gms | German Medical Science

The historic Theatrum Anatomicum was resurrected at the University of Ulm as a modern teaching tool for the 21st century. Today’s Theatrum Anatomicum with its high-quality technical equipment allows up to 200 people to experience and observe preparation and surgical procedures [1]. The Theatrum has become a meeting place, in particular for students in the preclinical stage of study and their clinical colleagues. Clinicians of different surgical disciplines serve as role models for allowing medical students to understand medicine and to get an introduction to their respective areas of study.

We have shown in the past that activities in the macroscopy course - especially dissection - impart medical professional skills such as teamwork [2]. The body donor can be viewed as the first patient of the future doctors early on in their studies [3]. This is a concept we have continued in the Theatrum Anatomicum by using the body donors in a simulated surgical setting for surgical intervention. The bodies have been embalmed using the Thiel technique [4] which ensures realistic preservation of the consistency and color of body tissues. The theatre thus offers possibilities for professionalization both for medical under and post-graduates. In parallel to the macroscopic anatomy course during the second year of training, behaviors and skill sets can be taught which are often underrepresented in the medical core curriculum. But these behaviors are often already expected in the first student clerkship, even though they are usually left to acquire these through random, non-standard process of learning by doing. For example, a needs analysis amongst students in the 7th semester in Ulm showed that up to 69.1% of respondents felt rather uncertain during their first visit to the OR. 17.1% of respondents had not yet learned how to carry out surgical hand disinfection. Only 35.8% of students at the time of their first OR assistance felt secure regarding compliance with the measures necessary to ensure sterility and 22.5% of them did not feel secure or probably even made themselves non-sterile (own unpublished data). This data is consistent with the data published by Hamdorf and Hall [5] and highlights the need for teaching basic surgical skills in a structured way before the first clerkship.

Anatomical and surgical teaching forms a synergistic interaction in the training of students and assistants and a good balance ultimately is in the best interests of patients. And in the worst case, a bad balance could lead to clinical malpractice [6]. In this process, dissection is a teaching method which imparts manual skills, anatomical variability and the anatomical vocabulary needed for clinical work [7], [8]. Both disciplines could benefit a lot more from each other though as the option to acquire practical skills is particularly attractive for students in their pre-clinical studies and therefore a promising motivator in the struggle to make students study even more. By bridging this gap, they gain deeper anatomical understanding [9] and their motivation for learning pre-clinical content increased [10], [11]. The surgeon in a way is the “icing on the cake” and brings the anatomical content to life [12]. In addition, students see medical skills such as teamwork in action in the surgical theatre. Not only students, but also surgical assistants have the opportunity to practice surgical techniques under ideal simulated conditions in anatomy, without time pressure and without bleeding and to experience and to understand possible errors in the dissection room rather than the operating theatre [12]. To meet the wishes of doctors in surgical professional development for improved training [13], surgical professional development in Switzerland is already being supported through exercises using bodies that have been embalmed using the Thiel technique [14], with benefits which are perceived as very high [15] and judged more effective in comparison to video presentations [16], [17]. Students have the opportunity to learn surgical skills in the pre-clinical phase of their studies [16], [18]. But so far there are only a few offers which are coordinated by surgeons and anatomists [9], [10], [12], [16], [19], [20]. Naylor and al. describe a current project which is integrated into the curriculum [18].

The effectiveness of simulation-based medical education is indisputable today, especially if it meets best practice requirements in planning and implementation [21], [22], [23]. Today it is virtually considered standard for a faculty to have a skills lab [22]. But the combination of anatomical education - in particular the use of bodies that have been embalmed using the Thiel technique - and simulation-based surgery with teaching of basic surgical skills is innovative and not integrated enough into the degree courses. The Institute of Anatomy and Cell Biology at the University of Ulm therefore for the first time developed and implemented an elective for 25 students of the third pre-clinical semester in the winter semester 2009/10, who were simultaneously participating in the macroscopic anatomy course. The aim was to transfer anatomical teaching to a clinically relevant surgical operational context to increase the motivation to learn and ideally to improve in the anatomical knowledge and test results through optimized learning strategies. In this article we would like to present the project “Ready for the OR” (FOP), the results of the acceptance evaluation, and to investigate the following questions as part of a pilot study and in comparison with a control group:

1.

Does participation in the FOP course have an effect on student motivation compared to students of a control group who attended only the macroscopic anatomy course?

2.

Does participation in the FOP course have a positive effect on the exam results achieved in the macroscopic anatomical course compared to students in the control group?

Project Presentation: "Ready for the OR" (FOP) is a bridge between pre-clinical and clinical surgical disciplines. Students are actively involved in the management of surgical demonstrations (OR demos). In preparation for surgery basic skills are taught with three to four learning goals defined for each, which are practiced during the teaching events and examined at the end of the course in an OSPE (Objectively Structured Practical Examination). The lessons took place in small groups (n=5) under the supervision of a student assistant each. During the OR demos, one group had the opportunity to assist the surgeon and even perform individual steps of the operation. The event included a total of 28 teaching units. The content of FOP is closely aligned with the course on macroscopic anatomy. This is divided into five units on the body sections of lower extremity/back, upper extremity/ventral body wall, situs, head/neck and central nervous system which are examined both orally and in writing. For each section, an OR demo which matched in content was offered. In preparation for working in the operating theatre, the students should be able to carry out surgical hand disinfection, sterile dressing, perform simple suturing and knotting techniques at the end of the course. Likewise they should be able to name common surgical instruments or be aware or able to prepare a patient for surgical intervention.

The project was staffed by anatomical staff, 5 student assistants with prior medical training and had the support of clinical colleagues in the accident, neurological, vascular/thorax and maxillo-facial surgery and anesthesiology (see Table 1 [Tab. 1]). From a group of 69 online applicants, 50 individuals (m=23/f=27) were randomly assigned to the FOP group (m=11/f=14) or the control group (m=12/f=13) and their written consent was obtained for participation in the study. The event was held in the Theatrum Anatomicum, which also has a master's workstation, and the adjacent surgeon’s prep room. The usual formalin-fixed bodies were not used for surgery, but donor bodies that have been embalmed using the Thiel technique [4]. This fixing process primarily uses boron and sodium sulfate salts, which preserve the tissue in its natural color and texture. Donor bodies, surgery equipment and sterile covering of the operation area produced a realistic surgical scenario (see Figure 1 [Fig. 1]). A script was produced to accompany the event. Each course date contained a chapter with historical background information, data and information on the surgery equipment was explained, presented and supplemented by handouts on the surgical step of the surgery demo. To check the acquired learned at the end of the semester, an OSPE was conducted consisting of 6 stations with 12 tasks. The evaluation was conducted by tutors using checklists. Through regular course participation and successful completion of the OSPE with at least 60% of the possible score, the participants received a certificate of participation.

The following instruments were used to evaluate the classes:

1.

The acceptance evaluation was paper-based, using the evaluation system (EvaSys) by Electric Papers at the end of the course and conducted by the Studies’ Office and electronically evaluated. The evaluation was conducted using a six-point scale (1 = unfavorable, 6 = favorable).

2.

In addition, questions designed by ourselves (internal questionnaire) were put to the students but also using the above scale to obtain detailed feedback on individual classes and the subjective assessment of the effect of this course by the students.

3.

To measure the outcomes of the learning objectives in the FOP, the results of the OSPE exam will be presented in the case group.

4.

To answer the above mentioned Question 2, the exam results of the FOP students on the macroscopic anatomy course were collected and compared with the results of the control group. For the oral and written examinations all students and examiners used the same learning target catalog.

5.

In order to objectify any effect of FOP on the motivation of the students (Question 1), a licensed version of the SELLMO ST motivation test for students was handed at the end of the course. SELLMO is a standardized reliable questionnaire test for detecting the learning and achievement motivation among students on four different scales [24]: “Learning objectives” scale (Cronbach's α=0.75), the “approach performance objectives” scale (α=0.82), the “avoidance performance objectives” scale (α=0.90) and the “work avoidance” scale (α=0.87). In total, SELLMO contains 31 Items. The “learning objectives” scale describes the goal of wanting to expand one’s own abilities. The “approach performance objectives” scale describes the goal of wanting to demonstrate one’s skills in front of others, a property associated with somewhat short-term learning success, but without ensuring adequate long-term learning success. The “avoidance performance objectives” scale describes the tendency to try to hide low skills or inability/ignorance due to previous negative experiences. A property associated with poor short and long-term benefits. The "work avoidance” behavior is not learning or performance motivated, i.e. the motivation to invest as little effort. This attitude has a particularly negative effect on interest and intrinsic motivation [24].

Statistical analysis was performed following manual data entry using a licensed version of SPSS 17.0 by SPSS Incorporation. Results are described through mean and standard deviation (SD). Significance was tested (p <0.05*, p<0.01**, p<0.001***) using the Mann-Whitney U-test for independent samples and not normally distributed data. The t-test was used if the Kolmogorov-Smirnov test demonstrated a normal data distribution. Correlation data was collected using the Pearson or Spearman test based on the distribution and scale of the data. The questionnaires used are included Appendices 1 [Attach. 1] and 2 [Attach. 2] ^{1, 2}.

The event was successfully implemented using manageable resources and one donated body. The participants on average were 21.3 years old. Except for 3, all participants were aiming for a career in surgery, of which 32% cited trauma surgery. All questionnaires were returned completed. 23 (92%) out of 25 students completed the FOP successfully.

In the overall assessment, the participants awarded an average point score of 5.4±0.7 out of a possible 6 points. Particularly high points were awarded to the fact the event promotes interest in the subject area (5.4±0.6) and high relevance to practical issues (5.9±0.3). In this the participants rated the fact that the tutor dealt with questions in depth as particularly positive (5.7±0.6). The opportunity to actively participate was awarded a score of 4.8±1.0. According to the students, the event encouraged them to think for themselves (5.0±0.8) and the participants had sufficient prior knowledge (5.4±0.7) to follow the content well. The following free response suitably rounds off the response picture: “[...] and of course, you truly understand why you study all that anatomy in general.”

The result of the open questions made it clear that the students judged the number and duration of individual events to be balanced. While the size of the small groups (n=5) only received a satisfactory verdict (2.96±0.71), tutoring was perceived as very good (4.19±0.73). Participants assessed the topical connection to the dissection course as particularly successful (4.39±0.5) and the opportunity to develop a better understanding of anatomy through clinical examples (4.26±0.69). Unexpectedly, the participants deemed the timing of courses in the 3rd pre-clinical semester of undergraduate studies as being somewhat too late (2.35±0.57). The evaluation of classes for teaching basic surgical skills showed consistently that the theoretical content and the instructions for applying these skills were adequately and well explained, but that there often was too little time for independent practice.

Out of a maximum of 100 points, 23 of 25 achieved pass grades, with two participants scoring more than 90 points (grade: “very good”), 6 a “good” score, 12 a “satisfactory” score and 3 a “sufficient” score. On average, the achievement was 77.7±7.82 points. Taking into account the overall low level of participants and station numbers, the OSPE achieved a reliability of a=0.57 (see Figure 2 [Fig. 2]).

The control group and the FOP group showed equally good exam results of the macroscopic anatomy course. Both the overall score (2.43±1.01 against 2.46±1.02) and the individual results of the oral and written exams regarding the various body segments, no significant differences were noted between the FOP participants and the control group.

The internal consistency of the calculated scales in the case and control groups were mostly consistent with the data in the literature (see above), with the following results for the case and control group: learning objectives scale α=0.75 and 0.68; approach performance objectives α=0.83 and 0.77; avoidance performance objectives α=0.87 and 0.84; work avoidance α=0.79 and 0.83. The item parameters of the combined groups (FOP plus control group) were significantly to highly significantly above the item mean values of the test group described by Spinath et al. (n=265; 161 women and 103 men, mean age 22.6 years) [24], both in the “learning objectives”, “approach performance objectives” and “avoidance performance objectives” scales and the individual items of these scales. Only the “work avoidance” scale showed no differences (see Figure 3 [Fig. 3]).

The control group and the FOP group showed no significant differences in the learning objectives, performance avoidance objectives and work avoidance scales. There was a trend towards the FOP group on average showing slightly higher sum values for the approach performance objectives scale (24.4±4.35 against 22.32±3.92), but these did not reach a significant level (p<0.082) (see Figure 3 [Fig. 3]). Accordingly, a significant difference between the two groups could only be seen in three items in the analysis of individual items using the Mann-Whitney U-test: The item “It’s important to me that others think I’m smart.” (from the approach performance objectives scale) was valued more highly by the FOP participants than the control group (2.92±1.12 against 2.2±1.2*). Similar results were seen with the items “It’s important to me that the others notice if I do well in tests and exams” (2.92±0.95 against 2.4±0.91*) and “It’s important to me not to show if one task is more difficult for me than another.” (2.76±0.83 against 2.24±0.72*) (from the prevention performance objective scale).

The results of the Pearson correlation analysis between

• the value of the total score and the OSPE points received,
• the mean sum scales of SELLMO-ST and the points scored for the OSPE, and
• the mean sum scales of SELLMO-ST and the final grade

in the dissection course showed no significant correlations.

FOP has managed to prepare pre-clinical students for their clinical surgical activities in a practice-oriented way which has received excellent evaluations (Grade: 5.4 out of 6.0). Students stated that they were able to transfer anatomical knowledge to the clinical context, to be motivated and to understand the clinical relevance of what they learned. To optimize the course sequence, in the future more time should be made available for practicing the practical skills. Interestingly, the students believe that the contents of FOP were offered to them almost too late in their course of study. The consistently good OSPE results show that the students at the pre-clinical stage of their studies are able to understand, learn and apply clinical teaching content and skills presented to them. However, the reliability of the OSPE in this case should be improved through more testing stations, a review and an examiner training.

The question underlying this pilot, whether the event objectively leads to an increase in motivation, must at this point be answered negatively due to the SELLMO test results. However, this clearly contradicts the subjective perception of the students. Kozianka and colleagues [11] also describe an increase of subjective learning motivation and could not objectify these observations. They were also unable to document improved test results. Our study group overall showed significantly higher scale values than the SELLMO-ST test group, which was composed of students from humanities/social sciences, teacher training, technology and mathematics, and not only from students of human medicine. This could generally speaking have an influence on the level of learning motivation. It is likely that medical students, in addition to the known high study motivation [25], also have high learning motivation, so that a difference between the study groups in this maximum range is difficult to prove. A longitudinal study of the development of learning motivation in the study groups at various points in time, including a baseline prior to the course beginning, could provide additional information in future studies. In addition, we suspect that it is difficult to demonstrate statistical significance in learning success with not strictly standardized teaching/learning conditions and low numbers of participants in this pilot study.

The significant differences between the case and control groups in the analysis of the individual items suggests that students primarily applied to participate in FOP to be able to present themselves positively in front of others and not so much due to the endogenous motivation to expand their own abilities. This is a phenomenon which ought to be compared with the motivation for participating in other optional events.

The subjective feeling of FOP participants to have gained a better understanding of anatomical topics unfortunately did not lead to better exam results in the dissection course. It is likely that the increased subjective learning motivation was not translated into more time being invested by students in studying anatomic topic. But this also implies, however, that the examinations for the dissection course and the examination format may not be the right or not the sole instrument for evaluating the learning success through participation in the FOP. It has not been investigated yet whether FOP participants have or have not developed a more meaningful learning strategy through the clinical approach to teaching but with static exam results. The learning orientation described by Entwistle [26] as “deep”, “strategic” or “superficial” are strongly influenced by the curriculum design and amongst others have an effect on the sustainability of the learning process [27]. The use of the ASSIST questionnaire after Entwistle (Approaches to study skills inventory for students) could lead to differentiated conclusions about the quality of learning by FOP participants in the future. The sustainability of learned material, should be reviewed both in the case group and the control group by evaluating performance in real-life OT situations.

In summary, the experiences with FOP from the point of view of the 25 participants and the anatomy staff and surgery representatives are extremely positive. A deeper integration of anatomical and surgical teaching would be desirable in the future to develop a longitudinally oriented anatomical curriculum in addition to the foundation stone of anatomy, the dissection course. With this small study group it was not possible unfortunately to gain statistically reliable data of an objective increase of learning motivation and examination performance. But the results to date from this pilot study should be of use in optimizing the study design of future studies on the added benefits of the integration of clinical content into anatomical teaching.

¹ Questionnaires (Evasys, Internal questionnaire and SELLMO-ST) are validated for the German-speaking use only.

² The The SELLMO-ST motivation test for students is copyright-reserved and therefore not added as a supplement. SELLMO-ST is acquireable at the Hogrefe publishing company: http://www.testzentrale.de/programm/skalen-zur-erfassung-der-lern-und-leistungsmotivation.htm

No public or third party funding. The presented manuscripts includes data which were partly published as a poster presentation on the yearly meeting of the GMA in Bochum 23.-25.Sept. 2010. Coauthor D.Lippold applied for the "GMA-Preis für Junge Lehrende, 2010" with the described project and became one of the last five finalists.

The authors declare that they have no competi8ng interests.