Original ReportsSelf-Directed Interactive Video-Based Instruction Versus Instructor-Led Teaching for Myanmar House Surgeons: A Randomized, Noninferiority Trial
Introduction
Myanmar׳s health care system is burdened with aging infrastructure, limited resources, and high rates of disease and injury.1 However, the country has only 31,000 physicians caring for its population of 53.2 million.2, 3 A challenge faced by many low- and middle-income countries is the training of adequate numbers of qualified physicians, and Myanmar is no different. To help alleviate its physician shortage, by 2011 nearly 14,000 medical students were enrolled across the country׳s 4 medical schools (University of Medicine 1 [UM1], Yangon; University of Medicine, Mandalay; University of Medicine 2, Yangon; and University of Medicine, Magway).4 In 2011, Myanmar׳s medical education governing body convened to discuss and vote on policies to improve the quality of physician training. This group voted to reduce the total annual medical student intake by half with the goal of providing more individualized training for students.5
Myanmar׳s medical school curriculum is based on the United Kingdom׳s MBBS degree system, and Myanmar׳s House Surgeons—medical students in their final year of training—serve as the primary medical providers for patients in many hospitals across the country. Equivalent to the American College of Surgeons׳ “Essentials for Medical Students and PGY-1 Residents”, Myanmar׳s “Reference Handbook” is a text outlining core skill sets and objectives that House Surgeons are expected to learn during their hospital rotations, including emergency and routine procedures.6 It is imperative that all House Surgeons master these basic skills to progress in their training as a means to provide safe and essential health care to the population.
Surgical skills training at medical schools around the world is traditionally led by instructors or faculty. However, skills training in low-resource settings is limited by several factors, such as the availability of qualified instructors, variations in knowledge and teaching style between instructors, and the absence of dedicated educational infrastructure (e.g., classrooms, skills laboratories, and simulation models). Interactive video-based instruction (IVBI) is an alternative to traditional instructor-led teaching. With IVBI, students learn skills from instructional videos, using interfaces that permit control of speed of video play, replay of video segments, and video access at any time. IVBI relies on voice-over narration and on-screen annotation to guide learning. As IVBI modules are centrally recorded and then disseminated, IVBI learning is innately standardized across students and institutions. Studies have demonstrated improved skills acquisition and retention with IVBI compared to traditional modalities.7, 8, 9 Of note, IVBI has been shown to be effective in a self-directed learning environment. IVBI׳s defining features should make it adaptable and useful in low-resource settings, but its effectiveness and cost have not yet been studied in a low-resource medical school environment.10, 11
In this study, we introduce a systematic approach for testing the effectiveness of IVBI for basic surgical skills training in Myanmar, a country with a low-resource medical training system. Our objective was to compare the efficacy of self-directed IVBI with instructor-led teaching in the acquisition of basic surgical skills by House Surgeons at a large academic referral hospital in a major urban center. We hypothesized that self-directed IVBI is noninferior to instructor-led teaching for learning 1-handed knot tie, 2-handed knot tie, vertical mattress suture, and instrument tie. Our secondary goal is to assess both the level of student satisfaction with IVBI, and the cost of deploying this low-fidelity, self-directed IVBI setup for use in low-resource settings.
Section snippets
Study Setting
This prospective, 1:1 randomized controlled trial was conducted in January 2016 at UM1), Yangon, Myanmar.
Student Sample
Eligible House Surgeons were those enrolled in their 3-month surgery rotation at the time of the study. House Surgeons who had previously completed their surgery/OBGYN rotation and were enrolled in a rotation other than surgery during January 2016 were ineligible to participate. A total of 125 House Surgeons registered to participate in this study, but only 74 were deemed eligible. Fifty
Results
A total of 50 House Surgeons participated in and completed the study (Fig. 1) In comparing baseline characteristics in the self-directed IVBI and instructor-led teaching groups, there were no significant difference between proportion of students within the treatment and control group except for “plan to take USMLE (step 1, 2, and 3)”. There was <1% missing demographic data. In all, 74% of participants were female. Less than 30% of participants had used videos for surgical skills training. More
Discussion
The goal of this study was to demonstrate that self-directed IVBI is noninferior to traditional instructor-led teaching of basic surgical skills in a low-resource setting. Participants in both arms of the study showed significant improvement in skills based on the improvement in OSATS scores from pretest to posttest. Self-directed IVBI was shown to be as effective as instructor-led teaching, as the upper limit of the 90% CI of the difference in mean posttest OSATS scores did not encompass the a
Limitations
This study was limited by a small sample size (n = 50), limited teaching time (1 h), administration of satisfaction survey to only the IVBI group, and lack of long-term follow-up. A larger sample size would produce a narrower a priori noninferiority margin, which may prove higher power to support noninferiority. Furthermore, time constrains of the House Surgeons only allowed for 1 hour of teaching, possibly reducing the degree of skills acquisition. Although there was a significant increase in
Conclusion
In low- and middle-income countries such as Myanmar, we conclude that self-directed IVBI is as effective as instructor-led teaching for skills training. Overall, House Surgeons were highly satisfied with self-directed IVBI, and were in favor of using it further and integration into their curriculum. The use of self-directed IVBI in low- and middle-income countries has the potential to significantly reduce the personnel required for teaching basic skills. Self-directed IVBI may also standardize
Funding
This publication is made possible by the Johns Hopkins Bloomberg School of Public Health and the Johns Hopkins Institute for Clinical and Translational Research (ICTR), which is funded in part by Grant no. TL1 TR001078 from the National Center for Advancing Translational Sciences (NCATS) a component of the National Institutes of Health (NIH), and NIH Roadmap for Medical Research. Its contents are solely the responsibility of the authors and do not necessarily represent the official view of the
Acknowledgments
Special thanks to Associate Professor Pa Pa Soe, Dr. Myo Lwin, and volunteers from University of Medicine (1), Yangon, Myanmar (Chaw Kay Khine, May Phyo Wai, Hnin Nandar Htun, Kaung Htet, Kaung Phyo Wai, Phyu Phyu Kyaw, Thiri Aung, Thet Oo Khin, Thet Paing Oo, Than Htike Zaw, and Thet Maw Tun). This project would not have been possible without their support.
References (31)
- et al.
Acquisition of surgical skills: a randomized trial of didactic, videotape, and computer-based training
Surgery
(1999) - et al.
Teaching suturing and knot-tying skills to medical students: a randomized controlled study comparing computer-based video instruction and (concurrent and summary) expert feedback
Surgery
(2007) - et al.
Comparison of expert instruction and computer-based video training in teaching fundamental surgical skills to medical students
Surgery
(2008) - et al.
Surgical skill acquisition with self-directed practice using computer-based video training
Am J Surg
(2007) - et al.
Filling a void: developing a standard subjective assessment tool for surgical simulation through focused review of current practices
Surgery
(2014) - et al.
Testing technical skill via an innovative “bench station” examination
Am J Surg
(1997) - et al.
Synthesis versus imitation: evaluation of a medical student simulation curriculum via Objective Structured Assessment of Technical Skill
J Surg Educ
(2010) - et al.
Surgical skills acquisition: performance of students trained in a rural longitudinal integrated clerkship and those from a traditional block clerkship on a standardized examination using simulated patients
J Surg Educ
(2014) - et al.
The impact of external feedback on computer-assisted learning for surgical technical skill training
Am J Surg
(2000) - Human Development Reports. Human Development Report 2015: Work for Human Development....
Healthcare in Myanmar
Nagoya J Med Sci
Successfully navigating the first year of surgical residency: essentials for medical students and PGY-1 residents
Am Coll sugeons Div Educ
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2018, Annals of Medicine and SurgeryCitation Excerpt :They have to rotate through internal medicine, surgery, obstetrics & gynaecology wards for three months, a paediatric ward for two and a half months, and community medicine training centre for two weeks [5]. The training is considered to be equivalent to Foundation Year One in the United Kingdom [6], and the trainees are considered as the first-line service providers in the government hospitals [7]. However, a limited clarity regarding roles and responsibilities [8] raises frustrations among them.
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2018, Journal of Surgical EducationCitation Excerpt :The new mobile platform was the only format available for participants since it simplified submission, review, and distribution. A recent randomized controlled trial comparing basic surgical skill acquisition via self-directed interactive video-based instruction or instructor-led teaching revealed no differences in performance between the 2 groups.31 This is just one of the many studies supporting computer-based instruction to teach surgical skills.