Using Touch Surgery to Improve Surgical Education in Low- and Middle-Income Settings: A Randomized Control Trial

doi:10.1016/j.jsurg.2017.06.016

Journal of Surgical Education

Volume 75, Issue 1, January–February 2018, Pages 231-237

https://doi.org/10.1016/j.jsurg.2017.06.016 Get rights and content

Background/Objective

There is a severe surgical workforce shortage in Rwanda. Innovative educational tools must be introduced to train more residents and increase surgical capacity. Touch Surgery (TS) is a smartphone application that offers trainees the opportunity to practice operations; however, its effect is unknown in low- and middle-income countries. Our objectives were to determine the training effect of TS and its feasibility for use in surgery education in a low-resource setting.

Design

We performed a randomized control trial of University of Rwanda surgical residents. Participants were blocked by postgraduate year and randomized to textbook or TS for learning tendon repair surgical technique. After the learning period, participants performed a tendon repair simulation, evaluated by blinded expert raters. Presimulation and postsimulation questionnaires tested their knowledge of tendon repair.

Setting

The study was conducted at the simulation center of the University Teaching Hospital of Kigali, a tertiary referral and teaching hospital.

Participants

The study included University of Rwanda surgery residents. A total 27 of 51 surgery residents (52.94%) were enrolled. Participating residents represented the following specialties: general surgery (51.85%), orthopedics (40.74%), and urology (7.41%).

Results

TS users scored 89.7% on tendon repair simulation, compared to textbook users who scored 63.4% (p < 0.001). Postsimulation questionnaires showed a significant improvement in cognitive scores for TS users (38.6%, p < 0.001), as compared to nonsignificant improvement for textbook users (15.9%, p = 0.304). About 92.3% of TS users reported that TS represents a useful training tool, and 61.5% reported that it would be a good or very good required part of the curriculum.

Conclusions

TS is a useful tool to improve both technical skills and knowledge of tendon repair procedure steps; however, its role may be limited to a supplemental tool as it does not improve the theoretical knowledge. TS has the potential to be implemented in a surgical academic curriculum in low- and middle-income countries.

Introduction

There is a severe surgical workforce shortage in Rwanda. In 2016, there were only 74 qualified surgeons for a population of 10.1 million.¹ This is in contrast to the recommended number of 20 to 40 surgical, obstetric, or anesthetic providers per 100,000 population.² To address this surgical workforce shortage, efforts must focus on increasing the rate and quality of training medical students and surgery residents. However, a lack of faculty trainers significantly limits the mentorship and education necessary for surgical human resource capacity-building. Innovative tools are essential to provide new and effective ways of training a surgical workforce. By increasing access to surgical simulation and improving surgical education in Rwanda, we may ultimately meet the surgical burden of disease.

Smartphones serve an increasing role in medicine, from monitoring and diagnosing patients to more efficient medical education and communication.³ Technology-enhanced simulation in health professions training has been consistently associated with a large effect on knowledge, skills, and behaviors.⁴ Recent studies have shown that smartphone simulation applications can contribute to improve cognitive and technical skills in surgery education in high-income countries.⁵ A study done in Kenya showed smartphone-based learning is becoming increasingly popular with medical students owning a smart device.⁶ In addition, the use of smartphone-based applications for clinical decision-making was shown to be prevalent among junior clinicians in Ghana.⁷ However, to our knowledge, there are no studies regarding the use of smartphone applications for surgical education in low- and middle-income countries (LMICs).

Touch Surgery (TS) is a clinical smartphone application that offers surgeons and trainees the opportunity to practice key stages of common operations, like laparoscopic cholecystectomy, intramedullary femoral nailing , tendon repair, and other procedures. The application provides a hands-on experience for learners to improve knowledge of the steps of an operation.⁵ TS has demonstrated construct, face, and content validity.8, 9 When used as a learning tool in a high-income setting, TS users demonstrated a significant training effect with practice.⁸ In addition, novices demonstrated cognitive competencies to ensure patient safety before operating.⁸ TS has been shown to be an effective adjunct to traditional learning methods with potential for curricular implementation, and in one study was shown to be more productive than traditional reading.8, 10, 11 However, its effect on cognitive and technical skills is unknown in LMICs.

This study aims to determine the effect of TS on technical and cognitive skills in low- and middle-income settings. This study also aims to assess the feasibility of TS in surgery education in low-resource settings by assessing opinions of trainees on its usefulness and value in surgical academic curriculum in LMICs. This study hypothesizes surgical simulation with TS improves surgical residents’ cognitive and technical performance in Rwanda.

Section snippets

Study Setting and Intervention

Rwanda is a country of 11.5 million in East Africa. In 2014, there were 110,857 surgical procedures performed, which is 961 major operations per 100,000 population.¹² There are an estimated 74 surgeons for the population of Rwanda.¹ The University Teaching Hospital of Kigali (Centre Hospitalier Universitaire de Kigali), is a public, tertiary referral hospital in the capital city of Kigali, Rwanda. It is one of the main teaching hospitals for surgical trainees. This study took place at the

Results

Of 51 total University of Rwanda surgery residents, 27 residents (52.94%) were enrolled in our study. Of the total participating residents, the following surgical specialties were represented: general surgery (51.85%), orthopedics (40.74%), and urology (7.41%). Among participants, 25.93% were postgraduate year one (PGY-1), 33.33% were PGY-2, 14.81% were PGY-3, 7.41% were PGY-4, and 13.52% were PGY-5. About 25 participants (92.59%) were male and 2 participants (7.41%) were female (Table 1).

Discussion

The aim of this study was to determine the effect of TS on technical and cognitive surgical skills in low- and middle-income settings, and to assess the feasibility and value of TS in a surgical academic curriculum in LMICs. We hypothesized using TS to review tendon repair would improve the cognitive and technical performance of University of Rwanda surgery residents in a simulation.

The results of this study partially confirmed our hypothesis using the TS tendon repair-based module improves

Conclusions

TS has been shown to be a useful tool to improve both operative skills. However further studies need to be done to determine how to best integrate TS into current surgical education methods. Users reported it to be a useful and feasible educational tool, despite the need for technology. TS has the potential to be implemented in a surgical academic curriculum in low- and middle-income settings. This is important as the platform allows for self-directed practice without requiring the time or

Acknowledgements

We acknowledge Ali Bahsoun for the support of this work.

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¹: Joint first authorship.

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Original ReportsUsing Touch Surgery to Improve Surgical Education in Low- and Middle-Income Settings: A Randomized Control Trial

Background/Objective

Design

Setting

Participants

Results

Conclusions

Introduction

Section snippets

Study Setting and Intervention

Results

Discussion

Conclusions

Acknowledgements

Lancet

Injury

Injury

Semin Thorac Cardiovasc Surg

Am J Surg

Original Reports
Using Touch Surgery to Improve Surgical Education in Low- and Middle-Income Settings: A Randomized Control Trial