1 Introduction

Simulated surgical experiences have become widely adopted in medical education over the past decade^1–5. These simulations are used to enhance medical education and can include bench-top training sessions with synthetic materials, the use of cadaveric models, or even virtual reality sessions for practice with medical instruments^1. Simulation-based training is frequently used at the medical student level for skills such as intubation, ultrasound, and foley catheter insertion, yet there is limited data regarding orthopedic simulated-based training at the medical student level.^6,7 The existing literature illustrates that simulation training promotes an enhanced team-building environment for orthopedic residents. However, there is limited data on the impact of these orthopedic simulation-based training workshops at the medical school level.^8–10 There have been many studies done in various other fields of medicine to evaluate the efficacy of simulation-based training for medical students. Yu et al., 2021 previously demonstrated that the use of high-fidelity simulation training significantly increased student confidence and decreased anxiety from pre and post-simulation training during an internal medicine rotation.¹¹ A systematic review by Mclnerney et al., in 2022 evaluated 19 articles across different medical specialties for the use of simulation-based training for medical students. All groups in the study reported a performance benefit to students associated with simulation-based training across a broad range of medical and surgical specialties in both acute and non-acute scenarios. Specifically, two studies in the review specifically examined simulation in surgery and compared a surgical simulation group to a traditional didactic-based education group. A significant performance benefit (p < 0.001) was seen in the simulation group, with higher levels of self-reported confidence and understanding of surgical principles and assessments in vascular, breast, and abdominal examinations.¹² Additionally, Hanada et al., 2022 evaluated the utilization of a 10-h simulation training on vascular graft anastomosis. They found that procedural time improved after 1 h, and all other factors including bite, pitch, and skewness all improved after 10 h of training on a web application system.³

The Orthopedic Surgery Interest Group (OSIG) at the University of Miami Miller School of Medicine is a student-run organization that aims to increase medical student exposure to the field of orthopedic surgery through mentorship, networking, and information sessions that teach students about orthopedic surgery. To increase exposure to the field, OSIG organized the sawbones simulation, a bench-top training session to enhance surgical education skills for medical students. Given that operative experience is essential in traditional surgical education, we decided to implement our own sawbones workshop to provide a similar experience for medical students by offering practice for basic procedural techniques and developing familiarity with surgical equipment.⁴

This pilot study seeks to investigate the participating students’ self-reported perceptions of the interactive sawbones workshop as it compares to the cadaver model, perceived confidence in basic orthopedic skills, ability to work in a team setting, and interest level in the continued integration of hands-on workshops as a longitudinal component of their medical education. Providing this kind of early hands-on training to medical students may increase interest in pursuing orthopedics as a career and improve preparedness for orthopedic sub-internships and electives.

2 Methods

2.1

2.1 Sawbones simulation

An email invitation was sent to all medical student (MS1-MS4) members in OSIG to apply for a position in the sawbones simulation training. This specific listserv consisted of students that have expressed interest in orthopedics. A total of 30 students were randomly selected to participate in the workshop, all 30 selected students were in attendance on the day of the workshop. All selected students first participated in a lecture-based training session facilitated by orthopedic trauma attending physicians and residents. This lecture reviewed the basic components of orthopedic instrumentation, including an overview of screw and plate designs, tools students would be working with during the simulation, and common uses of these tools in the operative setting. This lecture was followed by a hands-on session in the medical school labs where students were divided into groups of four to five students. Each group of students was paired with an orthopedic surgery attending or resident who guided the students throughout the simulation. During the hands-on training component, the students took turns working in their team to fix fractures and other compound injuries on model bones (Fig. 1). Specifically, the task of this session was for students to practice an internal screw fixation of a mid-shaft radial fracture using a radius made of synthetic material. Students were provided 2.4- and 2.8-mm drill bits with various types of plates and screw designs and were taught the various methods for fixation of simple and complex fractures of the radius, ulna, and tibia. Additionally, the surgeons familiarized the students with the different tools used in orthopedic procedures. In its entirety, both the lecture-based and hands-on components of training lasted a total of 4 h.

Close

Fig. 1 Hands-on training using orthopedic instruments.

Export to PPT

3 Results

A total of 30 medical students applied to participate in the OSIG sawbones workshop and 22 students completed the post-training survey (73.0% response rate). Medical students from all classes participated in the event; 14 (63.6%) were second-year medical students (MS2), four (18.2%) were third-year medical students (MS3), three (13.6%) were first-year medical students (MS1) and one (4.5%) was a fourth-year medical student (MS4).

The average reported student interest level in orthopedics was 9.2 (median 10, std 0.4) on an average scale of 1–10, with 1 being not interested at all, and 10 is committed to a career in orthopedic surgery. With regards to student interest in pursuing careers in specific orthopedic subspecialties, sports medicine was the most popular subspecialty of interest (n = 10, 33.3%), followed by total reconstruction surgery (n = 7, 23.3%) (Table 1). Additionally, respondents were asked to provide their prior experiences within orthopedic surgery, including hands-on training, shadowing in the OR, or prior practice with orthopedic instruments (Table 2).

More than half of the students reported having an orthopedic faculty mentor (n = 13; 59.1%). Interestingly, those students without a mentor had minimal experience (0 experiences on average; p = 0.0291). All 22 respondents (100%) reported that they would like more hands-on orthopedic surgical training as a component of their medical education. Additionally, 19 students (86.4%) reported that this training increased their interest in pursuing a career in orthopedic surgery and 21 students (95.5%) would recommend this training to other students. Data captured from the sawbones training experience is illustrated in Table 3.

Medical students' perceptions of the team-based experience are seen in Table 4. Results show that most students (n = 14, 63.6%) preferred working in a team setting as opposed to working alone or having no preference; of these 14 students, all of them felt that they work well in a team setting. Additionally, 63.6% (n = 14) of students had experience working in a team setting with other students interested in orthopedics prior to this simulation. Students who prefer working in team settings rated their overall team-based interactions with their peers better when compared to those who prefer working alone (p = 0.00188).

Additionally, in the free-response sections, most students (n = 15, 68.2%) indicated that they preferred using artificial bones for the workshop rather than cadavers. Their comments included statements regarding “increased visibility” and “maneuverability” when compared to cadaveric models.

4 Discussion

Simulation-based training models can be useful for enhancing surgical training outside of the operating room.¹ While this has been shown to be an effective method of teaching for resident physicians in orthopedic surgery departments, there is little known data on the effects of learning simulations at the medical student level. Due to the COVID pandemic, many of the restrictions set in place have resulted in less time in the operating room and the reliance on more creative methods of training.¹⁷ The self-reported results of our survey study reveal that most students participating in this workshop have had very few hands-on orthopedic surgical training exercises in medical school nor have they previously worked with orthopedic surgical instruments. This lack of orthopedic experience is common at many institutions.¹⁸ The Sawbones workshop was made to bridge these current gaps that exist between medical students and the lack of hands-on orthopedic experience. Administering this workshop was a positive experience for students, with most students (95.5%) reporting that this better prepared them for future orthopedic encounters and increased their perceived confidence in a surgical setting. Simulation-based training in other surgical fields has shown it can improve interest in a surgical career. Nilsson et al. developed a simulation-based curriculum in endoscopic surgery, and results showed that 74% of medical students enrolled in the course reported increased interest in surgical specialties as a career following the intervention.¹⁹ Additionally, Nitschmann et al., 2014 found that a gynecologic simulation curriculum for fifty-nine third-year medical students demonstrated that students had improved confidence in Intrauterine Device (IUD) insertion, dilation and curettage, and basic laparoscopy skills. The program also significantly increased their interest in a surgical career and interest in women's health.⁵ Incorporating simulation-based training in orthopedics similar to the successful aforementioned studies can improve interest from all medical school levels, which is important due to a substantial lack of orthopedic experience in traditional undergraduate medical education.¹⁸ Early hands-on exposure increases student interest in orthopedic surgery earlier in their education, as evidence shows that even a one-day course can increase interest in a surgical specialty. Over a one-day surgical training course, Seo et al. found a significantly increased interest in a surgical career from 56% to 81% after students went through a hybrid surgical simulation training.² Another important change in medical education was the new Accreditation Council for Graduate Medical Education (ACGME) guidelines for residents, which call for fewer hours in the operating room (OR). Now more than ever, it becomes increasingly important to consider simulation-based training as an essential component of medical education in order to familiarize medical students with both orthopedic techniques and instrumentation.²⁰

Importantly, literature has shown that medical students suffer from the well-known phenomenon of imposter syndrome along with other issues rooted in low self-confidence^21,22 While there are no concrete studies that address self-confidence and surgical outcomes, it has been shown in the literature that decreased perceived confidence is correlated with increased hesitation in operative tasks²³ Several studies have noted an increase in perceived medical student confidence following simulation-based training.^{2,3,5,12,13,24} Leopold et al. also found that confidence can improve after simulation training, and this can result in improved performance on simple surgical tasks.²⁵ Thus, increasing perceived confidence in orthopedic surgical skills is an important measure of the efficacy of this workshop.

One of the primary components of the sawbones simulation is providing a team-based learning environment for its medical students. Teamwork is a crucial factor for attaining a common goal, supporting peers, and developing a mutual understanding of orthopedic knowledge.²⁶ By placing four students at each workstation, Sawbones also simulates an operating room-like setting, where students can learn to work as a team to complete the surgical task along with their interpersonal communication skills. In our survey, 100% of students agreed that training such as this in the future with residents and attendings would make them feel more like part of a team. Additionally, diversity in orthopedics has been lacking for many decades. The inclusion of women in orthopedics as well as other minority groups is essential to consider now and, in the future.²⁷ Three females participated in this workshop, stressing the importance of increasing the interest of women and minority groups to become involved and interested early on. Sawbones provides a collaborative and inclusive environment for all students of any level to be involved in hands-on training regardless of skill level or background, so it is an important space for students to be able to assess their confidence and interest.

An important team-building component undoubtedly includes sufficient mentorship with residents and attendings. In competitive surgical specialties such as orthopedics, finding mentorship continues to be a problem for medical students.^28,29 Building an adequate mentor-mentee relationship offers students essential insight into their pathway for applying to and being successful in residency. Thus, mentorship needs to be a priority for students interested in a career in orthopedics.³⁰ When asked if students felt that this training workshop helped give them substantial connections to Orthopedic residents and attendings, 27.3% responded “definitely yes” and 31.8% responded “probably yes”. We suspect that these opportunities to develop more of these connections can continue to grow with further workshops as students continue refining their skills under the direction of residents and attendings.

It is also important to consider the advantages that sawbones may have in surgical education when combined with real surgical experience. Many types of simulation training with a combination of cadavers, bench-top models, and virtual reality have become much more prevalent in medical education in recent years.¹ Some of the perceived advantages of sawbones as a bench-top model include gaining proficiency through unlimited practice opportunities and familiarity with equipment used in the operating room during real cases. In addition, synthetic models are much less expensive than traditional cadaveric or animal models.¹ Cadaveric models have been shown to be considerably limiting due to the cost and availability of adequate numbers. Camp et al., 2016 importantly evaluated the use of cadaveric versus virtual reality simulation training for knee arthroplasty training. While cadaveric training remains highly effective, lack of funding remains one big problem for institutions. Camp estimated that 300 h of simulation training at their institution would make it more cost-effective than the use of the cadaver model.³¹ Additionally, Yu et al. proposed a 3-D printed model for Trochlear dysplasia and Trochleoplasty simulation for trainee education. The total overall cost for a synthetic polyethylene foam-made bone model can be as little as a few dollars and up to twenty dollars for a 3-D printed model.^16,32,33 Comparing this to the cost of one cadaver and the materials to keep them maintained, this cost can be one thousand to three thousand dollars per body.^34–36 Additionally, the ability to produce accurate and mass-scale models is an advantage that cannot be achieved on a cadaver.³³ Orthopedic simulations also allow realistic conditions by providing consistency for all students that participate with little preparation time.⁴ In this way, sawbones ensures that all participants are receiving standardized teaching compared to other forms of simulation such as cadavers, where there can be extensive variability in donors that may not be ideal for learning simple surgical skills at the medical student level.

It is clear from this pilot survey study that Sawbones has provided students with a strong team environment, significant orthopedic surgical skill and instrument exposure, and a positive experience that increased student interest in orthopedic surgery. These workshops may provide a substantial benefit longitudinally and further evaluation must be done at future sessions to observe the direct benefits of orthopedic surgical simulation training over time. Future directions include implementing this at the MS1 level to introduce new medical students to the field of orthopedic surgery and better prepare students for further clinical training in orthopedics.

There are several limitations to this study. The most fundamental limitation is the inherent highly selective sample, given that this was a workshop meant for students with a known interest in orthopedics and is not generalizable to all medical students going into any specialty. This made it more difficult to assess the true efficacy of this workshop. It will be important to reassess this intervention longitudinally and recruit more interested students for this workshop in the future to obtain a larger number of student responses. We also did not include demographic questions concerning age or ethnicity, which should be included in future studies to investigate other variables that may confound these results. Medical student year is also another factor that must be considered in future programs. Most participants were of the MS2 level, but further studies should analyze competency based on experience at each student level. Additionally, the study inherently carries some subjectivity with a self-reported methodology. The sawbones workshop should add clear-cut objectives for each workshop, including focusing on learning orthopedic instruments, learning a set skill for each session, and providing practice sessions for skills to be refined. With the addition of clear objectives and the results provided, Sawbones should be implemented regularly for students as an integral OSIG event to enhance their engagement with orthopedic skills, faculty, and instruments as well as to increase diverse representation in the field of orthopedic surgery.

5 Conclusion

Our pilot survey indicates that the incorporation of sawbones workshops to medical school curriculums would not only serve to increase surgical skill levels amongst medical students but also help bridge a crucial gap by providing a platform for mentorship in a specialty where interaction with attendings and residents can be difficult to attain. Providing these sessions early and longitudinally in medical school would allow interested students to gain unique experiences and important connections that better prepare them for residency. We suggest that sawbones be considered as a component of any medical curriculum to better address the lack of orthopedic exposure in medical school. Future studies should continue to longitudinally assess the Sawbones program through OSIG Miami and involve the data of other programs that do workshops like Sawbones.

Funding/sponsorship

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Institutional ethical committee approval

This study was approved by the Institutional Review Board (IRB) and was designed in accordance with the ethical standards set by the University of Miami Human Subject Research Office.

CRediT authorship contribution statement

Zachary Donato: Conceptualization, Methodology, Formal analysis, Writing – original draft, manuscript. Alina Syros: Conceptualization, Data curation, Writing – original draft, manuscript. Jacob Milner: Formal analysis, Writing – review & editing. Shivani Pandya: Formal analysis, Writing – review & editing. Marissa Tandron: Resources, Supervision. Giselle Hernandez: Supervision, Visualization, Conceptualization.