Advances in digital orthopaedic education: Techniques to enhance learning

Andrew J Hall, Rosemary J Hackney, Gavin SC Brown and Emily J Baird

Andrew Hall is a T&O SpR (SE Scotland) and PhD Research Fellow at the Scottish Hip Fracture Audit & Golden Jubilee National Hospital. His principal interest is in Sports Orthopaedics, working in professional sports as a Team Doctor for Heart of Midlothian FC and the Scottish Rugby Union.

Rosie Hackney is in her third year of run-through orthopaedic training. Her main interests include medical education and training, and global surgery.

Gavin Brown is an Honorary Consultant Orthopaedic Surgeon at Edinburgh Orthopaedics, and Senior Clinical Lecturer in Orthopaedics and Digital Education at the University of Edinburgh. His principle academic interest is the development of digital techniques in undergraduate education and surgical training.

Emily Baird is a Consultant T&O Surgeon in Edinburgh Orthopaedics at NHS Lothian Trust and Head of Education for the South East Scotland T&O Rotation, UK.

Acknowledgements: The authors would like to thank the following for their input: Joseph N Brennan Joe DT Esland Louise Chabrut (Johnson & Johnson) Scott R Morrison Jamie A Nicholson A Hamish RW Simpson Phil J Walmsley Neil RL Wickramasinghe.

Opportunity in adversity

Orthopaedics faces a monumental challenge to overcome a doubleedged educational emergency: postgraduate trainees are receiving a lower standard of surgical training as a result of reduced clinical volume, and undergraduate trainees are being discouraged from pursuing careers in surgery [1].

Many of the problems facing our clinical and educational services were brought about by the COVID-19 pandemic, however this has proved to be a catalyst for innovation. Orthopaedic training in South East Scotland has experienced growth through the adoption of digital solutions in postgraduate and undergraduate settings. Protecting the education of trainees now is key to ensuring an effective surgical workforce for the future. This article considers how advances in educational techniques might solve an impending generational crisis in orthopaedic training.

Postgraduate training

Bridging the training gap with simulated surgery

In August 2020 a focus group of trainees identified a training gap in arthroplasty procedures resulting from a nationwide decrease in elective surgical volume as a result of the COVID-19 pandemic [2]. Junior trainees felt that their position in the latent phase of the learning curve meant that they were affected disproportionately, and that the necessary prioritisation of available cases for senior trainees prevented the development of a sound foundation upon which to build their own competence.

A Total Knee Arthroplasty (TKA) Bootcamp was created for junior trainees that employed a multi-modality set of activities. This included short tutorials introducing fundamental knowledge such as indications, anatomy, and basic principles of TKA, followed by an afternoon of higher order activities including interactive workshops on patient selection and clinical discussion, technical tasks using saw-bones (Figure 1) and a VR-mediated TKA simulation (ATTUNE® Knee System VR Module, DePuy Synthes) that has been shown to be effective in arthroplasty training (Figure 2) [3,4].

Figure 1: Saw-bone component of the Total Knee Arthroplasty Bootcamp.

Figure 2: A trainee conducting a simulated total knee arthroplasty using the virtual reality module (DePuy Synthes, Johnson & Johnson).

A ‘working lunch’ encouraged discussion between trainees and the experienced faculty, and the flattened hierarchy and convivial environment facilitated curiosity-based learning that was more reflective of a clinical setting, rather than a classroom. Trainees that were not accustomed to working with industry representatives found their input especially valuable, and expressed a greater appreciation for the surgeon-rep partnership.

In the context of severely reduced clinical exposure, trainees and faculty found that the programme provided a useful reflection of an ‘ideal’ training process that mirrored the patient journey from clinical consultation, through surgical planning and management, to the consideration of complexity, complications, and continued care.

Feedback was very positive, with trainees being especially appreciative of: 1) the safety to practice power tools and arthroplasty kits without the pressures of time and sterility; 2) the chance to consider the process of TKA in detail, with expertise on hand to explain intraoperative decision-making, and 3) stimulating group discussions regarding selection, complex cases, and managing complications that replaced lost training opportunities in outpatient clinics.

There are limitations to VR simulation: unrealistic soft tissue replication; absence of faithful haptic feedback, and fixed procedural workflows. Nonetheless the VR session was extremely popular amongst the trainees and faculty. VR is not a panacea – rather a training adjunct with enormous potential to aid comprehension of surgical concepts and improve trainees’ ability to understand the process of procedures. Given the reduced volume of surgical activity, this form of simulation may add value to each learning opportunity in theatre.

Virtual Orthopaedic Trainee Education

A reduction in training opportunities and physical distancing precautions halted our region-wide postgraduate orthopaedic education programme. The Virtual Orthopaedic Trainee Education (VOTE) Programme was established in March 2020, within a week of national social distancing policies being introduced, and aimed to: 1) provide continued FRCS-specific teaching for all trainees; 2) facilitate workplacebased assessments in lieu of clinical activities; 3) maintain morale and social contact, and 4) provide opportunities for trainees to develop medical education skills through near-peer teaching and support.

There were nine live online VOTE sessions per week (reflecting the extraordinary working pattern at the time) each lasting one hour. The sessions were chaired by a consultant surgeon of the appropriate sub-specialty, and trainees were rostered to deliver a short multimedia précis of their chosen topic, with the programme aligned to the FRCS (Tr & Orth) curriculum. All sessions were recorded, generating an educational repository of over 90 hours of material for South East Scotland trainees.

Almost all trainees found the live sessions useful and the majority revisit the content online on an on-demand basis. The multimedia modality added value to the existing in-person clinical sessions, and the near-peer model strengthened buy-in from trainees. On the downside, opportunities to practice clinical examination were necessarily reduced, but this was tempered by the production of reference clinical examination videos by trainees, and group discussion was hindered by the virtual delivery method. We commend this model to other regions.

Undergraduate training

A digital orthopaedic curriculum for undergraduates

Undergraduate T&O education in South East Scotland faced a challenge ahead of the 2020-21 academic year when the University of Edinburgh curriculum was overhauled. Rotations through clinical placements were replaced with an all online delivery of specialty-specific teaching and a greater focus on ‘generic skills’ on ward and primary care placements [5]. This approach was catalysed by the COVID-19 pandemic but will endure beyond any necessary reduction in contact time, with the stated aim of this deviation from the time-served model of undergraduate education being a desire for the curriculum to facilitate the skills required by a doctor on the two-year UK Foundation Programme. This follows a nationwide trend towards reducing specialty exposure at university, preparing undergraduates primarily for ward-based roles in the early years of training, and encouraging students into generalist careers [1].

Against this difficult backdrop, the undergraduate T&O module was redesigned in order to replicate the varied clinical orthopaedic experience by creating a highly-interactive and engaging curriculum in a virtual orthopaedic learning environment.

Following the principles of Miller’s pyramid (in which learning is achieved progressively through demonstrating knowledge, competence, performance, and action) a cache of short, carefully-composed, narrated Core Lectures were made available for students to access on an on-demand basis [6]. These were supplemented resources such as BOAST and NICE Guidelines and optional sub-specialty educational materials, and a series of short, easy-toconsume Orthopaedic Quick Breaks webinars (created by SM, Acknowledgements) provided bitesize overviews of key topics.

A series of six Core Tutorials, delivered online by orthopaedic faculty, developed the fundamentals introduced in the Core Lectures, emphasised key concepts, and helped students apply new knowledge and skills to clinical contexts. Integrated online quiz functions allowed students to test their knowledge (relevant to upcoming exams), consider simulated clinical scenarios (replacing lost ‘realworld’ opportunities), and afforded real-time feedback on their learning. The module reached a climax with a highly-interactive Virtual Orthopaedic Shift – a live online activity that assimilated the themes of the course through a series of clinical cases that simulated a day as an on-call orthopaedic trainee (Figure 3).

Figure 3: Extract from the Virtual Orthopaedic Shift component of the undergraduate online module.

A particularly successful introduction to the module was the inclusion of small group T&O Clinical Breakout Sessions, facilitated by T&O trainees and Foundation Programme doctors, that aimed to: replace the lost community of learning in the clinical environment, afford junior doctors opportunities to develop teaching skills, and protect access to near-peer clinicians for support, tutelage, and mentorship. Sessionspecific workbooks developed by a senior medical student (JB, Acknowledgements) reduced the burden on tutors to increase junior doctor engagement, and served as useful ‘take home’ study tools for students.

Virtual Trauma Meeting

The Virtual Trauma Meeting (@EdinburghVTM) is a venture introduced to provide supplementary clinical orthopaedic exposure to undergraduates and junior doctors. Established by a senior medical student (JB, Acknowledgements), the monthly live online sessions provide a multimedia introduction to the orthopaedic subspecialties. Supervised by consultant specialists, T&O registrars present bespoke clinical cases for teaching and interactive discussion in a format that simulates a real clinical meeting. The series is extremely popular and continues to draw participants from across the UK.

All-online education: a future workforce problem?

Despite high levels of satisfaction with the online T&O module activities, there is evidence to suggest that students feel less prepared for clinical practice with an online teaching approach [7], which was mirrored by our own findings of an overwhelming majority of students expressing a desire to gain access to real-world T&O settings.

Further, it is of great concern that students reported online-only exposure to be inadequate to inform future career choices. In addition to a potential reduction in undergraduate interest in orthopaedic careers, a side-effect of an all-online teaching model may be a reduction in the accessibility of clinical orthopaedics. Perceptions of the specialty improve following exposure to the clinical environment, and the visibility of clinicians from minority groups helps to increase diversity in recruitment [8,9]. There is a drive to recruit more generalists from medical schools, but clinical workforces should reflect the population they serve and by reducing accessibility and visibility we risk undoing efforts to increase equity, diversity, and inclusivity.

Alarmingly, a significant proportion of students we surveyed reported a lack of confidence in their ability to conduct MSK clinical examinations to a level appropriate for basic clinical practice, as well as a perceived a deficit in informative exposure to MSK pathology. Opportunities to gain experience were severely restricted by the removal of the T&O clinical placement, and the widely-reported reluctance of non-orthopaedic clinicians to teach or observe MSK clinical examination skills compounded the neglect of this body system which accounts for one-third of all primary care visits. A recent UK-based study found that a significant proportion of undergraduates do not experience an orthopaedic clinical placement at medical school, and the duration of attachments that still exist is decreasing [10]. If we are to train more generalist clinicians then a greater emphasis on MSK health is required if they are to be competent in managing the needs of the population.

Discussion

The extraordinary events of 2020 and 2021 have revealed a deficiency in orthopaedic education that may develop into a major workforce challenge. As we strive to increase accessibility and inclusivity in our teams, and the specialty grows to meet the changing needs of the population, concerted efforts must be made to address: 1) the reduction in postgraduate surgical training opportunities, and 2) the trend towards steering pluripotent undergraduates away from surgical specialties.

These challenges must be met by us all – the Royal Colleges, specialty associations, training deaneries and programmes, academic and clinical departments, and individual clinicians. This article offers an example of some of the solutions to difficulties we’ve encountered, and describes how digital advances in medical education might support training for undergraduates and postgraduates. It’s the start of a conversation.

References

References can be found online at www.boa.ac.uk/publications/JTO.