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Article

Effectivity of Distance Learning in the Training of Basic Surgical Skills—A Randomized Controlled Trial

by
Zsolt Balázs Pintér
1,2,3,†,
Péter Maróti
1,4,5,†,
Eszter Kopjár
1,6,
Balázs Gasz
7,
Zsófia Duga
8,
Szilárd Rendeki
1,9,
Bálint Nagy
9,10,
Zsuzsanna Füzesi
2,11 and
Ádám Tibor Schlégl
1,11,12,*
1
Medical Skills Education and Innovation Centre, Medical School, University of Pécs, Szigeti út 12, H-7624 Pécs, Hungary
2
Department of Behavioural Sciences, Medical School, University of Pécs, Szigeti út 12, H-7624 Pécs, Hungary
3
Department of Oto-Rhino-Laryngology, Maxillo-Facial and Oral Surgery, St. John’s Hospital and North Buda Unified Hospitals, Diós Árok 1-3, H-1112 Budapest, Hungary
4
3D Printing and Visualization Centre, University of Pécs, Boszorkány út 2, H-7624 Pécs, Hungary
5
Department of Public Health Medicine, Medical School, University of Pécs, Szigeti út 12, H-7624 Pécs, Hungary
6
Department of Oto-Rhino-Laryngology, Medical School, University of Pécs, Munkácsy M. u. 2, H-7621 Pécs, Hungary
7
Department of Surgical Research and Techniques, Medical School, University of Pécs, Szigeti út 12, H-7624 Pécs, Hungary
8
Marketing and Communications Department, Medical School, University of Pécs, Szigeti út 12, H-7624 Pécs, Hungary
9
Department of Anaesthesiology and Intensive Therapy, Clinical Center, Medical School, University of Pécs, Ifjúság 14. útja 13, H-7624 Pécs, Hungary
10
Department of Operational Medicine, Medical School, University of Pécs, Szigeti út 12, H-7624 Pécs, Hungary
11
Division of Medical Education Development and Communication, Medical School, University of Pécs, Szigeti út 12, H-7624 Pécs, Hungary
12
Department of Orthopaedics, Medical School, University of Pécs, Akác u. 1, H-7632 Pécs, Hungary
 
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*
Author to whom correspondence should be addressed.
†
These authors contributed equally to this work.
Sustainability 2022, 14(8), 4727; https://doi.org/10.3390/su14084727
Submission received: 28 February 2022 / Revised: 6 April 2022 / Accepted: 12 April 2022 / Published: 14 April 2022
(This article belongs to the Special Issue Hands-On Science: Developing a Sustainable Education System)
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Abstract

:
Background: Distance learning is an interactive way of education when teachers and students are physically separated. Our purpose was to examine its effectivity in training of basic surgical techniques and to provide an alternative sustainable methodology for the training of medical professionals. Methods: Sixty students were involved in our single blinded randomized controlled study. Six homogenized groups were created then randomized into three groups of distance learning and three groups of in-person teaching. The groups completed the same curriculum using our own “SkillBox”. All students took the same pre- and post-course test evaluated blindly. The students filled out an online feedback form after the course. A financial analysis was also made. Results: There was no significant difference in the post-course exam results (distance 28.200 vs. in-person 25.200). We managed to achieve significantly better improvements in the distance learning of suturing (distance 19.967 vs. in-person 15.900, p = 0.043). According to 93% of the study group students, the quality of teaching did not decrease compared to the traditional classes. Conclusion: The results of the students improved similarly in distance learning and in-person education. The online form of teaching was received positively among the students; they found it an effective and good alternative.

1. Introduction

Online education has been present in the modern school system for a while; however, since the outbreak of the COVID-19 pandemic, its importance has increased dramatically. The pandemic forced most universities worldwide to convert to online education abruptly with limited time and resources [1]. Most medical instruments require a lot of practice to learn how to properly use them. Although some recommendations of how to provide a safe environment for patient care and education using easily accessible tools can be found in the literature, due to the high risk of COVID-19 infection, a lot of medical schools terminated teaching students at hospitals. As a consequence, the students could practice certain medical and surgical skills less often, which may negatively affect their ability to examine patients properly or perform basic procedures and will also potentially decrease their confidence [2,3]. The COVID-19 pandemic challenged medical schools to provide quality practical education in this exceptional environment [4]. The pandemic also had a huge impact on postgraduate education. Surgical residents face challenges considering their education during the pandemic [5,6,7], elective surgeries were suspended in most countries, with only emergency surgeries performed following state regulations [8,9,10,11].
However, surgical education has been changing since before the pandemic. Residents must perform under pressure and try to measure up to the expectations of others, which may shorten the time available for practicing skills. To provide high-level education, the traditional mentor–resident method needs to be improved and reformed. The development of technology, especially e-learning, can play an important role in this intention [12].
As recent research works highlighted, there is an urgent need to discuss and critically evaluate digital learning environments, including social and emotional impact on learners, teachers and education facilities as well [13]. One of the most commonly used terms is “e-learning”. Generally, e-learning refers to the performance of teaching and learning activities using electric media and transfer information, learning materials, and skills through electronic technologies [13]. With the widespread and rapidly increasing use of internet-based technologies, nowadays it is referred as “web-based education oriented” activities [14,15]. Traditionally, there are two methods of e-learning: distance education and computer-assisted education. The term “distance learning” refers to the “formalized instructional learning where the time/geographic situation constrains learning by not affording in-person contact between student and instructor”, or in other words, more generally, it means an educational method which can be characterized with “some form of instruction occurs between two parties (a learner and an instructor), it is held at different times and/or places, and uses varying forms of instructional materials” [14,16,17]. Computer-assisted education can be used to distribute multimedia files for both learning and teaching, and it is usually self-directed, which can cause the lack of student engagement and needs time and effort from the teachers to prepare the digital teaching materials [18,19,20,21]. Moreover, there are other interesting, engaging and interactive ways of distance education. For example, Collaborative Virtual Walls (CVW) offer a flexible, dynamic solution for exchanging ideas; moreover, it can increase the activity of the participants by allowing teachers to provide creative and interesting tasks outside from the classroom [22]. Massive Open Online Courses (MOOC) also help in the engagement of the students, involving them as an active participant of the learning process and considered an effective method in the development of skills. It has the benefit that the assimilation of knowledge can be provided any time, from anywhere [22,23,24].
Nowadays, several kinds of educational materials are available (videos, podcasts, microblogs, etc.) using different kinds of teaching methods, such as online lectures or virtual case reports. Although the benefits and cost effectiveness of e-learning have been proven, many authors draw attention to the disadvantages particularly because the quality of free content available on the internet is mostly not assessed and validated [25,26,27,28,29]. There are many studies discussing the disadvantages of the different methods of e-learning [30,31]. The most commonly referenced drawback of self-directed e-learning is the lack of interaction, not only between the student and the teacher, but among the students as well [32]. Although the use of e-learning and distance education is widely accepted in many fields of higher education, including medical training, there is limited experience of its use when teaching basic surgical skills. Citak et al. created an online curriculum about trauma surgeries which was used to implement lectures. In total, 309 students were involved in the study, 80% of which found this form of teaching constructive and helpful [33]. Michael Co et al. investigated the effectivity of web-based surgical skill learning session (WSSL) among graduate students, based on the modified version of OSATS, and they found that found that the outcomes of WSSL are comparable with standard, face-to-face tutorials [34]. Bernardo et al. instructed a five-week-long online surgical course for 56 students. A significant improvement was observed in the scores of the students after the course. No control group was involved [35]. Previous studies have also highlighted that the standardization in content creation and rater training must be improved, and cost-effectivity must be evaluated as well [36]. Another recent review highlights that several studies raised awareness about the satisfaction of students regarding online methods. In this study, 6069 students reported that this form of education is not effective enough. The conclusions remark that this phenomenon can be balanced with frequent communication between the instructor and the student, which underlines a major advantage of instructor-led distance learning [37]. It is important to note that some studies indicate the lack of digital skills and competencies among teachers based on the opinion of students [38], while they are engaged towards personal development and improving their digital competencies, according to a recent study [39]. The importance of digital skills education is more emphasized in the older adult population because their technological knowledge is on a lower level in general [40]; both students and teachers should be aware of having the adequate digital competencies [41], which is not only a personal responsibility; also, governments, decision and policy makers, and educational institutions have to work together in the development of ICT (Information and Communications Technology) skills on a population level [39,42].
The definition of basic surgical skills varies according to regions, universities, and specialties. Although, all publications have a few common points—handling instruments, knotting and suturing wounds, because all physicians (not only surgeons) need to be able to close a wound, secure a central line or a chest drain, etc. [43,44,45,46].
Since its introduction in 1997 by Martin et al., the Objective Structured Assessment of Technical Skills (OSATS) is one of the most widely used and accepted methods to evaluate surgical skills. Several modifications were published since then, not only to increase its validity but also to adapt it to specific skills or conditions. Despite this, the main characteristics of the method remain—the use of global rating scale, the use of task-specific checklist, the use of multiple tasks or stations and the need of continuous observation and evaluation [47,48,49,50].
In the literature, we did not find a study that used direct evaluation methods, such as discrete activity assessment in order to measure the effectiveness of teaching basic surgical skills online for graduate students, in terms of student satisfaction and learning outcomes [51]. Therefore, the aim of our study was to define the effectiveness of distance education in the teaching of basic surgical skills and comparing this to traditional hands-on teaching methods with a controlled study. The findings of the presented research work could potentially contribute to the emerging field of both online and distance learning, which appears as a major challenge in the training of healthcare professionals, mainly in terms of hands-on trainings and practical skills. The presented method and the conclusions also aim to inspire further investigations on the field of medical education; therefore, it is hoped that other skills-based courses will be investigated in the digital environment.

2. Materials and Methods

The goal of this study was to investigate the effectiveness of distance education related to basic surgical skills using objective methodology. We have hypothesized that an online, distance learning course with proper training tools can be as effective as a “normal” in-person course in the field of basic surgical skills.
Study design: Methodological triangulation of a single blinded randomized controlled trial, a self-administered online anonymous questionnaire and a financial analysis.
Enrollment: University of Pécs, Medical School

2.1. Study Population

The sample size was estimated to be 58 persons. The average exam results from the previous 2 years were taken for basis, and three points difference was anticipated between the control and the study groups (alpha was set to 0.05, and beta to 0.1). Therefore, 60 students were involved in our study (28 males, 32 females, average age: 22.8 ± 3.4 years). The students must complete the ‘Basics of Surgery’ obligatory course for the third-year pre-clinical curriculum of our university to be involved (this course covers theoretical and manual fundamentals of surgery and operation techniques, e.g., structure of an operating room, basics of asepsis, physiology and pathology of wound healing, surgical instruments, basics of knotting, suturing and laparoscopy); however, the students should not accomplish the surgery summer practice after the eighth semester or any other course to improve surgical skills. Therefore, participants were third- and fourth-year medical students. Accordingly, we believe the students had the same opportunity to practice and attain the mastery of the examined skills before our training.
Three practicing clinical physicians from a manual medical profession with a minimum of 3 years of teaching experience created the teaching staff (instructors). Every instructor taught a study and a control group.
Three senior instructors with at least 10 years of teaching and 5 years of examination experience as clinical specialists working in a manual profession were involved to evaluate the exams (senior instructors).
The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Institutional and Regional Ethical Review Board of University (8443—PTE 2020). Informed Consent Statement: Written informed consent was obtained from study participants. All participant agreed to take part in the study and approved the use of their data for research purposes.

2.2. Study Protocol

In order to perform the planned study, the following protocol was followed by the research group (Figure 1).
Prior to the course, all students underwent a preliminary test. In doing so, we assessed their existing skills in surgical knotting techniques and basic suture techniques. Knotting and suturing exercises were recorded on video, which was evaluated anonymously by the three senior instructors. We took into account the average of the scores given by the senior instructors (you can find the details of the exam under Section 2.3).
Based on the scores obtained at the pre-course test, 6 homogenous groups of 10 with almost equal starting scores were created:
I.
The students were ranked based on their pre-course results. Ten groups were created following the order of the student (6 students in each group), and a random number was assigned between 1 and 6 to each student in each group. This number determined the study group of the student; therefore, we created 6 groups of 10 students with similar pre-course test result and distribution (1 student from the first, second…tenth decimal in each group).
II.
The groups were randomly divided to 3 control and 3 study (distance learning) groups. The 3 instructors were randomly assigned to the groups, so each instructor had a study group and a control group.
III.
All groups took a 20 × 45 min course with the same timeline (for more details and teaching objectives see Appendix A).
IV.
The next day after the course, the skills of the students were assessed in the same way as the pre-course test (post-course test, see Section 2.3).
V.
The opinion of the students about the course and the application of distance education was collected after the course with a self-administered online anonymous questionnaire using a 5-point Likert scale (POTEcho v1.41, University of Pécs, Pécs, Hungary, was used for surveying).
The distance learning groups took the classes 4 h daily for 5 days on an online platform (Microsoft Office 365 Teams v. 4.7.19.0, Microsoft Corp., Redmond, WA, USA). For instructors and students, a SkillBox was provided which contained every tool that they needed (Figure 2). During the video calls, the instructor presented exercise for the day and also played tutorial videos, while the students simultaneously practiced the exercise while they could ask about the movements, with the instructor constantly watching them on the screen.
The curriculum and timetable of the control group was identical to that of the study groups; classes were taught for 4 h a day for 5 days. The same SkillBox set was used as in the study groups. The instructors played the same tutorial videos and demonstrated the moves of the exercise, after which the students tried to copy the movement patterns. The physical contact was allowed during the classes, although during the in-person education, the relevant epidemiological regulations and preventive measures were strictly followed.

2.3. Protocol of the Exam

We have used the identical exam protocol for the pre- and post-course test. The exams for the study and control groups also took place at the university and were video recorded.
Videos of the exams were randomly ordered and evaluated blindly by senior instructors based on OSATS. We have used the same evaluation protocol as in our previous studies [52,53]: a slightly modified version of the knotting assessment by Shen et al. and a self-developed criteria system for sutures [53,54].
Tasks of the exam (similar to our previous publications [52,53]):
I.
Two-handed knot in the tension tissue model (three right and three left)
II.
One-handed knot in the torn fabric model (three right and three left)
III.
Simple interrupted suture (three pieces)
IV.
Vertical mattress (Donati) suture (three pieces)
V.
Intracutaneous running suture (4 cm)
You can find the summary of the teaching conditions in Table 1.

2.4. Statistical Analysis

For randomization, we have applied the RANDBETWEEN function of Microsoft Excel (v14.0.6112.5000 Microsoft Corp., Redmond, WA, USA).
The data of the pre- and post-course tests were collected, and the grades of the 3 senior lecturers were averaged. Shapiro–Wilks test was performed to test normality. The results did not show normal distribution. To compare independent groups (the initial scores of the study and control group, and the improvement of the exam results in the study and control groups) Mann–Whitney U Test was used. Wilcoxon signed-rank test was performed to compare the pre- and post-course test results of the students.
The results of students’ feedback were exported from the POTEcho system to Microsoft Excel anonymously. As ordinal variables, we have chosen Mann–Whitney U Test to compare the answers of the study and control group.
We have used IBM SPSS (v23, IBM Corp., Armonk, NY, USA) for statistical analysis and chart building. The level of significance was set to p < 0.05.

3. Results

3.1. Pre-Course and Exam Results of Study and Control Groups

In our study, we compared the results of the students of distance learning to the results of those who participated in contact classes, then evaluated the effectiveness of distance learning for basic surgical skills. The initial scores were almost equal on account of the homogenization. The starting knotting scores were significantly higher at the distance learning group and slightly lower in suturing, but this was not significant (Table 2).
Taking into account the overall results of the students, a significant improvement was achieved in all areas during the completion of the course, which was analyzed by Wilcoxon signed rank test (Table 3). The results were similar if the results of the study group and the control group were studied separately.
Although there is a slightly greater improvement in the online course, it is not significant (online 28.200 vs. control 25.200, p = 0.198). There was no significant difference in tasks related to knotting (study 8.233 vs. control 9.300, p = 0.317). The difference was significant for the tasks related to sutures (study 19.967 vs. control 15.900, p = 0.043), especially for vertical mattress sutures (study 7.233 vs. 4.433, p = 0.005) (Table 4). The gender of the students did not affect their development, nor did the person who was the instructor.

3.2. Feedback of Students

There was a significant difference only in terms of interest, which was significantly higher in the distance learning group. According to 93.34% of students, the quality of education did not change or improved compared to contact classes. Moreover, 90% of them think that distance education is a better alternative and may replace traditional in-person classes (Figure 3, Table 5).

3.3. Financial Analysis

The content of a SkillBox is worth 128.70 USD. The delivery fee was an average of 11.33 USD per box. The wage of the instructors was 851.55 USD per group, with each group consisting of 10 students, accounting for 85.15 USD per student. There was an additional 20 USD payment for using personal resources in home offices. Altogether, the cost of the online course was 227.55 USD per student. This amount does not include the digital devices and infrastructure necessary for distance education. There is no delivery fee and home office allowance in the case of a contact class, but the infrastructure and the staff of the university were used. The cost was calculated from the rental fee of the classroom, which was 478.00 USD per group, meaning that the cost of the contact course was 262.02 USD per student.

4. Discussion

Medical education may be the most affected field due to COVID-19 pandemic because its focus is the human body, which was a great challenge to face to convert to e-learning. A recent study has highlighted that in the field of neurosurgery training, the trainees have less opportunity to take part in clinical tasks; moreover, they had the challenge of an increased stress level [55]. Similar results have been observed in case of orthopedic surgeons [56]. Overall, it must be mentioned that the entire healthcare system is severely affected by the pandemic, causing the increase in prevalence of burnout syndrome in healthcare staff [57] and students [58].
On the other hand, the recent years had a significant positive impact on e-learning and distance education methods in medicine. Worldwide, institutes teaching medicine had developed their ICT infrastructure, improved their e-learning materials and found new ways of virtual education [59]. The challenges are prevalent in surgical training as well, but the rapid adaptation in e-learning and different virtual platforms highly elevated the preparedness for similar situations, and it can empower future developments on the field [7]. Moreover, it must be mentioned that it had a beneficial impact on the problem-solving skills of the participants, developing their competencies not only in healthcare professions, and improved their nontechnical and soft-skills too [60]. E-learning methods can provide continuous, even live feedback for all stakeholders [61], which is a major advantage.
By a controlled, objective method, we successfully proved that distance learning can be effective in medical education, even in a field that requires high degree of manual skills and personal contact. We have chosen OSATS to assess basic surgical skills because it is one of the most accepted methods to evaluate surgical abilities. Its validity is supported by several papers, although its ability to assess surgical result was questioned [49,62]. To keep the rating blinded we have decided to make anonymous video records for evaluation. Hance et al. have not found difference between the reliability of video based and live ratings [63]. In the study of Pandey et al. the live evaluation showed higher interrater and interstation reliability, although the results were acceptable for both formats [64].
We had decided to involve those basic surgical skills to our study, which are necessary for all physicians. We have not assessed instrument handling separated, but it was part of the sutures’ evaluation. Regarding the whole population, we have found significant development in each technical procedure. In surgical knotting, there was no relevant difference neither in the initial scores nor the development. Although all suturing techniques showed similar rate of improvement through the course, the intracutaneous running technique was the most challenging for the students at the beginning of the course and after the training also. No difference between the simple interrupted and vertical mattress suture was observed, despite the fact that the latter is a more complicated method.
Altogether, there was no significant difference between the study and control groups. In detail, the scores for tasks related to knotting were minimally lower than the control group and those of suturing were slightly higher in the distance learning group. This controversial result may be due to several reasons. The need for a high degree of personalized attention to the teaching of knotting can be one of them because of the complexity of the movement, especially in the two-handed knotting technique, where the combined movement of both sides required [52]. In our previous study, we involved 46 students who used homemade tools and instructor-recorded videos to acquire basic surgical skills. Based on student feedback and final scores, their course efficiency was acceptable for learning surgical basics [53]. The instructor cannot watch the movements of the students as closely as in a contact class. At the same time, the teaching of a complex action through a 2D interface is a serious challenge. However, the students did not mention this deficit in the feedback. Motivated students had more possibilities to practice outside of class because the instruments were available for them at home. The students appreciated this and felt highly encouraged, which may provide an explanation of the better results related to the task of suturing. The idea of a distance learning course was welcomed with interest by the students; according to the feedback, they found it innovative and alluring, and the majority of them reported that this method of teaching can be a good alternative to traditional in-person education. It can be explained by the fact that younger generations are already accommodated to the digital environment. In the opinion of most of the students, the quality of education did not change or improve in comparison to contact classes. It should be highlighted that this answer refers to the general courses of surgical skills and not to this course’s contact groups. We did not find any publication in the literature; we reviewed articles that we could directly compare our results with.
Co et al. involved 30 senior medical students in their study where surgical knotting and suturing were taught online using a webcam. They stated that “according to the students’ feedback, internet-based education can be a good alternative for learning basic surgical skills”, although they did not have any control group and did not measure the improvement in exam results [65]. In their later study, they compared the clinical competency assessment score of 33 student participating in face-to-face teaching and 29 students participating in web-based surgical skill learning sessions. Harmonizing with our results, they found the surgical skills performance comparable in the two groups [34].
Quaranto et al. reported significant improvement of the aggregate confidence score in the knot tying and suturing ability of 31 students after 3 structured, interactive remote sessions [66]. Handaya et al. found the combination of tutorial videos and classes as the optimal teaching method for surgical knotting skills [67]. Davis et al. presented trauma surgery case reports to 15 surgical residents through interactive online classes. The test results increased in every case after the course, with an average improvement of 33% detected. They agreed that an online platform can be a good addition for the training of residents. The control group was not included in the study [68]. In the study by Satterwhite et al., 17 students were randomly assigned to the online group of the microsurgery course. On the webpage, the students found descriptions of necessary tools, step-by-step suturing techniques and surgical videos. The students were evaluated by written tests and videos taken before and after the course. Distance education did not take place in real time, and the groups were not taken into consideration after the random assignment of students [69].
We believe that the pandemic has provided a huge boost to development, especially in the area of distance education, from which we will still be able to benefit in a few years’ time. Our study compared traditional on-site teaching vs. teaching in a digital format, but it would certainly be interesting for the future to compare different online teaching formats in terms of effectiveness in teaching practical skills.

Financial Consideration

The training of surgeons is expensive and time consuming. According to Bridges et al., the cost of the training of surgical residents would be 53 million USD per year if the training took place only in operating rooms [70]. The expenses would include learning time, scientific work and the increased operation time caused by the resident [71,72]. The cost of the online course was by 13.2% less per student, which is also due to the 3D Centre of the University, where the SkillBoxes (suture pads and knotting trainers) were developed and produced for low cost (129 USD). However, in the case of distance learning delivery, fees and allowances for home offices were incurred, and the infrastructure of the university was not used, which significantly decreased the expenses. The cost of online education does not include digital devices.

5. Limitations

We tried to adjust the webcams to the same settings, but low-quality images were sometimes recorded. The students’ field of view was limited to the viewing angle of the instructor’s camera. The digital devices of students and instructors had different quality cameras, and the speed of the internet was also different in each home, which made it more difficult to conduct a continuous class without any lag. The students of distance learning groups had not taken the in-person form of this course previously, so they did not have any basis for comparison. However, it was not forbidden to the instructors to have any physical contact with the students; the course took place during the second wave of COVID-19 pandemic. We have asked the instructors to hold the in-person courses as equivalent to the previous “normal” courses as possible; nevertheless, the relevant epidemiological regulations and preventive measures were strictly followed. For this reason, the physical contact was minimized. We have not assessed the procedural knowledge of the students because they had to accomplish an obligatory course earlier. The feedback was most likely influenced by the fact that the students could keep the SkillBox after the course. The relatively low cost of the online course was due to the 3D Centre of the University, who kindly sold the suture pads and knotting trainers at production cost.

6. Conclusions

The results of the students improved similarly in both distance learning and traditional education. The online form of teaching was received positively among the students, as they found it an effective and good alternative. Based on our results, distance learning can be as effective as traditional in-person classes in the field of basic surgical skills. We believe distance learning can provide a functional and sustainable alternative (academically and financially also), not only for special circumstances.

Author Contributions

Conceptualization, Z.B.P. and P.M.; methodology, Á.T.S.; validation, Z.F., Á.T.S. and P.M.; formal analysis, B.G. and Z.B.P.; investigation, Z.B.P.; resources, P.M.; data curation, S.R.; writing—original draft preparation Z.B.P., B.N. P.M.; visualization, E.K.; supervision, Á.T.S., S.R. and B.N.; project administration, Z.D.; funding acquisition, P.M., Á.T.S. and Z.D. Contributed equally to this work: Z.B.P. and P.M. All authors have read and agreed to the published version of the manuscript.

Funding

This research was supported by grants from National Research, Development, and Innovation Fund of Hungary tenders [EFOP-3.6.1-16-2016-00004 and GINOP-2.3.2.-15-2016-00022]. Thematic Excellence Program 2020—National Excellence Sub-program; Biomedical Engineering Project [2020-4.1.1-TKP2020] of the University of Pecs, and provided support for: S.R.; A.S.; B.N. and P.M. The work was also supported by the [NTP-NFTÖ-20-B-0137] for A.S. and [NTP-NFTÖ-20-0071]—for P.M, granted by the Hungarian Government. Project no. TKP2021-NVA-06 has been implemented with the support provided from the National Research, Development and Innovation Fund of Hungary, financed under the TKP2021-NVA funding scheme.

Institutional Review Board Statement

The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Institutional and Regional Ethical Review Board of University (8443—PTE 2020).

Informed Consent Statement

Written informed consent was obtained from study participants. All participant agreed to take part in the study and approved to use their data for research purposes.

Data Availability Statement

The datasets generated and/or analysed during the current study are not publicly available due data protection of the participants but are available from the corresponding author on reasonable request.

Acknowledgments

We would like to express our sincere thanks to the following Colleagues at the University of Pécs, Medical School: Erlitz Luca, Ibitamuno Caleb; and at the 3D Printing and Visualization Centre, University of Pécs: Tamas Bulsz, Bence Manfai. We also thank our Colleagues at the Marketing and Communications Departmentand the Medical Simulation Education Center at the University of Pécs Medical School for their help.

Conflicts of Interest

No benefit in any form have been received or will be received from a commercial party related, directly or indirectly.

Appendix A. Description of the Course

The obligatory curriculum of the faculty contains a “Basics of Surgery” course. This course takes place in third-year pre-clinical curriculum. It is 42 × 45 min long, and covers the theoretical and manual fundamentals of surgery and operation techniques (e.g., structure of an operating room, basics of asepsis, physiology and pathology of wound healing, surgical instruments, basics of knotting, suturing and laparoscopy etc.).
Our course is an optional course for the students, who have already completed “Basics of Surgery”. The goal is to give the students additional opportunity to deepen their knowledge and improve their manual skills. The course is focused on hand-on training covering just the totally necessary theoretical knowledge.
  • The course is 20 × 45 min long, and divided to 4 × 45 min long section on 5 separated days.
  • The permissible group size is between 6 and 12 students. Learning objectives—knotting:
  • Mastering the technique of two-handed knot tying
  • Mastering the technique of one-handed knot tying
  • Mastering the technique of instrument tie knotting
  • No fumbling, thread not dropped during knotting
  • Keeps thread tight adequately during knotting
  • Correct orientation of knots
  • Tissue sparing tying technique
  • Adequate tightness of knot
All objectives above are carried out on “tissue under tension” model, “easily tearing tissue” model
Learning objectives—suturing:
  • Knowledge of the tools needed for wound closure, mastering their utilization/application
  • Hold the needle properly
  • Guide the needle perpendicular to the surface
  • Perform a rolling motion corresponding to the arch of the needle
  • The distance of the enter and exit points of stitches from the skin edge is adequate
  • Correct distance between the stitches
  • Align the tissue levels properly
  • Proper use of forceps
  • Knot in the right direction and tension
  • Tissue-friendly suturing technique
  • Mastering simple interrupted suture
  • Mastering simple running suture
  • Mastering simple running interrupted suture
  • Mastering vertical mattress suture (Donati)
  • Mastering Allgöwer–Donati suture
  • Mastering intracotaneous running suture
Timetable
(1)
Acquaintance with the contents of the SkillBox, deepening their knowledge of the instruments—2 × 45 min
(2)
Two-handed (surgical) and one-handed (Viennese) knotting—6 × 45 min
(3)
Simple knot stitch, instrumental (apodactyl/atraumatic) knot—2 × 45 min
(4)
Vertical mattress (Donati and Allgöwer-Donati) and instrumental knot—3 × 45 min
(5)
Running sutures—2 × 45 min
(6)
Intracutaneous running suture—3 × 45 min
(7)
Free practice according to the student’s preference—2 × 45 min

References

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Figure 1. CONSORT diagram of the study population involvement and distribution * Homogenization: The students were ranked based on their pre-course results. Ten groups were created following the order of the student (6 students in each group), and a random number was assigned between 1 and 6 to each student in each group. This number determined the study group of the student; therefore, we created 6 groups of 10 students with similar pre-course test result and distribution (1 student from the first, second…tenth decimal in each group).
Figure 1. CONSORT diagram of the study population involvement and distribution * Homogenization: The students were ranked based on their pre-course results. Ten groups were created following the order of the student (6 students in each group), and a random number was assigned between 1 and 6 to each student in each group. This number determined the study group of the student; therefore, we created 6 groups of 10 students with similar pre-course test result and distribution (1 student from the first, second…tenth decimal in each group).
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Figure 2. The contents of the SkillBox: (A) Atraumatic Monofilament, (2/0), (B) Monofilament (2/0) without needle, (C) Atraumatic Monofilament (3/0), (D) Atraumatic Monofilament (5/0), (E) Multifilament (2/0) without needle, (F) Knotting trainer (Original product of PTE 3D Printing and Visualization Center), (G) Wool for training of knotting, (H) Suturing pads and holder (Original product of PTE 3D Printing and Visualization Center, (I) Gloves, (J) Scalpel No. 22, (K) Scalpel Handle, (L) Hartmann MediSet (REF 478 119, LOT 000101134).
Figure 2. The contents of the SkillBox: (A) Atraumatic Monofilament, (2/0), (B) Monofilament (2/0) without needle, (C) Atraumatic Monofilament (3/0), (D) Atraumatic Monofilament (5/0), (E) Multifilament (2/0) without needle, (F) Knotting trainer (Original product of PTE 3D Printing and Visualization Center), (G) Wool for training of knotting, (H) Suturing pads and holder (Original product of PTE 3D Printing and Visualization Center, (I) Gloves, (J) Scalpel No. 22, (K) Scalpel Handle, (L) Hartmann MediSet (REF 478 119, LOT 000101134).
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Figure 3. Histogram of the study group feedback questionnaire answers. (a) Question: “In your opinion, how has the standard of teaching changed with the transition to distance education? (b) Question: “In your opinion, could be the distance education serve as a proper alternative of the conventional in-person course?”
Figure 3. Histogram of the study group feedback questionnaire answers. (a) Question: “In your opinion, how has the standard of teaching changed with the transition to distance education? (b) Question: “In your opinion, could be the distance education serve as a proper alternative of the conventional in-person course?”
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Table
Table 1. Comparison of the teaching conditions (MS Teams—Microsoft Office 365 Teams v. 4.7.19.0, Microsoft Corp., Redmond, WA, USA).
Table 1. Comparison of the teaching conditions (MS Teams—Microsoft Office 365 Teams v. 4.7.19.0, Microsoft Corp., Redmond, WA, USA).
Study GroupControl Group
Way of teachingDistance learning
(supported with instructional videos)		“Traditional”
(supported with instructional videos)
PlatformMS TeamsIn person
LocationSeparated in their homesUniversity’s Simulation Center
Instrument usedSkillBoxSkillBox
Duration of the course20 × 45 min20 × 45 min
Schedule4 × 45 min on 5 separated days4 × 45 min on 5 separated days
Learning objectivessame (see Appendix A)
Instructional videossame
Number of groups33
Number of students (per group)1010
Number of instructors (per group)11
Pre-course testsame
Post-course testsame
Table
Table 2. Initial scores of the study and control groups, Mann–Whitney U Test (* significant difference between study and control group).
Table 2. Initial scores of the study and control groups, Mann–Whitney U Test (* significant difference between study and control group).
Study GroupControl Grouppz
Overall pre-course points98.600100.1000.304−1.028
Knotting31.567 *28.733 *0.031 *−2.153
Sutures67.03371.3670.061−1.872
Table
Table 3. Improvement in the exam results for all students, Wilcoxon signed rank test (* significant difference between pre- and post-course).
Table 3. Improvement in the exam results for all students, Wilcoxon signed rank test (* significant difference between pre- and post-course).
Pre-CoursePost-CoursepZ
Overall results99.350 *126.050 *<0.001 *−6.737
Knotting30.150 *38.917 *<0.001 *−6.742
Sutures69.200 *87.133 *<0.001 *−6.625
Table
Table 4. The improvement of the exam results in the study and control groups, Mann–Whitney U test (* significant difference between study and control group).
Table 4. The improvement of the exam results in the study and control groups, Mann–Whitney U test (* significant difference between study and control group).
AlterationStudy GroupControl GrouppZ
Overall28.20025.2000.198−1.287
Knotting8.2339.3000.317−1.002
 Two-handed knotting3.8004.6000.304−1.028
 One-handed knotting4.4334.7000.847−0.193
Sutures19.967 *15.900 *0.043 *−2.027
 Simple interrupted6.3335.5670.199−1.285
 Vertical mattress7.233 *4.433 *0.005 *−2.824
 Intracutaneous running6.4005.9000.392−0.855
Table
Table 5. Results of student feedback (Average result, standard deviation and results of the Mann-Whitney U Test, * significant difference).
Table 5. Results of student feedback (Average result, standard deviation and results of the Mann-Whitney U Test, * significant difference).
Study GroupControl GroupMann-Whitney (p)Z
QuestionAverageStandard
Deviation		AverageStandard
Deviation
1. Do you consider the material taught to be useful for your future profession?4.900.314.900.311.0000.000
2. How do you judge the level of the course?4.670.614.500.680.285−1.070
3. Have you found the course interesting?4.93 *0.254.70 *0.470.021 *−2.316
4. Do you think the lessons were easy to understand?4.730.524.870.350.301−1.035
5. Did you have enough time for practicing?4.930.254.970.180.557−0.587
6. Did the course leader/demonstrator pay enough attention to you despite the online education?4.900.404.830.750.986−0.017
7. How do you feel and how much have your manual skills developed?4.670.554.670.551.0000.000
8. Overall, how would you evaluate the course?4.870.354.830.460.960−0.050
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MDPI and ACS Style

Pintér, Z.B.; Maróti, P.; Kopjár, E.; Gasz, B.; Duga, Z.; Rendeki, S.; Nagy, B.; Füzesi, Z.; Schlégl, Á.T. Effectivity of Distance Learning in the Training of Basic Surgical Skills—A Randomized Controlled Trial. Sustainability 2022, 14, 4727. https://doi.org/10.3390/su14084727

AMA Style

Pintér ZB, Maróti P, Kopjár E, Gasz B, Duga Z, Rendeki S, Nagy B, Füzesi Z, Schlégl ÁT. Effectivity of Distance Learning in the Training of Basic Surgical Skills—A Randomized Controlled Trial. Sustainability. 2022; 14(8):4727. https://doi.org/10.3390/su14084727

Chicago/Turabian Style

Pintér, Zsolt Balázs, Péter Maróti, Eszter Kopjár, Balázs Gasz, Zsófia Duga, Szilárd Rendeki, Bálint Nagy, Zsuzsanna Füzesi, and Ádám Tibor Schlégl. 2022. "Effectivity of Distance Learning in the Training of Basic Surgical Skills—A Randomized Controlled Trial" Sustainability 14, no. 8: 4727. https://doi.org/10.3390/su14084727

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