|Year : 2019 | Volume
| Issue : 2 | Page : 72-80
Applied teaching model for veterinary junior surgery laboratory
Andrea Kalei Herndon Erickson1, Andrew B West2, Margaret K Bruner2, Dean A Hendrickson2, Catriona M MacPhail2
1 Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, Florida 32607, USA
2 Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, CO, USA
|Date of Web Publication||5-Nov-2019|
Dr. Andrea Kalei Herndon Erickson
College of Veterinary Medicine, University of Florida, PO BOX 100116, 2015 SW 16th Avenue Gainesville, FL 32601-0126
Source of Support: None, Conflict of Interest: None
Objective: To assess perceived veterinary student confidence and surgical skill set following a live animal, nonrecovery porcine surgical laboratory and to assess veterinary alumni long-term surgical confidence benefits from this laboratory during their first few years in practice. Sample Population: Four hundred students pre- and post-laboratory self-assessment surveys were analyzed from veterinary students participating in the junior surgery laboratory (JSL) from 2009 to 2018. One hundred and fifty veterinary alumni surveys were analyzed from JSL participants graduating between 2014 and 2018. Materials and Methods : Procedures performed on swine culled from food production included wound closure, abdominal exploratory, abdominal closure, splenectomy, nephrectomy, gastrostomy, intestinal anastomosis, and cystotomy. Procedures performed aimed to facilitate development of atraumatic tissue handling, vessel ligation, and hollow organ surgery. Results: All participants demonstrated significant self-evaluation improvement (P < 0.001) in all categories to include prepping and draping, scrubbing, gowning and gloving, sterile technique, instrument handling, gentle tissue handling, knowledge of abdominal surgery, abdominal surgical exploration, skin incisions, vessel ligation, handling and suturing of abdominal viscera, comfort in a surgical setting, perceived surgical ability, and knowledge of abdominal surgical procedures. Surveyed Professional veterinary medicine (PVM) alumni agree that JSL contributed to their perceived confidence and surgical skills. Conclusions and Clinical Relevance: Authors believe that the skills-oriented teaching method and deliberate practice using a combination of bench models, cadavers, and live animal procedures build perceived student surgical skills and confidence. The majority of surveyed PVM alumni support this statement and report long-term perceived surgical skill and confidence benefits gained from the JSL during their 1st year of practice.
Keywords: Practice expectations, student confidence, surgical education, surgical simulation
|How to cite this article:|
Herndon Erickson AK, West AB, Bruner MK, Hendrickson DA, MacPhail CM. Applied teaching model for veterinary junior surgery laboratory. Educ Health Prof 2019;2:72-80
|How to cite this URL:|
Herndon Erickson AK, West AB, Bruner MK, Hendrickson DA, MacPhail CM. Applied teaching model for veterinary junior surgery laboratory. Educ Health Prof [serial online] 2019 [cited 2019 Nov 13];2:72-80. Available from: http://www.ehpjournal.com/text.asp?2019/2/2/72/270284
| Introduction|| |
General surgical skills are a highly ranked qualification for new veterinary graduates., However, confidence in surgical ability and the ability to perform surgical procedures have been two of the most commonly reported educational shortcomings., Tertiary referral caseload limits student hands-on exposure to primary care cases and procedures outlined by the AVMA veterinary school accreditation standards. Employers seek new graduates with skill sets including ovariohysterectomy, cystotomy, mass removal, laceration repair, and management of intraoperative hemorrhage. Additional skill practitioners' desire in new graduates include proficiency in vessel ligation, atraumatic tissue handling, creating and closing skin and visceral incisions, application of surgical anatomy, correct aseptic technique with gowning and gloving, and wound management with drain placement and tension relief., However, current veterinary curricula tend to limit student exposure to surgery and therefore skill development in these common surgical procedures. Furthermore, opportunities for individual application of surgical skills are rare. One study demonstrated that approximately half of graduating veterinary students had not performed an unassisted feline spay, canine neuter, or canine spay before graduation. This is problematic as surgical literature associates practice and experience as fundamental to mastering surgical procedures, resulting in many veterinary students graduating lacking surgical confidence and competence.,
Although not a direct comparison to veterinary medicine, human medical schools demonstrate similar trends reporting that the operating room can be a challenging learning environment and one that contributes to student anxiety, especially when expectations of faculty and experience levels of students vary. Heavy emphasis on patient safety concerns has also significantly limited hands-on medical student training during their clinical rotations. This disparity between the surgical skill sets necessary for physicians versus the opportunities to develop these skill sets is similarly lacking when relying solely on clinical rotations as preparation for future practice.
Disproportionate surgical expectations to experience levels are concerning as the majority of veterinary students enter private practice after graduation. Veterinary students commonly report lack of self-confidence in the surgical setting. This lack of confidence impacts an individual's ability to remember procedures and act appropriately in unexpected situations. Conversely, a high level of confidence contributes to the ability to focus, engage, remember procedures, and generally strengthen the surgical learning experience. One goal of this study was to assess perceived student confidence and perceived surgical skills before and after an intensive week-long, hands-on, live-animal surgical training laboratory, where students perform common entry-level surgical procedures. The other goal of this study was to assess long-term perceived surgical skill and confidence benefits of the junior surgery laboratory (JSL) for novice veterinarians during their first few years of practice. We hypothesized that the JSL would increase both veterinary student perceived confidence in surgery and surgical skill set. We also hypothesized that veterinary alumni would receive long-term surgical confidence benefits from JSL during their first few years of practice.
| Materials and Methods|| |
Junior surgery laboratory curriculum objectives
The JSL is a skills' oriented  laboratory focused on breaking down surgical procedures into basic surgical skill sets using live animals. The general objectives of JSL are to practice aseptic technique, learn and perform basic surgical procedures, and develop self-assessment skills. JSL centers on basic surgical principles that apply to all species. Specific objectives include patient preparation, scrubbing, gowning and gloving, suturing techniques, knot tying, proper instrument handling, and basic surgical techniques. In this laboratory, students learn proper handling and manipulation of various tissues including skin and connective tissue, hollow organs, and parenchymal organs.
Veterinary student training before junior surgery laboratory
Before the 3rd year JSL experience, students receive training in basic surgical concepts in a series of Foundations of Veterinary Medicine courses during the first four semesters of their DVM program. In the first semester of the course, students participate in a basic instrument-handling laboratory. During their second semester, students engage in a soft tissue dissection laboratory to gain experience using surgical instruments on cadavers. In the third semester, students learn basic suturing patterns and techniques using bench models, while the fourth semester focuses on skin and subcutaneous closure on cadavers. This laboratory brings together the concepts of instrument handling, suture patterns, tissue handling, and abdominal closure. At the beginning of the 3rd year of the DVM program, veterinary students participate in the Surgical Principles Laboratory. This laboratory teaches principles of aseptic technique and reinforces proper handling of surgical instrumentation using inanimate models. Here, students practice manual surgical skills such as suturing techniques, knot tying, and proper tissue handling. Additional electives in surgical anatomy are available for interested students, which include surgical procedures performed on canine and equine cadavers with an emphasis on understanding surgical anatomy.
The junior surgery laboratory
A week before the start of the JSL rotation, students are provided a set of notes describing the procedures that will be performed as well as a DVD with video segments of the specific techniques. At the beginning of each day of the laboratory, a faculty instructor provides a 30-min didactic session to review lessons learned from the previous session and to discuss procedures that will be performed in the current session. Students participate in 5 days of 4 h-long surgical sessions. Each week's laboratory consists of 22 students broken up into groups of 2. Students alternate between being the surgeon for each procedure and assisting their partner. Each group works with a pig that is humanely euthanized at the end of each day's session. Laboratory sessions are facilitated by 1 board certified surgeon and 2 surgical residents. Students are assessed by visual walk by evaluation. All procedures must be performed by each individual student to pass the JSL rotation.
Skills-oriented teaching method
Surgical trends and feedback favor the skills-oriented teaching method. This method emphasizes breaking down surgical procedures into basic surgical skill sets. These foundational surgical skills then serve as building blocks for all surgical procedures. The skills-oriented method is based on the fundamental concept that students can learn complex procedures when separated into less complex steps. This enables students to gain confidence, dexterity, and solidify each step before performing the entire procedure. JSL is taught entirely using the skills-oriented method and builds on the fundamental surgical laboratories that the students participated in during the first 2 years of veterinary school. In the JSL, students practice surgical skills including gentle tissue handling, instrument and suture handling, hemostasis, and ligation and then combine these skill sets to perform more complex procedures such as an abdominal exploration, splenectomy, and cystotomy. Authors believe that repetition of these fundamental skill sets enables students to apply learned concepts and then work through multiple abdominal procedures.
All portions of the laboratory are approved annually by the Institutional Care and Use Committee. JSL is conducted using 15–30 kg swine that are ill or have failed to thrive in production settings and will be culled from the food supply. To address possible biosecurity risks, proper personal protective equipment to include cap, mask, scrubs and/or isolation gown, and shoe covers are worn at all times during the JSL. At the end of each day, the JSL is cleaned with a neutral disinfectant cleaner, surgical instruments are cleaned daily, and autoclaved at the end of each week's session. The biosecurity team frequently cultures the JSL, and to date, there have not been any cultures come back positive for infectious disease. Anesthesia and monitoring are performed by technicians and are based on protocols recommended by anesthesia faculty. In preparation for the laboratory, students are invited to attend an ethics panel to discuss the terminal nature of the laboratory. This question and answer panel with faculty and laboratory staff gives students the opportunity to learn about the pigs, including where they come from, their cull status, and how they are cared for and handled at the university. The ethics panel helps students make an informed decision as to whether or not they would like to participate in this elective laboratory. Since the beginning of the JSL, 99%–100% of 3rd year students choose to participate.
Surgical procedures and skill sets taught in the JSL are described in [Table 1].
|Table 1: Objectives and surgical procedures for junior surgery laboratory|
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Pre- and post-laboratory self-assessment
All portions of this survey study have been approved by the Institutional Review Board (IRB). The week before entering the JSL, students complete a written self-assessment survey aimed at eliciting their level of confidence in selected surgical principles and procedures. Students are given the same written survey immediately after completing the 1-week JSL rotation, which includes a section for additional comments [Figure 1]. Four hundred pre- and post-JSL self-assessment surveys were included in this study from over nine hundred veterinary student participants from 2009 to 2018. Survey breakdown is as follows: 40 surveys (2009–2010), 27 surveys (2010–2011), 56 surveys (2011–2012), 94 surveys (2012–2013), 66 surveys (2013–2014), 34 surveys (2014–2015), 17 surveys (2015–2016), 12 surveys (2016–2017), and 67 surveys (2017–2018).
|Figure 1: Survey used for pre- and post-self-analysis of surgical skills|
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Professional veterinary medicine alumni junior surgery laboratory survey
All portions of this alumni survey study have been approved by the IRB. Surveys were sent out via email and social media to alumni of the PVM from the classes of 2014–2018. The aim of this survey study was to determine long-term perceived surgical skill and confidence benefits of the JSL for novice veterinarians during their first few years of practice. One hundred and fifty PVM alumni surveys responses were received and included in this study from over seven hundred veterinary student alumni from the classes of 2014–2018. Survey breakdown is as follows: 44 surveys (PVM class of 2014), 8 surveys (PVM class of 2015), 25 surveys (PVM class of 2016), 59 surveys (PVM class of 2017), and 14 surveys (PVM class of 2018) [Figure 2].
Four hundred veterinary student surveys from 2009 to 2018 with both pre- and post-JSL self-assessments were analyzed. Descriptive statistics including mean and standard deviation was calculated for each student's 13 perceived surgical skills. Paired t-tests were then used to compare the pre- and post-self-assessment values separately for each of the 13 surgical skills.
One hundred and fifty veterinary alumni study surveys from the classes of 2014–2018 were analyzed. Percentage frequency of responses was recorded for each category (strongly agree – strongly disagree). Depending on the year, student survey response rates vary from 10% to 70%.
| Results|| |
All respondents demonstrated a significant perceived improvement in average scores for all thirteen categories and surgical skills after completing the JSL. [Table 2] demonstrates the pre- and post-laboratory self-assessment data. A comparison of cumulative pre- and post-self-assessment scores demonstrated significance with P < 0.001 in all categories. Student comments and feedback about the JSL while currently enrolled can be found in [Table 3].
[Table 4] demonstrates the respondent PVM Alumni JSL survey study data. Ninety-six percent of respondent PVM alumni agree or strongly agree that JSL helped them to become a more successful surgeon in their chosen field. 98.7% of respondent PVM alumni agree or strongly agree that the surgical skills learned and practiced in JSL transferred to working in the operating room. 97.3% of respondent PVM alumni agree or strongly agree that surgery skills learned and practiced in JSL transferred to working in practice. 75.3% of respondent PVM alumni agree or strongly agree that their employer felt they were ready to perform surgery when they entered practice. Fifty-four percent of respondent PVM alumni agree or strongly agree that their employer felt their surgery skills on entering practice were more developed than other recent graduates. 94.7% of respondent PVM alumni agree or strongly agree that JSL contributed to both their confidence and perceived competence performing surgical procedures in their chosen field. Respondent PVM alumni feedback about perceived long-term surgical skill and confidence benefits of the JSL can be found in [Table 5].
| Discussion|| |
All respondents demonstrated a significant improvement in perceived surgical confidence and surgical ability. Authors believe this is due to the skills-oriented approach focusing on repetition and deliberate practice of fundamental skills that apply to any entry-level surgical procedure. Student comments strongly support this reported increase in student confidence [Table 3]. Additional student feedback about JSL's learning environment and process can be found in [Table 3]. PVM Alumni Survey feedback supports long-term perceived surgical skill and confidence benefits of the JSL for novice veterinarians during their first few years of practice [Table 4]. PVM alumni survey comments further support these findings [Table 5].
Despite decreased exposure to hands-on surgical experiences, new graduates are expected to attain a high level of surgical proficiency by the time of graduation, as surgical skills are highly sought out by employers.,, Employers expect new graduates to be proficient in aseptic technique, suturing patterns, ligations, knot tying, and instrument handling., Common requests for improvement lie in areas such as ovariohysterectomy, cystotomy, mass removal, laceration repair, and management of intraoperative hemorrhage., As the majority of new veterinary graduates enter private practice, veterinary schools must work to prepare students to become competent entry-level veterinarian surgeons., The findings from this present study suggest that a surgical experience that culminates in a live animal surgical laboratory strengthens student surgical confidence and perceived surgical skills.
Veterinary professions agree that the operating room can be a challenging learning environment. This daunting learning environment can contribute to veterinary students' high anxiety, low confidence, and perceived unsatisfactory skill set., The most common source of negative emotion among veterinary students is a lack of self-confidence. The JSL creates a context where surgical procedures can be practised in a comfortable learning environment and students can get immediate feedback from professors and peers. This laboratory allows students an opportunity to perform deliberate practice of surgical skills, which has been shown to improve performance and skills acquisition. This laboratory incorporates the four requirements for deliberate practice by providing real-time feedback, granting opportunity for repetition and refinement of skills, clearly defining daily goals, and creating an environment that motivates students to improve. This mock surgical simulation is an opportunity for students to experience success and difficulty using a realistic model in a calm learning environment. Student feedback supports these findings. Students state, “I enjoyed the calm instruction with constructive feedback. The attitude and instruction I received really helped me learn and improve.” “I loved being able to have my first surgical experience in this supportive and controlled setting.” Educators highlight the components of effective learning environments, including providing high intensity of interactions and feedback, having specific goals and established procedures, being motivational, providing a continual feeling of achievable challenge, providing a sense of direct engagement in the task, providing appropriate tools for the task, and avoiding distractions and disruptions during the experience. Learning has a strong emotional base, which makes it essential that students experience a psychologically safe environment., Students report that positive emotions such as engagement and excitement help them focus and increase their ability to learn. The ability to prepare well is the most common source of positive emotions in veterinary students. In contrast, students report that negative emotions such as anxiety, anger, and shame reduce motivation to learn and inhibit cognition and memory.,,
Authors believe passive observation of experts performing surgical procedures is not adequate to prepare students to enter private practice. The JSL is the culmination of over 2 years of didactic and practical surgical training and is an opportunity for students to apply surgical skills and concepts on live animals. A survey study by Hedlund et al. found that students strongly agree that live animal surgical experience during veterinary school was essential to prepare for general practice. Students strongly disagreed that observation and assisting clinicians during surgical clinical rotations was adequate experience for clinical practice. The advantages of live animal models include their high fidelity, availability, realism, pulsation of blood vessels, and use in learning ligatures for major blood vessels, tissue hemostasis, and dissection of natural planes.,, Studies of medical students propose live animals as the best way to prepare for the anxiety and demands of the operating room. However, disadvantages of nonsurvival surgical laboratories include loss of life, high cost, single use, and the special facilities and personnel required for use in laboratories.,, For this reason, we recommend a surgical training model that begins with nonlive animal experiences and that culminates in a live animal surgery. Ethical feedback from student participants can be found in [Table 3].
There are advantages and disadvantages to all current surgical teaching models [Table 6]. Common methods include bench models, cadavers, live animals, and virtual reality surgical simulators. Caston et al. reported that students trained using simulated tissue for equine intestinal anastomosis performed as well as students trained using equine cadaver tissue, with the benefit of models allowing students to practice motor skills repetitively and to direct their own learning. However, students were concerned with the lack of reality of intestinal eversion and lack of bleeding for both the bench and cadaver models. Current studies demonstrate encouraging data toward the efficacy of models and simulations for surgical training. However, these findings also support the perspective that simulators should not completely replace all animal use at this time but should be included as a part of the building blocks of surgical education.
|Table 6: Advantages and disadvantages of current surgical teaching models and simulations (Modified from Reznick et al., Davies et al., and Stefanidis et al.)|
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The benefits of porcine surgical models have also been demonstrated in other medical professions. Several medical schools use porcine surgical simulation laboratories to prepare future doctors for procedures in thoracic surgery, ophthalmic surgery, laparoscopic abdominal, and urologic surgery. The porcine model has also been established as a successful teaching model for polytrauma courses, vascular procedures, interventional radiology techniques, and abdominal surgical procedures such as laparotomy, small bowel resection, splenectomy, and cholecystectomy.,, Studies have shown that medical students do not feel adequately prepared for future practice through experience gained solely through clinical rotations,, while subjective and objective data demonstrate an increase in confidence and surgical skills along with positive feedback of students that have used the porcine surgical simulation model., Students experiencing this type of surgical laboratory report not only an improvement of surgical technique but also an increased level of confidence in the operating room later on in their careers., Medical schools using this type of simulation state that, “The realism derived from live animal laboratories is currently unparalleled by other forms of surgical simulation.” PVM veterinary students also support these findings and additional statements about the value of live patient surgical experience; this can be found in [Table 3] and [Table 5].
Authors acknowledge area for future study such as student surgical assessments using scoring scales such as the OSATS; and comparing the JSL laboratory to students trained using only cadavers, synthetic, and virtual surgical models. Authors acknowledge limitations of this study to include the lack of a control group, inherent bias associated with subjective self-reported data, the use of in-house unvalidated surveys, and <100% student survey response rate.
Today, many biomedical programs have moved toward the use of alternative models for current veterinary education, and although the pigs used in this laboratory were destined to be culled due to failure to thrive or illness, the terminal nature and number of pigs used in the JSL may also be seen as a study limitation. Further limitations include that the JSL is performed at a single institution with limited sample size and that individuals were only evaluated over a 1 week time period. The duration of the JSL training sessions was also above the suggested 1 h training time frame for maximal concentration toward effectively improving performance. Cognitive load theory is another possible limitation of the JSL design, as this type of laboratory may overwhelm memory capacity due to the breadth of novel information presented. Furthermore, it has been shown in human and veterinary medicine that the precision of technical skill self-evaluation increases with time and training  and many of those surveyed were performing live surgery for the first time. Despite study limitations, authors believe this type of subjective self-reported survey data is valuable to the veterinary surgical educational community.
The JSL design models current surgical trends and feedback in veterinary education favoring the skills-oriented teaching method and opportunities for deliberate practice., This method supports the Fitts–Posner 3 stage theory of motor skill acquisition, which includes cognition, integration, and automation. The first stage is cognition, where an individual understands the task through explanation and demonstration and then performs the task in distinct steps. Once cognition has been achieved, integration begins. Integration includes deliberate practice  and feedback and results in a more fluid performance., Once integration is achieved, automation can begin. At this final stage, the individual can perform the task with speed, efficiency, and precision with little cognition and a fluid performance.
| Conclusion|| |
At this time in surgical education, we believe that the skills-oriented teaching method and deliberate practice using a combination of bench models, cadavers, and live animal procedures builds student surgical skills and confidence. The majority of surveyed PVM alumni support this statement and report long-term perceived surgical skill and confidence benefits of the JSL for novice veterinarians during their first few years of practice.
We acknowledge the students and staff who dedicate their time to making this laboratory a possibility.
Financial support and sponsorship
Student work study award Colorado State University.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]