (PS). b The next step shows the surgical preparation of the external oblique muscle (EO) with its fascia before exploring the inguinal canal. c An islet of abdominal wall muscles consisting of internal (IO) and external oblique muscle attachments is tunneled manually. All structures passing below this islet, continuing to the muscular and vascular lacuna, are tunneled. The spermatic funiculus (FS) is retracted. cd caudal, cr cranial, l lateral, m medial
Table 1 List of surgical exposures demonstrated to and practiced by the students
Session
Anatomical region
Name of exposure
Presected
1
Shoulder and arm
Anterior approach to the clavicle
•
Delta split
•
Pelvis
Trans delta Ilio-inguinal (Letournel)
• 4
Stoppa
4
Hip joint
Extended anterior (Smith-Petersen)
4
Anterolateral (Watson-Jones)
4
Lateral transgluteal (Bauer, Hardinge)
4
Posterior (Kocher–Langenbeck)
4
Dorsal paraspinal (thoracolumbar spine)
•
Dorsal posterolateral (thoracal spine)
•
2
3
Spine
Anterior retroperitoneal approach (lumbar spine) 4
Posterior approach to lumbar spine
•
Femur shaft
Lateral access
•
Knee joint
Medial parapatellar approach
4
Midvastus approach
4
Subvastus approach
4
Anterolateral approach to the tibial plateau Posteromedial approach
4 4
Posterolateral approach
4
Lateral head of the tibia Ankle
Study setting and participants Twenty-two preclinical students were enrolled in the course of 2014, held in January and February. Informed consent was ratified from all students. An anonymized,
paper-based and voluntary survey consisting of 14 items (six-point Likert scale; 1 = I strongly agree/excellent/grade ‘‘A’’, 6 = I strongly disagree/failure/grade ‘‘F’’) was handed out at the end of session 4. The students were asked on the workshop design, how they believe the
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Fig. 2 Students practicing surgical exposures to the knee joint (84year-old female donor), guided by a peer team an anatomist and clinician
acquired knowledge will integrate in their future practice as medical doctors. The questions are given in Table 2. The students were asked to return the completed survey on the examination day after the multiple-choice examination to circumvent any biasing related to the examination or Hawthorne effects [39]. The results of this survey were compared to the data of the 2013 gross anatomy course, consisting of 346 undergraduate first-year students and a 12-item Likert scale. For statistical comparison of the survey data, SPSS version 20.0 (IVM Corp., Armonk, NY, USA) was used. Student’s t test was applied to compare the survey data. P values of 0.05 or less were considered as statistically significant.
Results Three Thiel-embalmed body donors were provided by the Institute of Anatomy, University of Leipzig for the preclinical surgical exposures workshop in January and February 2014, one female (84-year-old) and two males (75 and 85-year-old). The exposures demonstrated to and practiced by the students are given in Table 1. The faculty–student ratio was 2/22 (including the anatomist and the surgeon) and the male–female ratio was 10/12 in the surgical exposures workshop. In the gross anatomy course, the staff–student ratio was 1/22 (excluding Table 2 Baseline data including the staff–student ratio, the male–female ratio and student time required for preparing the course
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student assistants) and the male–female ratio was 58/101 (Table 2). Overall course time was 30 h for the workshop. Overall preparation and follow-up working time of one workshop accounts for 60, 40 and 30 h for the anatomist, the surgeon and the technical staff, respectively. The survey was returned by 91 % of the students (20/22) attending the surgical exposures workshop and by 45 % (159/346) of the students attending the gross anatomy course. Student preparation time was significantly shorter in case of the surgical exposures workshop than for the gross anatomy course (p \ 0.001; Table 2). The overall evaluations of the courses were ‘‘good’’ (1.6 ± 0.7) for the gross anatomy course and ‘‘excellent’’ (1.2 ± 0.4) for the surgical exposures workshop (Fig. 3a). Students were significantly more sufficed by the teaching time invested by the staff in the surgical exposures workshop (Fig. 3b) and they evaluated the clinical relevance of the surgical exposures to be significantly higher than the clinical relevance of the gross anatomy course (Fig. 3c). Applying the peer concept answer to students’ questions was rated as significantly better (1.0 ± 0.0, ‘‘excellent’’) than in the standard gross anatomy setting (1.6 ± 1.0, ‘‘good’’). The working atmosphere was evaluated as better in the surgical approaches workshop than in the gross anatomy course (Fig. 3d). The students felt that their learning achievements and in-depth knowledge after the course were ‘‘excellent’’ in both courses (Fig. 3e). The group size of the classes was evaluated as ‘‘satisfactory’’ in both courses and clearly a subject to criticism in both settings (Fig. 3b). A majority of the students felt that the group size should be smaller and that longer training times would increase their learning achievements (Table 3). Further student suggestions included providing live video transmissions from the surgery ward to the dissection room. In their free text responses the students emphasized that their interest to become a surgeon was raised by the surgical exposures workshop and that peer team of anatomists and surgeons contributed to the positive atmosphere of the class (Fig. 4).
Discussion The gross anatomy course may be regarded as the closest discipline to surgery in the preclinical curriculum. Shared values of anatomy and surgery go far beyond the use of scalpels and tweezers or topographical knowledge of the
Ratio Faculty/student
Preparation time (min) Male/female
\30
30–59
60–120
p value [120
Surgical exposures
2/22
10/12
5
15
–
–
Gross anatomy
1/22–1/20
58/101
4
10
10
135
\0.001
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Fig. 3 Summary and statistical comparison of the student survey from the surgical exposures workshop and the gross anatomy class. a General evaluation; b organization; c structuring; d practical part; e class benefit
site of intervention. The key to success in both disciplines is the ability to work in an interdisciplinary team [40]. Our workshop entitled ‘‘Surgical exposures’’ explicitly addresses this role of gross anatomy and promotes surgically relevant anatomy to second-year students in order to
increase their interest in orthopedic and trauma surgery. This workshop aimed at promoting students’ interest in surgery at a very early stage of their career in medicine based on personal experiences [3, 19]. We have started offering the workshop on surgical exposures in 2011.
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800 Table 3 Quotations from representative free text responses Quotations from representative free text responses Pros ‘‘I felt like a surgeon’’ ‘‘Nice workshop that raised my interest to become a surgeon’’ ‘‘The clinical relevance of anatomy was clearly emphasized’’ ‘‘Clinically relevant depth anatomy beyond standard student knowledge’’ ‘‘Highly motivated team of anatomists and clinicians, answering all questions in a great atmosphere’’ ‘‘Best workshop of the preclinical curriculum’’ Cons ‘‘A video transmission of real-live surgery would be desirable’’ ‘‘More specimens and longer training times would be great’’ ‘‘The group size was too large’’
Fig. 4 Grades of the lectures held by the anatomist and clinicians
Similar approaches to enhance students’ interest in surgery were recently demonstrated by Allen et al. [6] and Haggerty and coworkers [41]. In the surgical exposures workshop, students are encouraged to take over responsibility as acting surgeons [42–44], which is different from the students’ role as passive observers, e.g. in the ‘‘Theatrum anatomicum’’ concept with clinicians [45]. Students are presented a variety of surgical exposures to choose from, with the pros and cons of each of the exposures discussed in depth. Doing so helps enhance students’ knowledge of the site of surgery [46] and to gain an appreciation for a minimally invasive and tissue preserving approach. The subvastus approach may be regarded as one illustrative example of the 2014 workshop in this context. Though this approach is one of the least invasive ones in knee arthroplasty, it has certain limitations in contractures and varus deformities [47, 48]. Such deformity was presented by one of the donors used
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for the workshop, limiting the applicability of the subvastus approach (Fig. 2). Another aspect is the relatively short amount of time the students were given to complete each of the surgical exposures. This lack of time helped create a realistic atmosphere well known from the surgical ward, where time constraints are second only to patient safety [49]. Though the time issue was remarked critically by some of the students (Table 3), it may offer a straightforward and transparent glance into surgical everyday work [14]. In recent years, there has been an alarming decrease in applications to surgery especially in Germany [1, 2, 4, 5, 7, 41, 50–52] in spite of an increasing need for surgeons in future [1, 25]. Anatomy is a key subject in medical training [14, 15] and its impact is most evident especially in the surgical disciplines [13, 42, 53]. However, anatomy course contact hours have been consistently decreasing over the last decades [9]. Declining numbers of applications in surgery may be related to the decreasing emphasis of anatomy in the preclinical curriculum [10]. Though causation between decreasing anatomy contact hours and declining applicant numbers to surgery is most hypothetical, the majority of the teachers believe that surgery should play a greater role in undergraduate medical education [3, 4, 20, 21, 24, 46, 54] and the majority of the students would prefer to revisit dissection in a clinical context [10, 11, 37]. The survey data on our surgical exposures workshop confirm this standpoint. Students rated the surgical exposures workshop as highly relevant for a potential later career in the field of orthopedic or trauma surgery (Fig. 3). Furthermore, the students expressed their enthusiasm about the peer concept, consisting of anatomists and surgeons acting as a well-integrated team. The students reported that this approach created a great atmosphere for the students (Fig. 3; Table 3) and for the teaching staff. Highly qualified demonstrators, preferably from the respective medical field, have been shown to be more efficient than inexperienced or exclusively theoretical medical educators [53, 55]. Also, the peer concept proved to be highly efficient in our workshop (Fig. 3; Table 3) and elsewhere [4, 20, 21, 56, 57]. Another important aspect that needs to be taken into account is the skeptical stance of students toward the occupational image of surgeons. A majority of students consider surgeons as unapproachable [58]. Surgeons becoming part of the preclinical education may aid to resolve this issue [20–22, 44]. We expressively address the image of the surgeon as part of the teaching philosophy to the effect that all of the surveyed students rated the way the peer team answered their questions excellently and without exception (Fig. 3d). None of the students found the workshop to be too advanced, which might be related to the role of the anatomist in continuously connecting the mostly
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theoretical knowledge to the new clinically relevant information from the surgeon. The AOTrauma (AO Foundation, Davos, Switzerland) or Swemac Education (Swemac Orthopaedics, Linko¨ping, Sweden) offers similar surgical exposures workshops for clinical residents at prices of 1000 € (1400 US$) [59, 60]. These courses are mostly sponsored by the medical industry and specifically address colleagues that have already decided to work as surgeons. In contrast, we aim at getting young medical students interested in surgery. We provide the given workshop without any additional costs for the students, using Thiel-embalmed body donors with lifelike visual and haptic properties [32, 34]. Doing so was only possible with the support of medical product manufacturers that provided all necessary instruments and with the help of the Institute of Anatomy that provided the Thiel-embalmed donors as a surplus from previous workshops in anatomy provided for clinicians [34]. Consequently, the students commented on the relatively large group size and on the limited number of body donors (Fig. 3; Table 3). Though this criticism is valid, larger numbers of donors would necessarily involve high costs for the students or the faculty [34], which was not acceptable to the authors. As compared to the gross anatomy course presented in this study, the surgical exposures workshop was evaluated as better with the only exception of the impact on students’ later career and time issues. The workshop was rated as significantly better regarding the general evaluation, time spent by the teaching staff, clinical relevance, the way questions were addressed and the working atmosphere. These differences may likely be explained by the interdisciplinary approach and by the high faculty to student ratio in the surgical exposures workshop. The aim of this comparison was not, however, to show the superiority of one class over the other. Instead, the surgical exposures workshop serves as a repetition of clinically relevant anatomy on basis of the gross anatomy course, providing students with skills necessary for competent clinical practice [11, 23]. Another field of application of the course concept would be the use as a selection tool for future trainees who consider pursuing a career in surgery. Vice versa, the ‘‘Surgical exposures’’ concept could potentially be applied for assessing the technical skills of trainees or trainee applicants, as proposed by Martin et al. [61] and Van Hove and coworkers [62]. Furthermore, the concept may help enhance skills of candidates seeking for higher surgical training [63, 64]. The given study has a couple of limitations. First, the surgical approaches workshop was an elective course, whereas the gross anatomy course is mandatory for medical students. Therefore, the main participants of this elective course likely already have an interest and inclination to
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pursue a surgical career. Second, long-term data of our teaching concept are pending. Follow-up data of the preliminary results presented here will help determine the efficiency of this workshop to interest medical students to start their career in surgery.
Summary and outlook The surgical exposures workshop provides preclinical undergraduate students with clinically relevant anatomy and manual dexterity. The course concept combined clear and achievable learning objectives taught in an efficient way with relevant clinical correlates [23, 35]. Overall students’ rating was excellent with the exception of group size and practicing time. The course requires extensive teaching time and resources. Though the results of this study are preliminary, they clearly show that full-scale integration of surgical skills is possible in the preclinical curriculum, offering enjoyable anatomy in a surgical context. Further research is necessary to evaluate the effectiveness of anatomy and surgery taught as fellow disciplines. Acknowledgments The authors would like to thank Christine Auste for taking the pictures of the workshop. Matthias Henze helped with the student survey. Robert Mo¨bius performed the statistics. Gustav F. Preller proofread the paper as a native speaker. Conflict of interest
None.
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