Students are expected to acquire surgical skills and knowledge during the clinical clerkships, while time and exposure to different procedures are limited. The need to ensure similar medical education to all students, in a landscape of increasing differentiation among surgical (sub) disciplines and hospitals and thus decreasing exposure to all facets of surgery, is a challenge to every medical school. However, newer learning tools, such as online surgical videos and courses to supplement traditional didactic lectures and hospital-based learning are becoming available. In this study, we found that surgical knowledge increased significantly during the surgical clerkship when students are provided access to a structured online video-based surgical education platform in addition to the standard surgical curriculum. More importantly, surgical knowledge was more uniformly spread in students in the video group, despite the inhomogeneous exposure to different “live” surgical procedures due to differences in teaching hospitals. Also, self-reported knowledge increased significantly over the course of the clerkship in the video group compared to students who did not have access to this platform and who used publicly available sources. It is interesting to note that the control group had previously out-performed their peers in the test group, but this advantage was seemingly negated by the use of the video platform. Students felt more prepared due to better tools and sources for the clerkship in general and for the different interventions they were going to see specifically. Because the access to the video’s did not stop for all student immediately after the surgical clerkship, several students also viewed video’s for the urology and gynecology courses (n = 62). This shows that students had a positive experience with the platform and continued to use it beyond the scope of our study. They almost unanimously rated the platform essential for future students in the clerkship. Furthermore, the supervising surgeons (n = 10) in this study rated the knowledge of the students in the video group higher compared to the control group.
Earlier studies have reported comparable positive results of increased knowledge and self-confidence of students from educational surgical videos [14,15,16,17]. Several features of this type of education can explain these effects. First, students have the time to prepare themselves beforehand by viewing an uncomplicated procedure, and therefore know what to expect. These videos can be watched and -selectively - re-watched at the students’ desired pace and moment (just in time). Consequently, they will be able to concentrate better on the next procedural steps during the live operation and have fewer problems determining surgical anatomy. Feeling prepared also increases student confidence and therefore facilitates optimal learning in the operating theatre [18,19,20].
Furthermore, the structured step-by-step explanations of surgical procedures decrease the cognitive load by fragmentation of the study material . The structured pre-, per- and post-operative objectives form an essential part of the preparation for the procedure and provide relevant information based on validated sources and guidelines. This is especially important because inexperienced students may not be able to tell if a shown procedure on a non-official platform is following national or international guidelines [21, 22]. Although the majority of students use YouTube as a learning tool in medical school, recent studies have shown that half of the educational videos of laparoscopic cholecystectomies on YouTube showed dangerous situations and only 10 followed the international guidelines in demonstrating the “critical view of safety” [4, 23, 24]. Another review that focused on videos on the treatment of distal radius fractures found that only 16 of the 68.000 videos met the international criteria . Videos of knee arthrocentesis were deemed suitable for educational purposes in 62% of cases . A study focusing on face-lift procedures points out that videos for educational purposes did not cover pre- and postoperative aspects as indications, complications, and patient selection . These results indicate that students need to be cautious when using YouTube videos in their learning and preparation [3, 27,28,29,30,31]. The courses on the online video-based surgical education platform in this study follow international guidelines and are supervised by expert surgeons, anatomists, and surgical educators.
In this study, the use of this platform by students was voluntary. By incorporating the platform as an obligatory learning and teaching tool for students and teachers, the learning yield may increase. And although this study or its contents were not officially included in the final exams, we did see overall higher scores on the exam in the video group (data not shown). Additionally, students used the platform solely during the clinical clerkship and not during the preparatory course. This might be explained by the extensive number of texts, videos and cases they have to study during the course prior to the clerkship. However, this also shows that students indeed use the videos as a tool to prepare themselves for the procedures they are going to encounter in the hospitals.
Lastly, structured, high quality, educational videos offer a more homogeneous education for students independent of the surgeons and procedures they encounter during their clerkship. One of the problems we wanted to overcome with the incorporation of an online video-based educational platform was the differences in surgical exposure for the students enrolled in the academic center (Erasmus MC) or one of the eleven affiliated community hospitals. Even though several studies have found no differences in performance and study results between students in academic or community hospital clerkships, we found in this study that students assigned in the university center for the clerkship reported longer preparation times for procedures (data not shown) [32, 33]. Procedures performed in tertiary centers are generally more complicated and information on these procedures is less readily available and more complex. Understandably, these students also reported lower numbers of observed interventions and fewer operations in which they actively participated. However, the location of the clerkship did not affect students’ test scores on the knowledge test (p = 0.06) or the mandatory university test (p = 0.15; data not shown).
Strengths and limitations
Unfortunately, randomization in this study was unfeasible. Due to the nature of the intervention in the video group, two consecutive cohorts were needed to avoid contamination of the groups by cross-contact of the students in daily life or via social media as much as possible. As mentioned, the selection for these consecutive cohorts was made by the university and based on students’ progress in the previous 3 years of medical school. Therefore, students that progressed faster through the first 3 years were placed in the first group (control group), and the students that required more time for the first 3 years in the second group (video group). This effect is visible in the knowledge test scores at T0 where the control group had slightly higher scores (p = 0.09), but that is reversed at T1 with higher scores for the video group, underlining the effect of the intervention (p = 0.001).
Although a large number of students participated in this study, the decreasing number of students filling out the second survey might overestimate the increase in self-reported knowledge and test scores. Highly motivated students may engage more in available study materials and may have been more eager to fill out the surveys. We did see a difference between the control and video group in the number of surveys filled out at T0 (66% vs 90%) because the second group had already had an introduction to the platform prior to filling out the first survey. This difference in the number of filled out surveys was not seen at T1. Furthermore, we did not see a significant difference in students interested in a career in a surgical specialty in both groups or in scores on the knowledge test in students that indicated to be interested in a career in surgery and those who were not.
Also, because theoretical knowledge is the easiest to test, this might misjudge technical abilities, clinical thinking, and skills like communication, professionalism, and teamwork in students. Although we did see a clear trend in more positive opinions of the surgeons on students in the video group in this regard, these results were not significantly different due to the small number of surgeons in our cohort.
This study demonstrates intensive use by students, an increase in self-reported and tested knowledge, and better evaluations of supervising surgeons. This is especially true in the case of differences in exposure that occurs between hospitals. With increased use, the database of courses including videos can be expanded to include more complex operations and different approaches to certain procedures. When used internationally, a more standardized universal language for surgical procedures can be created which may facilitate (research) collaborations in the future within the surgical community and beyond.