Surgical skills training outside the operating room has become a routine part of residency training in the United States and continues to expand as an important part of residency curriculums. In resource-limited countries, where there are often few trained surgeons to care for a large population, it is often difficult to meet surgical training needs with on-the-job learning. The global burden of surgical disease has been increasingly recognized as a significant issue and, although shown to be a cost-effective area of intervention, has not been a priority in global health.1 One of the limitations of training in Uganda, as with many resource-challenged countries, is the ratio of skilled attending surgeons to the number of patients served, as well as the number of trainees.
Studies in Ethiopia and Tanzania have demonstrated feasibility as well as measurable improvement of technical skills with surgical skills training in low-resource settings.2,3 However, these studies did not address the time constraints of local faculty or the practicality of having long-term visiting faculty to allow these endeavors to be sustainable.
Inadequate access to health care is a significant factor that contributes to decreased life expectancy for pregnant women. Improving the care available by increasing the level of surgical skills acquisition and number of skilled providers fits with the Millennium Development Goal 5 of decreasing maternal mortality.4 Additionally, the Ugandan Road Map for Reduction of Maternal and Neonatal Mortality and Morbidity also has identified skills acquisition as an area of critical importance, stating that “the capacity of training is insufficient to meet the human resource needs for maternal and newborn health” and “some of the medical officers at the district hospital or health centers have no skills for maternal and newborn care, despite the critical role they are expected to play at this level.”5 We planned a feasibility study for remote teaching and learning of basic surgical skills aimed at interns who will soon practice independently in remote settings. We hypothesized that remote teaching would be superior to standard teaching for learning basic surgical skills, namely knot-tying. If effective, this teaching modality could provide a mechanism for participating in global health training without travel and reduce the teaching burden on already strained local faculty.
MATERIALS AND METHODS
The Obstetrics and Gynecology Departments of the University of California, San Francisco and Mulago Hospital at Makerere University in Kampala, Uganda, embarked on a collaboration to share education techniques and skills acquisition in the clinical and research areas of obstetrics and gynecology. As one of the first steps, faculty from the University of California, San Francisco visited Mulago to assess and compare areas of interest and need in both departments. Across the department at Mulago, surgical skills training and resources for resident, faculty, and students with a focus on development of advanced gynecology and subspecialty skills were noted as a need. Mulago is a 1,500-bed hospital with 32,000 deliveries per year, 22% of which are by cesarean delivery. There are 40 clinical faculty in the department, 35 resident physicians who are senior house officers in a 3-year training program, and rotating junior house officers (interns) who have completed medical school but are prespecialization. At Mulago Hospital, there are 80 interns per year who rotate in a group of 16–20 through the specialties of obstetrics-gynecology, pediatrics, surgery, and internal medicine for 3 months each. During their first week on the obstetrics-gynecology rotation at Mulago, interns participate in a skills course taught by a Ugandan faculty member that includes the teaching of one-handed and two-handed knot ties, instrument ties, and suturing techniques, particularly abdominal wall entry and closure and uterine closure. The course also includes instruction on obstetric emergencies and neonatal emergencies, as well as other obstetric and gynecologic skills. After 1 year of rotations as interns, these physicians will then fulfill 2 years of government service; each of these physicians possibly will be the only surgeon for a large referral area. Although Lugandan is spoken in many rural areas, all physicians in Uganda speak English and are taught in English.
We obtained institutional review board approval from Makerere University, Kampala, Uganda, and the University of California, San Francisco. In April 2012, we randomized all interns performing their obstetrics-gynecology rotation to either standard learning or standard learning and remote teaching sessions over the course of 4 weeks. We provided all of the interns in both study arms with knot-tying boards that were to be returned to the department after study completion. Our study was designed to include all interns performing the obstetrics-gynecology rotation in one 3-month intern rotation. We made videos of each intern tying two-handed surgical knots before study onset and 2 weeks after completion of the study using a small video camera, and we uploaded the video files to a file hosting service that offers cloud storage. Participants were deidentified in the videos. One University of California, San Francisco faculty member (A.K.), located in San Francisco, scored all videos using the Objective Structured Assessment of Technical Skills technique that we currently use to assess our own residents at University of California, San Francisco. Each knot was graded according to the following six categories: correct distance from the knot, crossing knots, gathering to shorten suture, laying down knots with finger, smooth recovery, and knot quality. Each category was scored from 0 to 3, for a total of 18 points.
Three faculty members at the University of California, San Francisco proctored the video teaching sessions at 6:00 AM Pacific Standard Time, which correlated with 4:00 PM Ugandan time. The teaching sessions were scheduled for 1 hour, with one University of California, San Francisco faculty member and three students taught individually during each session. A Ugandan Faculty member (Y.N.) organized and facilitated all teaching sessions. Compensation for this faculty member included travel to the United States for the presentation of this study. The faculty member provided no additional instruction and was present solely for technical support and time-keeping. Video Internet communication software was used with a laptop computer located in a designated teaching location at Mulago Hospital. Internet access was obtained through a commercially available Internet service provider in Kampala. Each intern participant was expected to have three separate teaching sessions. When possible, we distributed the students among the faculty so that each session was with a different faculty member. Interns in both groups were encouraged to practice two-handed knot-tying between video sessions. Both faculty and intern participants completed a survey at the end of the study.
Statistical analysis was performed using Fisher exact test to compare the proportion of participants whose scores improved by at least 50% in each group and those whose scores declined. Two-sided P values also are reported.
Eighteen interns participated; nine were randomized to each group and we had complete data for eight in the intervention group and seven in the control group. We found score improvement of 50% or more in six of eight (75%) in the intervention group compared with one of seven (14%) in the control group (P=.04). In the control group, five of the seven (71%) participants had scores that declined between the pretest and posttest, whereas no participant in the intervention group had declining scores (Table 1).
Fifteen interns completed the survey. Both intervention and control groups primarily used attending supervision, colleagues, and the Internet as sources for learning about two-handed knot-tying. Eighty percent of the control group practiced two-handed knots less than two times during the study time frame, whereas 80% of the intervention group practiced three or more times (P=.007). All of the interns in the intervention group enjoyed this teaching technique, and all but one found it helpful. Although the timing of the sessions was difficult, the majority liked the interactive nature of the teaching, thought remote teaching was enjoyable, thought it was equal to in-person teaching, and felt the University of California, San Francisco teachers were patient. All University of California, San Francisco faculty involved in the teaching sessions enjoyed participating and thought the interns improved their knot-tying skills (Video 1, available online at http://links.lww.com/AOG/A397).
All files were shared through a file hosting service that offers cloud storage. In addition to the nine completed sessions, two sessions had to be rescheduled because of technologic difficulties and Internet speed. One session was cancelled because the interns were on strike because they had not been compensated for 1 month. Data are incomplete for three interns who were unable to be scheduled for the remaining teaching sessions or the final video before the end of the rotation because of service obligations and availability. On average, there was one dropped call per session. Subsequent sessions required less time to complete with interns who previously had been taught with this method.
There are several potential advantages to learning basic surgical skills in a laboratory setting. Simulation allows for repetitive and deliberate practice, rather than observatory learning. Errors can be tolerated and corrected in a skills session. Additionally, developing and solidifying basic skills outside the operating room allows for a higher baseline skill level and, thus, improved learning when in the operating room. A 2011 study confirmed that ex vivo technical skills training improves technical skills in the operating room and improves cognitive retention of clinically relevant information provided verbally in the operating room.6
Previous studies have demonstrated the feasibility and success of low-cost, in-person, surgical skills laboratories in resource-restricted countries (Tanzania and Ethiopia) with shortages of skilled health care providers.2,3 There are several limitations to this type of low-cost skills laboratory. Local physician teachers are often struggling to meet the time demands of clinical care and other routine responsibilities and may not be able to dedicate time for a skills laboratory. Although visiting faculty can be scheduled for skills laboratories, there are significant financial and time constraints for this model. To make a skills training program more sustainable and available, the use of remote teaching is a viable option. This potentially allows faculty, residents, and students who are not able to travel to participate in global health education.
A 2010 study showed that telesimulation was an effective method of teaching the fundamentals of laparoscopy, demonstrating a 100% technical pass rate for the telesimulation participants as compared with a 38% pass rate in the self-practice group.7 This study required more equipment and cost than our model for basic surgical skills and targeted higher-level learners. Multiple studies have shown that low-fidelity simulation is equally effective as high-fidelity models.8,9 Interestingly, the study of the surgical skills laboratory in Ethiopia showed improvement in three different areas of skills acquisition but no improvement in knot-tying skills, the most basic of the skills tested.2
In addition to performing a feasibility and acceptability study, basic knot-tying is a critical principle required for good surgical technique and may be lacking in the skill set of practitioners performing the majority of cesarean deliveries in rural Uganda. The ability to improve this basic skill through remote teaching to early practitioners should not be overlooked. Our study found improved skills acquisition in the remote teaching participants compared with the standard practice group. There are several possible explanations for this difference. The interns in the remote teaching group self-reported practicing more. This may be because they were motivated by the fact that they were involved in the remote sessions or because knew they would be evaluated by the instructors, or because they were being observed by the Ugandan faculty member who organized the session and often also by their peers who were waiting for their turn in the teaching session. It is also possible that even the small amount of “protected time” to perform the skills sessions was a contributing factor. Another consideration is that the surgeons in Uganda often use instrument ties to conserve suture, so it is likely that the participants in the standard practice group received very little instruction about two-handed knot-tying and thus lacked feedback to correct mistakes and allow practice of proper technique, an important aspect of skills acquisition. We chose to study two-handed knot-tying because we believe it is important for surgeons to have this skill set in their armamentarium.
There are several challenges with this type of teaching program. To perform this successfully, reliable (fast) Internet access is essential. In our study, several sessions had to be rescheduled because of slow Internet, dropped calls, or work-related issues. The difference in time zone makes scheduling a challenge and requires some planning and commitment on both sides. Our study model included a local physician facilitator, which may not be possible in all settings.
Overall, it is encouraging to show that basic surgical skills (two-handed knot-tying) can be improved with a low-cost remote teaching model. We believe that this basic technology can be applied to many different surgical skills and teaching modalities. With the use of Internet cameras to help guide arm movement and body mechanics, there are many more potential surgical applications (ultrasonography and laparoscopy) and other learning opportunities (remote case discussion, Morbidity and Mortality conference). Teachers and interns enjoyed the remote teaching method and were interested in exploring additional applications.
This type of teaching is a good way to foster ongoing collaboration and to help build a meaningful relationship between departments with significant geographic constraints.
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4. The Millennium Development Goals Report 2012. New York (NY): United Nations Department of Economic and Social Affairs; 2012.
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