The rationale for combining an online audiovisual curriculum with simulation to better educate general surgery trainees Yazan N. AlJamal, MBBS, Shahzad M. Ali, MD, Raaj K. Ruparel, MD, Rushin D. Brahmbhatt, MD, Siddhant Yadav, MD, and David R. Farley, MD, FACS, Rochester, MN

Background. Surgery interns’ training has historically been weighted toward patient care, operative observation, and sleeping when possible. With more protected free time and less clinical time, real educational hours for trainees in 2013 are precious. Methods. We created a 20-session (3 hours each) simulation curriculum (with pre- and post-tests) and a 24/7 online audiovisual (AV) curriculum for surgery interns. Friday morning simulation sessions emphasize operative skills and judgment. AV clips (using operating room, whiteboard, and simulation center videos) take learners through 20 different general surgery operations with follow-up quizzes. We report our early experience with this novel setup. Results. Thirty-two surgical interns (2012–2013) attended simulation sessions on 20 separate subjects (hernia, breast, hepatobiliary, endocrine, etc). Post-test scores improved (P < .05) and trainees enjoyed using surgical skills for 3 hours each Friday morning (mean, >4.5; Likert scale, 1–5). The AV curriculum feedback is similar (mean, >4.3) and usage is available 24/7 preparing learners for both operating room and simulation sessions. Most simulation sessions utilize low-fidelity models to keep costs 20 separate sessions within the framework of an overall general surgery education program. Over the past year, an AV curriculum was developed by coupling short, YouTube-type video clips via whiteboard drawings and explanations with actual intraoperative video of operative procedures. Sequential clips (30–90 seconds each) take the learner through one operative procedure in 15– 25 minutes. These online modules are available 24/7 and surgical interns were encouraged to use them and the online quizzes after each module in preparation for our Friday morning simulation sessions. General surgery interns were tested for baseline skills and knowledge via our Surgical Olympics in July of 2012 and then again in January of 2013 to assess for improvement. Additionally, interns completed weekly pre- and post-tests on all simulation sessions they attended. Interns were confidentially surveyed on their assessment and opinions of both the online AV curriculum and the Friday morning simulation sessions. Continuous features were summarized with means, standard deviations (SDs), median values, and ranges; categorical features were summarized with frequency counts and percentages. Statistical analyses were performed using the SAS software package (SAS Institute, Cary, NC). All tests were 2-sided.

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RESULTS All 32 surgical interns actively participated in our surgical curriculum. Pre- and post-test results of 32 interns participating in the Friday morning simulation sessions confirm an improvement in testing scores with each session (Fig 1; P < .05). Surgical Olympics scores increased for all 31 trainees participating in both the July (2012) and January (2013) events. Overall mean scores improved from July (49.6) to January (82.9; P < .05) with 9 trainees more than doubling their initial scores. Individual usage of the online AV curriculum varied among interns (mean, 42 hours per learner; range, 0–153) using the site. A total of 2,910 hours of video and quiz time was captured over 8 months with categorical general surgery interns being the greatest users (Fig 2). Usage of video occurred more frequently on weekdays. Survey results suggest that interns enjoyed and found useful the Friday morning simulation sessions (Fig 3) and preferred the hands-on sessions over didactic lectures provided elsewhere within our training program. The cost of simulation models for trainees to work on as a group (3 simulation scenarios per each Friday morning session) and individually (after debriefing and instruction) was low: Pancreaticojejunal anastomosis, mastectomy closure, mesenteric repair, fascial closure, and melanoma resection models cost 20,000 hours of patient contact, work, and operative learning (5 years 3 49 weeks/ year 3 ;100 hours/week = 24,500 hours). Using a maximum of 80 hours per week, interns this year can plan to log 19,600 hours of educational and working time in their 5 years of training. Although mastering pancreatic operations, counseling breast cancer patients, and running a trauma code require more varied skills and knowledge than playing the piano, some 19,000 hours should be sufficient to train general surgeons---if they obtain the needed repetitions. Our Friday morning simulation sessions offered interns hundreds of repetitions on cutting, sewing, tying, and judging the appropriate course of patient care in an intense setting working both within groups and individually. Feedback from surgical staff, a simulation fellow, and 2 simulation researchers was continuous throughout each session. Deliberate practice in this setting was fun based on our survey feedback and useful based on post-test data and Surgical Olympics improvement. Millennial learners. The rationale for combining online learning with efficient simulation education seems logical to us: Millennial learners enjoy and use online learning resources well, they work and learn better in groups, adults learn best using actual skills they will need to perform, and hands-on strategies plant knowledge

AV Curriculum Usage by Day 700 Total Hours 7/2012-3/2013

Hernia

600 500 400 300 200 100 0 S

M

T

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Th

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Fig 2. Resident usage of online general surgery audiovisual curriculum.

and information into long-term memory more effectively.7,8 Modern simulation resources allow a better method to deliver repetitions without practicing on a human being, and the internet can offer basic knowledge anytime to Generation Y learners who have grown up accustomed to both. Indeed, preemptive learning online may potentially cheat the 10,000 hours we need to become expert.9 Online learning has exploded over the past 2 decades. Success stories such as the Khan Academy, the University of Phoenix, and free college courses offered by Stanford, Harvard, MIT, and others suggest that this novel approach is not only accepted by modern learners, but actually preferred.10-12 Having a library of engaging learning modules available (24/7) for duty-hour–restricted trainees is common sense. Indeed, if basic and advanced learning can be achieved voluntarily on the surgical residents’ own time, then the 1970s training model of retracting for 50 open cholecystectomies before performing 100 cholecystectomies may be converted to an abbreviated version: Watching operations online, complete engaging online modules and quizzes to 100% accuracy, practice in the simulation center with feedback and assessment, observe several real operations, and then be proctored in and proceed to perform 50 cholecystectomies. Might that allow

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AV Curriculum Survey 5

Mean Likert Scores

4.5 4 3.5 3 2.5 2 1.5 1 Operave Steps

Knowledge

Preparedness for OR

Simulaon Session Survey 5

Mean Likert Scores

4.5 4 3.5 3 2.5 2

1.5 1 Hernia

Endocrine

Breast

Bowel

Fig 3. Survey results of confidential feedback from surgery interns.

the 2013 trainee to be just as good as the 1975 resident in less time? Although our recent study of simulation and practice before total extraperitoneal approach inguinal hernia repairs showed improved resident operating room performance and better patient outcomes,13 the data in this study confirm that interns improved their knottying, central line placement, fascial closure, and other skills within make-believe, low-fidelity surgery. We need to prove that simulation, practice, and online learning do assist in better intraoperative judgment and skills and does so in less time than traditional methods. Our surgical trainees used the online AV curriculum more than we expected. With one staff surgeon (D.R.F.) mandating his residents achieve a 100% score on the online quizzes before scrubbing in on real operative procedures, perhaps we underestimated the commitment millennials have to achieving set objectives. Categorical general surgery interns spend 4 weeks with this attending and usage of ;150 hours of video learning is impressive in preparation for operative procedures. Others have shown that engaging online learning is effective.14 Based on this utilization, we are embarking on making video clips that teach and prepare learners before their Friday morning simulation sessions, let alone more clips before they head to the operating room.

Patient care models versus best teaching practices. The cost of caring for patients and the diminishing reimbursement crystalize the importance that training in surgery must be streamlined and become less expensive. We have emphasized to our learners that better preparation before working in the operating room, intensive care unit, emergency room, clinic, or on hospital floors is mandatory to gain the maximum benefit of a surgical residency. Although outpatient operations and shorter stay hospitalizations help institutions’ bottom line, it lessens our trainees’ exposure to real patients with real problems. Patient care, communication skills, and systems-based practice experience are lessened. Simulation efforts with standardized patients, mannequins that talk, blink, and interact combined with online learning showing right and wrong strategies to care for and interact with patients are logical efforts to replace the lost repetitions. Educators must adapt to the changing paradigm of patient care; physician assistants and nurse practitioners facilitate streamlined patient care with less cost in our institution, but surgery residents will find themselves on the outside looking in if program directors and staff do not insist on better models of surgical education. Innovative strategies that combine resident time to care for actual patients along with a commitment for protected time for trainees and staff to educate in a controlled environment are needed. A 10% time commitment for 1 staff member (D.R.F.) paid for by the Department of Surgery and an additional 10% slot covered by our Simulation Center budget shows the importance of this effort in our institution; added physician assistants and nurse practitioners to alleviate service burdens and allow mandatory attendance for interns has been backed by our general surgery program director and department chair for this project (as well as to meet duty-hour regulations). These ‘‘hidden costs’’ of education are immense. Sharing resources between teaching institutions and maximizing the efficiency of online learning may be ways to combat the high costs of training surgeons. Simulation and preemptive learning. Using simulation with low cost modules within a surgical curriculum has been shown to work.15-17 Evidence suggests that learning within a system of simulation that utilizes an intense, short experience (;12 minutes) with a longer debriefing/question and answer session (;40 minutes) achieves greater long-term recall and knowledge that a learner can actively use.18-20 It seems realistic that three 50minute simulation sessions within a 3-hour period

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offer more educational potential and benefit than holding a retractor for 3 hours during an elective abdominal aortic aneurysm repair. Clearly, young surgeons in training need a variety of experiences from which to draw on as they mature into competent surgeons. But in a duty-hour–restricted world, time efficiency must be maximized and the time honored method of see one, do one, teach one may be irrelevant. If real-life repetitions are limited, then being better prepared for those experiences is crucial to getting more out of each teachable moment. Self-directed learning online, at home on a box trainer, or within a group at a formal simulation session may win back more than the sleep-deprived hours lost in house---it may very well be a better way to learn. Our most energetic and committed learners doubled their scores on the Surgical Olympics, whereas those with less AV curriculum time and poorer Friday morning attendance made only small gains. Not surprisingly, Ericsson’s thoughts on deliberate practice and feedback are always intertwined with the need for the learner to be motivated and driven to excel.5 Mastering surgery takes effort. Becoming a master surgeon is difficult, but Generation Y learners are willing to work to become ‘‘expert.’’ Their path to mastery is slightly different than a baby boomer’s: They want and need clear objectives, they desire ready access to information resources, and they want to practice and use skills immediately---all the while being provided feedback in group and individual settings to allow rapid progression through the curriculum.21 Our curriculum does provide this format, but our data have not determined whether this method is better or worse than other curricula. The onus is on educators to identify the ideal method to train young surgeons.22 Is simulation and online learning better than cadaveric sessions and reading? Or animal labs and journal club? Our own bias, given the paid for resources of a simulation center and 20% time for a single surgeon educator, is that online learning and simulation can be offered inexpensively and are excellent learning tools for Generation Y learners.23-25 Given the variety of individual learning preferences, one format will not fit all and real, live operating must remain the pinnacle of any surgery training program. Our future endeavors will involve more engaging online modules (interactive video sessions/games that mandate the learner demonstrates understanding of all concepts before the AV clips move forward to more learning

opportunities). Studies suggest that retention, pleasure, and desirability of such gaming sessions is far more acceptable to millennials than our basic AV modules.26 The simulation portion of our curriculum undergoes yearly modification, and additional sessions that advance knowledge and skill are being developed for our senior level trainees within a format of graded assessment and demonstration of competency. These so-called ‘‘X-Games’’ are competitive, not punitive, and have stimulated our learners to achieve better performance and has opened our eyes to weaknesses in our program’s educational system. An innovative curriculum using online learning and weekly simulation sessions seems to be wellaccepted by millennial surgery interns and inexpensively improves their knowledge and surgical skills. REFERENCES 1. Roberts DH, Newman LR, Schwartzstein RM. Twelve tips for facilitating millennials’ learning. Med Teach 2012;34:274-8. 2. Zendejas B, Cook DA, Farley DR. Teaching first or teaching last: does the timing matter in simulation-based surgical scenarios? J Surg Educ 2010;67:432-8. 3. Zendejas B, Cook DA, Hernandez-Irizarry R, Huebner M, Farley DR. Mastery learning simulation-based curriculum for laparoscopic TEP inguinal hernia repair. J Surg Educ 2012;69:208-14. 4. Eagle DM, Coltvet G, Farley DR. The Mayo Clinic Multidisciplinary Simulation Center. J Surg Educ 2010;67:470-2. 5. Ericsson KA. The acquisition of expert performance: an introduction to some of the issues. In: Ericsson KA, editor. The road to excellence: the acquisition of expert performance in the arts and sciences, sports, and games. Mahwah (NJ): Erlbaum; 1996. p. 1-50. 6. Kneebone RL. Practice, rehearsal, and performance: an approach for simulation-based surgical and procedure training. JAMA 2009;302:1336-8. 7. Philippe AC, Botchorishvili R, Pereira B, Canis M, Bourdel N, Mage G, et al. Interest of a structured laparoscopy training in a simulation center: survey of resident’s point of view. J Gynecol Obstet Biol Reprod (Paris) 2013;42: 238-45. 8. Fonseca AL, Evans LV, Gusberg RJ. Open surgical simulation in residency training: a review of its status and a case for its incorporation. J Surg Educ 2013;70:129-37. 9. Kerfoot BP, Baker H, Jackson TL, Hulbert WC, Federman DD, Oates RD, et al. A multi-institutional randomized controlled trial of adjuvant Web-based teaching to medical students. Acad Med 2006;81:224-30. 10. Rosser JC Jr, Lynch PJ, Cuddihy L, Gentile DA, Klonsky J, Merrell R. The impact of video games on training surgeons in the 21st century. Arch Surg 2007;142:181-6. 11. Lee JC, Boyd R, Stuart P. Randomized controlled trial of an instructional DVD for clinical skills teaching. Emerg Med Australas 2007;19:241-5. 12. Grover S, Currier PF, Elinoff JM, Katz JT, McMahon GT. Improving residents’ knowledge of arterial and central line placement with a web-based curriculum. J Grad Med Educ 2010;2:548-54.

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13. Zendejas B, Cook DA, Bingener J, Huebner M, Dunn WF, Sarr MG, et al. Simulation-based mastery learning improves patient outcomes in laparoscopic inguinal hernia repair. A randomized controlled trial. Ann Surg 2011;254:502-11. 14. Topps D, Helmer J, Ellaway R. YouTube as a platform for publishing clinical skills training videos. Acad Med 2013; 88:192-7. 15. Denadai R, Toledo AP, Martinhao Souto LR. Basic plastic surgery skills training program on inanimate bench models during medical graduation. Plast Surg Int 2012;2012:651863. 16. Friedman Z, Siddiqui N, Katznelson R, Devito I, Bould MD, Naik V. Clinical impact of epidural anesthesia simulation on short- and long-term learning curve. High- versus lowfidelity model training. Reg Anesth Pain Med 2009;34:229-32. 17. Chandra DB, Savoldelli GL, Joo HS, Weiss ID, Naik VN. Fiberoptic oral intubation. Anesthesiology 2008;109:1007-13. 18. Sturm LP, Windsor JA, Cosman PH, Cregan P, Hewett PJ, Maddern GJ. A systematic review of skills transfer after surgical simulation training. Ann Surg 2008;248:166-79. 19. Sutherland LM, Middleton PF, Anthony A, Hamdorf J, Cregan P, Scott D, et al. Surgical simulation. A systemic review. Ann Surg 2006;243:291-300.

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20. Kneebone R. Simulation in surgical training: educational issues and practical implications. Med Educ 2003;37:267-77. 21. Cook CB, Wilson RD, Hovan MJ, Hull BP, Gray RJ, Apsey HA. Development of computer-based training to enhance resident physician management of inpatient diabetes. J Diabetes Sci Technol 2009;3:1377-87. 22. Cook DA. If you teach them, they will learn: why medical education needs comparative effectiveness research. Adv in Health Sci Educ 2012;17:305-10. 23. Matheiken SJ, Verstegen D, Beard J, van der Vleuten C. E-learning resources for vascular surgeons: a needs analysis study. J Surg Educ 2012;69:477-82. 24. Cook DA. The research we still are not doing: an agenda for the study of computer-based learning. Acad Med 2005;80: 541-8. 25. Al-Kadi AS, Donnon T. Using simulation to improve the cognitive and psychomotor skills of novice students in advanced laparoscopic surgery: a meta-analysis. Med Teach 2013;35(Suppl 1):S47-55. 26. McGonigal J. Reality is broken: why games make us better and how they can change the world. New York: Penguin; 2011.

The rationale for combining an online audiovisual curriculum with simulation to better educate general surgery trainees.

Surgery interns' training has historically been weighted toward patient care, operative observation, and sleeping when possible. With more protected f...
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