A questionnaire-based study on the use of medical simulation models by Greek General Practice and General Surgery residents; testing hand-made models as low-cost alternatives.
The introduction of simulation models in medical education had a long history, before it comes into industrial interests. With peculiar hand- made models many surgeons used to struggle to educate their team, for essentials in surgery, in many countries worldwide. To use the patient for visualizing things in teaching, is not conformed with human rights when the patient is not in good physical condition, does not feel well, does not agree to participate to the "lesson", and students are not yet able to handle the patient's complaints. So, sometimes, instructors used to invent simulation "creatures" with very short life on earth (each one was used for one time only); and this was the only way to show to many residents or students something that you could not show on the patient. Even if the patient agrees to help, there are some techniques that cannot be shown repeatedly on the patient, as for example the digital rectal examination. In such cases, the patient would tolerate one or two examiners, but would not stand it for more [although the opposite has somewhere on earth happened (!) and this is of course a violation of human rights]. For such occasions, but mainly for the needs of teaching resuscitation courses, professionally designed "toys and dolls" for practicing purposes, were introduced to help medical education through simulation.
This way of education has been used in a respectable degree in many countries, but in Greece the use of simulation models, although spreading in congresses and courses, is practically limited to zero in the work environment; it does not have the precious use of education at home, due to the high costs needed for buying the various existing models in the market (available for online orders by foreign online shops only). In Greece, you can see simulation models only in courses, and there is not even one representative company to have a serious interest for the trade of simulation models in the country, except for resuscitation dolls, that have been used, on a rental basis, mainly by anesthesiologists and ICU clinicians in courses for teaching resuscitation.
The messy situation with simulation models in Greece, is probably a result of a general confuse and lack of interest on the proper education needs of residents in Hospitals. In current clinical practice, residents are mostly offering managerial work in Hospitals, and less medical (1), while education is offered on the basis of essential help for training doctors who do not belong to the network of nepotistic/corporate elites of public Hospitals. (2) This makes training doctors very disappointed from their education, and obliges them to participate to courses for "completing" the education they did not receive inside Hospitals. In practice, most of them receive essentials in courses and pay for knowledge they had the right to receive for free. This has made the organizers of the courses lose every control regarding participation fees, with fees reaching to 500 Euros for a course of 30 minutes duration, and 1500 Euros for longer courses, and create scenes like 12 persons looking one pig operated by the instructor (or not looking anything if they are not tall). This leads to many useless certificates and many expenses, but unfortunately again to disappointment as far as real education is concerned.
This study was made with a questionnaire based research; questionnaires were distributed to Greek residents at the first year of education in General Surgery or General Practice (GP), and has the aim to investigate:
a) The residents' opinion about the usefulness of simulation models in Medical education, and the models' role in the various stages of medical education,
b) The residents' opinion about the possible use of simulation models for home practice &
c) The usefulness of simulation models for special purposes (specialized questionnaire)
d) Finally, the residents' attitudes and perceptions of the future of medical education (with or without simulation models).
Material and Methods
During 2006-2008, a series of free courses was organized using professional and hand-made simulation models for young residents in General Surgery and GP. Some days after the end of the courses (2-7 days) questionnaires about the use of simulation models were distributed. In total 500 questionnaires were distributed. A number of 434 completed questionnaires were submitted. The respondents were 198 residents in General Surgery and 236 residents in GP, 299 men and 135 women, aged 28,8[+ or -]1,2 for men and 28,4[+ or -]1,5 years for women respectively. The general questionnaire is shown in Table 1. For statistical analysis the Student's t-test was used.
Types of (professionally produced) simulation models used in the courses
1. Rescucitation doll (adult, child and neonatal model).
2. IVN (Intravenous Hyperalimentation) Care Simulator: A teaching aid for explaining central venous catheterisation and the proper care of patients receiving Total Parental Nutrition (TPN) and Intravenous Hyperalimentation (IVH).
3. Tracheotomy model simulator.
4. Simulator for practicing fiberoptic tracheal intubation.
5. Simulator for regional anaesthesia blocks.
Types of hand-made simulation models used
1. Hernia repair models for open surgery: these were made for the education of the anatomy of hernia, of the pathophysiology of hernia formation and in order to teach the essentials of surgical repair in detail.
2. Bleeding Esophagus model: This was made for the education of upper gastrointestinal bleeding for GP residents with the use of Sengstagen--Blakemore catheter and without.
3. Thoracostomy model: This was made for teaching emergency thoracostomy to both surgical residents and GP residents.
4. Peritoneal lavage model: This was made for teaching the essentials for surgical approach of peritoneal lavage to surgical residents. Altough this technique is theoretically replaced by abdominal CT in trauma patients, many Greek Hospitals do not offer emergency CT (especially in small rural Hospitals, or very often if the CT equipment has technical problems), so in that case peritoneal lavage is very useful in clinical decision making.
The offered simulation models were assessed by the residents in detail, giving in general positive results. The answers given in the general questionnaire are shown in Table 2, where 434 answers were given (N=434). Home practice was the first choice of all asked doctors, which is explained by the fact that the time devoted to education in Greek Hospitals is lasting enormously less than the time they are working. (1) They seem to thoroughly understand the role of simulation models for essentials' teaching and for introducing new techniques as well, but they generally don't like hand-made simulation models (at least the ones they experienced in the courses).
The GP residents (Table 3) are not satisfied by the medical education they receive in their hospitals and agreed that the future offered to them is not encouraging. It is obvious that simulation models are important for their education (100% agreement) , but only one out of 3 supported that the clinical approach to the patient would be differentiated if he had the experience in simulation models first, result that reflects confusing perceptions of what exactly teaching with simulators offer. All believe that education on patients cannot be replaced by simulators, but also accept that emergencies are not taught in adequate degree to young GP residents. The 27,96% pay more than 1000 Euros a year for congresses that include courses with simulators. All of them agree that certificates provided in congresses do not reflect the real education offered.
General Surgery residents do not receive the education they need (100%). More than half agree that they need simulation models for been educated properly (55,05%). They also note that approach to the clinical examination and surgical skills changes if it is taught in simulation models before (71,71%). The surgical resident would not feel confident in emergencies if was educated in simulators only (100%). However, General Surgery residents stated that they do not receive adequate education in emergencies on patients (71,22%). All of them pay more than 1000 Euros for congresses that offer training with simulation models for surgical skills, and all agree that certificates of congresses do not reflect the real value of education offered. They are all dissatisfied with the future offered as far as medical education is concerned (100%).
For hernia surgery, the 44,95% answered that they do not need to receive lessons in hernia surgery through simulators. On the contrary, all surgical residents agree that they need lessons in colorectal surgery,trachea surgery and thyroid surgery, via simulators. Role-playing in surgical team is not properly taught in the Operation Theatre, according to the 79,29% , while this succeeded in the team of the course provided with the help of simulators (100%). The surgical residents admitted that they don't have equal chances with other residents in their Department (85,35%), and all believe that surgical skills can be acquired at home via simulation models.
Table 5 includes the most interesting answers among the common questions in Tables 3 and 4. We see that GPs seem to be assessing the value of simulation models as higher, in comparison to General Surgery residents (answer Q2). A very interesting answer was that 71,71% of General Surgery residents assess that their clinical approach and skills would be different if they were taught in simulation models first, while only the half of GPs believe the same, which shows that skills needed for surgeons are much more in number and more complicated than the ones needed in General Practice, so detailed instructions are needed, and in the operation theater many times there is not the needed time for a detailed lesson to be given. About their experience in emergencies, we see that the 28,78% feel that they have received adequate education for emergencies, which is at least better than the 0% percentage in the answers of GP residents. This probably happens because in large Hospitals, like the ones Thessaloniki has, GPs have a secondary role, which is lower than the role of a nurse in the emergencies team. This happens because the GP residents stay in the Surgical Department for only 3 months for education, and this makes them almost invisible for the instructors. (3) There is not any control to the instructors, and this makes GP residents' education mostly depending on the willingness of senior surgical residents to help them learn essentials in emergencies, and the same usually happens in internal medicine emergencies, too. About the expenses for courses with simulation models, we see that more surgical residents spend money for simulation teaching courses than GP residents, probably because they need to learn more techniques. This answer however is in contrast with the answers given in question Q2 (if residents need simulation models) where General Surgery residents answered "No" at the percentage of 44,95%. The question is, if they do not need simulation models , why do they pay more than GPs? This probably happens because although they would like to receive more education in the Operation Theatre and generally prefer to be educated in the Operation Theatre as ideal educational way, this does not happen, so they have to find a substitute in the education with simulation models, in order to be educated, even in plastic dolls.
Inadequate medical education is a longstanding problem and simulation models may help a lot, especially via the innovation of home self-education and practice. Because Greek hospitals use training doctors more for working than for receiving new knowledge in Greece1, training doctors would be very much helped if they had the luxury of simulation models at home. For surgeons in particular, home practice with simulation models is very important as the surgeon acquires autonomy in his surgical skills knowledge and confidence, and it is pioneering because the surgical resident this way is not dependent to the teaching Hospital's adequacy (or inadequacy). (4)
The cost of simulation models can be very low with the use of simple materials, used in the everyday practice. Although professionally made simulation models are very expensive, simple models made by the instructors could help a lot. Even papaya was used efficiently as simulation model for training in uterine aspiration! (5) The courses that use simulation models have 10-fold price, because these products are not available in shops in Greece. Except for the expenses, that some residents may pay, many Greek doctors become dependent on pharmaceutical industries because the companies pay for their participation fees. (6)
The general culture and perceptions of training doctors play a very important role for the education they finally receive. Training doctors are not organised in associations in Greece, and therefore cannot demand their rights in education efficiently although they are not satisfied with the education provided. In Greece, training doctors have a mixed culture and very confused perceptions for education needs, about what is a successful career in Medicine and how to pursue it. In particular, the relationship of instructors and trainees is something like the relationship between Spartans and Helots. (7) This situation does not include all training doctors, because relatives and children of economically powerful and influential families have a special treatment and receive absolutely supreme education in comparison to the general "mass".
Emmez H et al (8), created a skull simulation model for the surgical treatment of brachycephaly. This model was available for mature surgeons for preoperative surgical planning and with the goal to find new techniques, predict the outcome of the operation, use the model in all complex and syndromic craniosynostoses for both better results and reducing the operative time and associated blood loss. Thomas et al (9), used simulation models to teach teamwork during a Neonatal Resuscitation Program; they emphasized that because clinicians are not provided teamwork training in medical and nursing schools, things like information sharing, inquiry and assertion, vigilance and workload management may not be taught and may lead to lower efficiency in resuscitation practice. Dorman et al (10) used simulation models for essential surgical skills in order to educate surgical residents in Ethiopia, with the goal to help the severe shortage of health care providers in Ethiopia and educate as many residents as possible. In an other study by Laskowski et al (11) simulation models for emergency medicine cases were used in order to reduce the waiting time of the patients. All the above mentioned researchers, used simulation models for different reasons; for better planning of operations by abvanced surgeons, for teaching teamwork, for teaching more persons or for improving working rhythms. What is needed for Greek hospitals is closely to the study conducted in Ethiopia, with some different points. In Ethiopia they do not have many skilled doctors to instruct many residents and have many patients, that is why they need more instructors and simulation models. In Greece on the other hand, there are instructors, but they do not instruct all existing residents, but only the ones who are "in" the system of nepotistic networks and corporate elites. (2)
As far as special surgical techniques are concerned, there are two problems for Greek residents. The one is that the education they receive is incomplete or absolutely absent for advanced surgical techniques. (12) Because residents do not have (or think they do not have) ways to press instructors for better education (or for just essential education) they accept to deal with hernia surgery only and minor surgery in general. This creates in the long term 2 categories of surgeons; the ones who can operate advanced cases and the surgeons with basic skills; (13) this is of course not accidental or fatal, but an absolutely scheduled " educational program", made by the in-Hospital-established "mafias". (2) In full sychronisation with the previously reported facts, the Greek Ministry of Health pushed in the law-system the official name for this kind of doctors; the name is "Assistant Physicians" and can belong to all medical specialties (assistant surgeons, assistant pediatricians, etc). These doctors work on 1 year contracts to rural Hospitals mostly, and of course until they get to know their work environment, colleagues and patients of the area, they have to leave, so their prospects are zero. The other problem of surgical residents is that when they receive the specialty title they have to pay huge amounts to learn something in half-an-hour courses in congresses, among dozens of others, or to take their place in primary surgical clinical practice and stop hoping for something more. The problem in reality is not only caused by the "instructors' evil network", but it is equally caused by the ignorance shown by surgical residents for their own rights (and for their patients'rights to have better services in the long term). Because in Medicine we do not fight for ourselves when we demand good education, we fight for our future patients who have the right to receive a minimal level of health services. Unfortunately, most of those who are visiting luxury hotels to be educated in courses, are fighting for the minimal level.
Although hernia surgery is thought to be easy, it is much easier to be taught out of the operating theatre, because this way you can teach step by step every resident, even the ones who have not studied hernia anatomy at home. Hernia simulation models have been introduced in the market with success, but they are not used in Greece, not even in courses. Many residents (44,95%) who answered that hernia is adequately taught in the Operation theatre, and hernia simulation models are not needed, derives from the fact that they were not aware of the needs for the management of recurrent hernias and complex hernias problems. This is due to the fact only young surgeons, coming from the 1st year of residency were asked. On the contrary, they seem to be aware of the needs they have in colorectal surgery, thyroid and trachea surgery.
(1.) Christodoulou Ir. Managerial work in Hospitals; is this Medicine? Archives Inter J Med 2009;2(3):255-6.
(2.) Christodoulou I. Nepotism in Medicine and the concept of franchising. Archives Inter J Med 2008;1(2):58-61.
(3.) Christodoulou I, Charalabidis P, Kardassis D, Pogonidis C, Xenodoxidou E. Evaluation of the surgical education offered to general practitioners. Hellenic Journal of Surgery 2007;79:175-180.
(4.) Christodoulou I, Babalis D. Surgeons left behind-The real percentage of uneducated surgeons in Laparoscopic Surgery. Archives Inter J Med 2008;1(1):48-54.
(5.) Paul M and Nobel K. Papaya: A Simulation Model for Training in Uterine Aspiration. Family Medicine 2005;37(4):242-244.
(6.) Christodoulou I. Truth and Myth for free health services in Greece. Inter J Health Science 2008;1(1):2-4.
(7.) Lendering J. Helots. In: (Online Edition) Livius. Articles on Ancient History. Available at http://www.livius.org/so-st/sparta/helots.html.
(8.) Emmez H, Kucukoduk I, Borcek AO, Kale A, Secen E, Erba[degrees] G, et al. Effectiveness of skull models and surgical simulation: comparison of outcome between different surgical techniques in patients with isolated brachycephaly. Childs Nerv Syst. 2009; DOI 10.1007/s00381-009-0939-y [In Press].
(9.) Thomas EJ, Taggart B, Crandell S, Lasky RE, Williams AL, Love LJ, et al. Teaching teamwork during the Neonatal Resuscitation Program: a randomized trial. J Perinatol. 2007;27(7):409-14.
(10.) Dorman K, Satterthwaite L, Howard A, Woodrow S, Derbew M, Reznick R, Dubrowski A. Addressing the severe shortage of health care providers in Ethiopia: bench model teaching of technical skills. Med Educ. 2009;43(7):621-627.
(11.) Laskowski M, McLeod RD, Friesen MR, Podaima BW, Alfa AS. Models of emergency departments for reducing patient waiting times. PLoS One. 2009;4(7):e6127.
(12.) Christodoulou I. Pancreatectomy is still a myth for young surgeons in Greece. HPB (Oxford) 2006; 8(S1): 2-22.
(13.) Christodoulou I. The good doctor profile in Greece; a multifaceted opinion. Archives Inter J Med 2009;2(2):213-4.
B' Surgical Department, Papanikolaou Hospital, Thessaloniki, Greece
Address correspondence to: Irene Christodoulou 8 Heronias Str, Sikies, 56626, Thessaloniki,Greece Tel.+30 2310613736 E-mail: Irene-christodoulou@ hotmail.com
Table 1. Questionnaire for the Assessment of Simulation Models in Medical Education (ASMME) G1. Do you think that simulation models are helpful in medical education in general? G2. Do you think that the role of simulation models is important in the first steps of residents in new examination approaches and techniques? G3. Are simulation models necessary for current medical education needs? G4. Should simulation models be used for the introduction of new techniques in the education of mature surgeons? G5. Do you agree with the opinion that home practice of training doctors with simulation models would improve their performance in Hospitals? G6. Do you agree with the opinion that simulation models should be used in congresses only? G7. Do you agree with the policy of making the in-Hospital education during the first training year with simulation models only? G8. If you were offered a set of simulation models for free, would you practice at home? G9. Do you find that simulation models are expensive to be bought by individuals? G10. Do you find that hand-made simulation models are helpful for educational purposes in Medicine and for practicing new skills? Table 2. Answers on the Questionnaire for the Assessment of Simulation Models in Medical Education (ASMME) G1. Do you think that simulation models are Yes: 100% helpful in medical education in general? G2. Do you think that the role of simulation models Yes:100% is important in the first steps of residents in new examination approaches and techniques? G3. Are simulation models necessary for current No:25.29% medical education needs? G4. Should simulation models be used for the Yes 93.31% introduction of new techniques in the education of mature surgeons? G5. Do you agree with the opinion that home Yes:100% practice of training doctors with simulation models would improve their performance in Hospitals? G6. Do you agree with the opinion that simulation No: 100% models should be used in congresses only? G7. Do you agree with the policy of making the No:100% in-Hospital education during the first training year with simulation models only? G8. If you were offered a set of simulation models Yes:100% for free. would you practice at home? G9. Do you find that simulation models are Yes:88% expensive to be bought by individuals? G10. Do you find that hand-made simulation models Yes:17.51% are helpful for educational purposes in Medicine and for practicing in new skills? Table 3. Questionnaire of General Practice residents --Completed (N=236) Q1. Do GP residents receive the education they need? No: 100% Q2. Do GP residents need simulation models for been Yes:100% educated properly? Q3. Does approach to the clinical examination changes Yes:33% if it is taught in simulation models before? Q4. Is the GP resident confident in emergencies if No: 100% educated in simulators only? Q5. Do GP residents receive adequate education in No:100% emergencies on patients? Q6. How much do you pay for congresses that offer More than training with simulation models for GPs? 1000Eurosa year 27.%% Q7. Do certificates of congresses show the real No: 100% education offered in congresses? Q8. Are you satisfied with the future offered to you No:100% as far as medical education is concerned? Table 4. Questionnaire of General Surgery residents --Completed (N=198) Q1 Do General Surgery residents receive the No: 100% education they need? Q2 Do General Surgery residents need simulation Yes 55.05% models for been educated properly? Q3 Does approach to the clinical examination and Yes 71.71% surgical skills change if it is taught in simulation models before? Q4 Is the General Surgery resident confident in No: 100% emergencies if educated in simulators only? Q5 Do General Surgery residents receive adequate Yes 28.78% education in emergencies on patients? Q6 How much do you pay for congresses that offer More training with simulation models for General than 1000 Surgeons? Euros per year:100% Q7 Do certificates of congresses show the real No: 100% education offered in congresses? Q8 Are you satisfied with the future offered to No: 100% you as far as medical education is concerned? Q9 Do you need to receive lessons in hernia surgery Yes 55.05% through simulators? Q10 Do you need to receive lessons in colorectal Yes: 100% surgery via simulation? Q11 Do you need to receive lessons in trachea Yes: 100% surgery via simulation? Q12 Do you need to receive lessons in thyroid Yes: 100% surgery via simulation? Q13 Is role-playing in surgical team properly No: 79.29% taught in the Operation Theatre? Q14 Was role-playing in surgical team properly Yes: 100% taught in the recent simulation courses? Q15 Do you have equal chances with all other No: 85.35% residents in your Department? Q16 Can surgical skills be acquired at home via Yes: 100% simulation models? Table 5. Comparison of the attitude of GP residents and General Surgery residents towards Medical Education and medical simulation models' use (only the different options are reported). Q2 Do GP/General Surgery residents need GP: Yes-100% simulation models for been educated properly? General Surgery: Yes- 55.05% Q3 Does approach to the clinical examina- GP:Yes-33% tion and surgical skills change if taught in simulation models before? General Surgery: Yes -71.71% Q5 Do GP/general surgery residents receive GP:Yes-0% adequate education in emergencies on patients? General Surgery.-Yes-28.78% Q6 Do you pay more than 1000 Euros per year GP:Yes-27.96% for congresses that offer training with General Surgery:100% simulation models for general practitioners/general surgeons?
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