Best practice learning methods to prepare graduate students for clinically relevant surgical procedures. Evan Goldman, PhD.

Transcription

1 Best practice learning methods to prepare graduate students for clinically relevant surgical procedures Evan Goldman, PhD. Abstract Current teaching methods in anatomy, though preparatory for subsequent coursework, are not fully addressing students needs as medical practitioners. The goal of this proposed study is to evaluate novel methods of improving anatomical education in order to prepare students for current and future medicine trends. Specifically, modern surgical techniques such as laparoscopy and arthroscopy involve placing surgical instruments into the body via minute holes and as such, the view of the surgical field is extremely limited. A student, however, of necessity learns anatomy through visualizing an entire body region and thus they have almost no context with which to identify structures within the limited view. This study proposes to evaluate the best set of methods for teaching whole body anatomy that can also serve to minimize the amount of additional training a graduating student needs to prepare them for the minimally invasive operating theatre. By the conclusion of this study, a best practice solution of teaching anatomy may be instituted and the results disseminated via midterm posters and one or more publications in peer reviewed journals including those in support of Anatomical, Physician Assistant, Medical, Osteopathic, and Physical Therapy education. Scholarly presentations of the study would be sought at the annual conference of the American Association of Anatomists and American Association of Physician Assistants. Ultimately, the results from this study could significantly impact the way in which anatomy coursework is structured in professional medical training facilities Narrative The anatomy learned as a graduate student of the Medical Sciences (Nursing, Physician Assistant, Medical Doctor, Osteopathic Medicine), though preparatory for their subsequent coursework, does not necessarily prepare students for what is needed as a medical practitioner. The difficulty is the mismatch between how anatomy is learned versus how knowledge of anatomy is used in clinical and surgical practice. In the operating room, for example, the trend continues towards minimally invasive procedures in which minimal incisions, guided instrumentation, and computer systems are heavily relied upon rather than classical surgical techniques that carry greater risk and longer recovery periods. The challenge of the modern surgical techniques such as laparoscopy and arthroscopy, both of which involve placing surgical instruments into the body via minute holes, is that the view of the surgical field is extremely limited. A student who has learned gross anatomy using the typical approach, in which a student learns all of the structures within a large region, has no context with which to identify structures within the limited view. Without seeing nearby structures, there is no basis for understanding anatomical relationships. An analogy would be to drive a car through a mountain pass through the fog. One might see a nearby rock face but has no context with which to understand it s relation to the mountain at large. Conversely, training a student using only a video of the surgical technique fails to show the general relationship of nearby structures, thus also making identification of nearby structures nearly impossible.

2 A problem lies in that the obvious and most efficacious solution, that of teaching both methods simultaneously, is logistically almost impossible within the time constraints of a typical anatomy course. The question being asked in this study is therefore, what is the best set of methods for teaching whole body anatomy that can minimize the amount of additional training a graduating student needs in order to prepare them for the minimally invasive operating theatre. Because the knowledge base of the field of medicine is expansive and growing, yet the amount of time available for didactic training is finite, it is of great interest to all graduate programs to be efficient with their training. Anatomy in particular, takes up a huge quantity of time in the early professional phase of a graduate medical training. Subsequent training in radiological anatomy (x ray MRI, CT scan, Ultrasound, arteriogram) is a huge consumer of time and effort as is subsequent surgical training. Further training, for example, using the DaVinci robotic system, requires over 1000 hours of yet additional training. There is arguably a huge financial and manhour incentive therefore to reduce the time to mastery for training medical practitioners in use of modern surgical techniques. In this proposed study, the question is how to best teach students to recognize anatomical structures when viewed in contexts they had not previously experienced. In a best case scenario, anatomy training would consist of whole body anatomical dissections, correlated with 2D photographs, 2D illustrations, surface anatomy (what you can see or feel on the body surface), radiological anatomy (x ray, MRI, CT scan), 3D visualization (virtual reality, 3D software), and videos of minimally invasive surgeries. As stated, in reality, there is minimal time for such in depth training within a Physician Assistant, Nursing, or Medical program. It is therefore, of great interest to develop a training regimen that promotes learning anatomy then facilitating a student s potential to conceptualize and transfer the information to an alternate frame of reference. Methodology: In this proposed study, undergraduate and graduate students of medical sciences will be asked to learn about specific anatomical regions using one of four training modules. Students will subsequently be tested on: 1) recall of the information 2) critical thinking through a clinical correlation 3) identify anatomical structures on a previously unseen laparoscopic view 4) describe nearby structures that are NOT visible on the previously unseen laparoscopic view (i.e., a test for comprehension of relational anatomy). In this first round of experiments, the training modules will include: 1) viewing 2 D photographs and illustrations 2) module 1 plus laparoscopic videos 3) module 1 plus cadaver dissection 4) module 1 plus 3 dimensional anatomical visualization software. The expectations (hypotheses) are as follows: 1) Similar recall of information among all 4 modules 2) Training with modules 3 or 4: superior performance on critical thinking tests as compared with Modules 1 or 2

3 3) Training with modules 3 or 4: superior performance on tests of laparoscopic identification as compared with Modules 1 or 2 4) Training with modules 3 or 4: superior performance on comprehension of relational anatomy as compared with Modules 1 or 2 Of particular interest is whether a difference exists between training with modules 3 and 4 as they pertain to comprehension of relational anatomy. 3 D anatomical visualization software greatly supplements cadaver dissection; however it is difficult to understand structures using the latter without the former. Each of the training modules will include training in the anatomy of the abdominopelvic region. This region is complex with many layers and overlying structures. The mobility of the organs within this region makes it ideal for testing a student s comprehension of the relationships between different structures. The 4 training modules will focus primarily on the layers making up the abdominal wall and the organs immediately behind the wall (e.g. stomach). Developing the training modules will be one of the main goals during the summer The first module will consist of a presentation of relevant photographic and illustrative images. Students will have unfettered access to these images for a period of 1 week after which they will be tested on their recall, critical thinking, identification of new structures, and comprehension of relational anatomy. These four tests will be developed during the summer The second module will provide content from module 1 and will add laparoscopic surgery videos highlighting specific upper and lower GI (gastrointestinal) procedures. The third module will include content from module 1 and will add cadaver dissection of the abdominal region. The fourth module will consist of module 1 plus 3 dimensional anatomical visualization software. This 4th module will take into consideration some of the latest anatomical visualization software. A variety of software packages will be used including those which convert MRI /CT scans to virtual 3 dimensional volumes (allows the user to manipulate and fly through human scans), virtual 3D computer graphic software, and 3D hardware/software making use of 3D glasses and technology. For all modules, students will have 1 week of unfettered access to the material. Results from this study will be used to refine the modules, tests, and develop subsequent modules and tests. This study has great potential for a number of midterm posters and one or more publications in peer reviewed journals including those in support of anatomical, Physician Assistant, Medical, Osteopathic, and Physical Therapy education. Scholarly presentations of the study would be sought at the annual conference of the American Association of Anatomists as well as American Association of Physician Assistants. A number of grants are available through the American Association of Anatomists, the American Association of Clinical Anatomists, and the Human Anatomy and Physiology Society for research relating to improving anatomy education. Within the discipline of anatomy and anatomical education, I have written 4 articles (2 published), given 2 oral presentations, 3 posters, consulted in the construction and education of anatomy students for 3 institutions outside of Philadelphia University, and have presented over 10 workshops and reviews to non Philadelphia University students and over 30 workshops and reviews for graduate students outside of the Physician Assistant program. The impact of this study is hugely relevant to professional programs in which anatomical training is a foundation for the profession. By improving the efficiency of training and the students ability to comprehend anatomical

4 relationships, the already huge quantity of time spent in the early professional phase of a graduate medical training can inherently help offset subsequent training in radiological and surgical realms. In addition, there is arguably a huge financial and man hour incentive to reduce the time to mastery for training medical practitioners in use of modern surgical techniques. Timeline: Summer 2012 Fall 2012 Spring 2013 Summer 2013 Develop teaching modules 1 4 Develop testing protocol Recruit students, train using modules, testing Preliminary results, Initial reports and abstract/poster submissions Make improvements to training and testing modules 2 nd round of training new students using modules, run 2 nd round of tests Results writeup, Abstract/poster submission Manuscript preparation Manuscript submission and presentation proposals Expected completion date: June 28, 2013

5 Philadelphia University RESEARCH, SCHOLARSHIP & PRACTICE BASED PROJECT GRANT BUDGET FORM Personnel: Faculty Stipend: $ $2000 (Up to $2,000 per faculty member only available for the summer) (Please do not include travel on this line. Travel should be listed below.) Student Workers: Number of Students Total hours needed Pay per hour $7.25 (Please justify if higher.) Total amount (a x b x c) a. 2 b. 75 c $ $ Equipment: Please list items with prices. Supplies, software, other: Please describe. $ 3D software with 3D glasses and controller: $850 Travel: Please list destination and cost. $ TOTAL BUDGET REQUESTED: $ (Maximum $5,000)

6 Philadelphia University School of Science & Health School House Lane & Henry Avenue PHONE EVAN M GOLDMAN, PhD Education PhD Temple University, Philadelphia, PA; Physiology MEd Temple University, Philadelphia, PA; Physiology BA Case Western Reserve University, Cleveland, OH; Chemistry Postdoctoral training Postdoctoral Fellow University of Pennsylvania & laboratory manager Integrative Muscle Physiology Laboratory Academic and research appointments Associate Professor of Biology Philadelphia University - School of Science & Health 2011 Assistant Professor of Biology Philadelphia University - School of Science & Health Adjunct Professor Philadelphia University - Physician Assistant Program 2005 Visiting Assistant Professor Philadelphia University - School of Science & Health Post Doctoral Fellow University of Pennsylvania & Laboratory Manager Integrative Muscle Physiology Laboratory Course Director, Lecturer University of Pennsylvania, School of Arts & Sciences, Biology Lecturer University of Pennsylvania College of General Studies 2001 Adjunct Professor Roxborough Memorial Hospital School of Nursing, PA Adjunct Professor Saint Joseph s University, Philadelphia, PA 2000 Adjunct Professor Community College of Philadelphia, Philadelphia, PA Research Consulting Allegheny University (MCP/Hahnemann), Physiology/Molecular Medicine Research Assistant Temple University School of Medicine/ Biokinetics Research Laboratory Publications Goldman E.M., Shah Y.S., Gravante N. A Case of an Extremely Rare Unilateral Subscapular Trunk and Axillary Artery Variation in a Male Caucasian: Comparison to the Prevalence within Other Populations. (at Press). Morphologie., 2012 Goldman, E.M. Building a Low-Cost Gross Anatomy Lab: A Big Step for a Small University. Anatomical Sciences Education. 3: , Goldman E.M., Shah Y.S., Gravante N. A Case of an Extremely Rare Unilateral Subscapular Trunk and Axillary Artery Variation in a Male Caucasian: Comparison to the Prevalence within Other Populations. (at Press).

7 Goldman, E.M., A Customized Computer System and Interface for use within a Physician Assistant Gross Anatomy Course. Anatomical Sciences Education (in review). Gangi, Tony. Anatomy of Sword Swallowing (Goldman, EM) in: Carny Sideshows: Weird Wonders of the Midway. Citadel Press, Kensington Publishing Corp Goldman EM. Human Factors Testing of Military Body Armor. In: Last Line of Defense. Armor & Mobility. January 2010, p. 30. Samuels C, Massam D, Payne J, [Goldman EM]*. Last Line of Defense. Armor & Mobility. Jan 2010, p *Note: System Testing section was written by Goldman EM and edited by Samuels C and Massam D. No credit was given to Goldman EM for this section due to full credit given to Goldman EM for the inset article. Rome, L.C., Flynn, L., Goldman, E.M., Yoo, Taeseung, D., Generating Electricity While Walking with Loads, Science, Vol. 309, pp , Sept. 9, 2005 Rome, L.C., Flynn, L., Goldman, E.M., Yoo, Taeseung, D., Online Supplement: Generating Electricity While Walking with Loads, Science, DOI: /science Liu Y., Ren K., Goldman E.M., Rome L.C., Hoffmann H, and Zhang Q.M. Harvesting electrical energy with electroactive polymers. IEEE, Proceedings of the 13 th International symposium on unmanned untethered submersible technology, 2003,. Rome L.C., Goldman E.M., Sprague RC. Harvesting electrical energy with electroactive polymers, Part 1. biomechanical and physiological considerations. IEEE, Proceedings of the 13 th International symposium on unmanned untethered submersible technology, 2003, Goldman E.M. All-trans retinoic acid inhibits the development of phenylephrine-induced hypertrophy in adult rat ventricular myocytes (Doctoral Dissertation). Goldman E.M., Ridenour M.V. Women and sailing, Encyclopedia of Women in Sports, Goldman E.M. Precision and accuracy of a filming technique for estimating distances and velocities on a small sailboat, 1996, Masters Thesis. Goldman E.M. Data acquisition of on-the-water Finn sailing using the PEAK System, U.S. Finn Class newsletter, Ridenour M.V., and Goldman E.M. A 3-D comparison of attack distances of Junior Olympic women foil fencers, Data presented to US Olympic Fencing, Government/Industry Reports Goldman, E.M. Human Factors Testing of Military Body Armor. Report compiled for KDH Defense Systems, Inc; United States Air Force. November Massam D, Goldman EM. Progress report and path forward. Report compiled for KDH Defense Systems, Inc. March Goldman EM. Pastore C. Evaluation of Effects of Compression Garments on Human Performance. Report compiled for Lontex Corporation. February Posters Goldman, E.M. Student interaction with a novel computer interface in a gross anatomy lab. American Association of Anatomists national meeting, Goldman, E.M. Low cost, high-impact video system for use in a gross anatomy laboratory. American Association of Anatomists national meeting, Goldman, E.M.,Axillary Artery and Branch Variations in an 83 year-old Caucasian Male. American Association of Anatomists national meeting, 2007 Goldman, E.M., Perceived Value of Computer-Aided Learning in a Gross Anatomy Course. American Association of Anatomists national meeting, 2007