Over the past decade, there has been growing concern within the veterinary profession that new veterinary graduates are less prepared for the demands of clinical practice than they were in previous generations.1–4 Whether new veterinary graduates are successful in clinical practice is multifactorial and dependent, in part, on a variety of nontechnical competencies such as communication skills, business acumen, and critical thinking.5,6 Although instruction in these types of nontechnical competencies is often incorporated in veterinary curricula,3,4 this training must not come at the detriment of the development of core clinical skills.
Historically, surgical skills in veterinary medicine have been taught in an expert-guided apprenticeship model wherein standard didactic lectures are combined with laboratory exercises.7–10 The apprenticeship model has known drawbacks, namely variability in instruction depending on the expert instructor, an inability to guarantee exposure to all essential skills, and a lack of effective outcome-based assessment.10 With veterinary classes increasing in size, some by as much as 20%,11 these existing potential pitfalls will likely be amplified given that, often, fixed amounts of time and materials must be allotted to larger numbers of students.
In 2009, the WSU CVM restructured its surgical skills curriculum, moving the introductory surgery course (which consisted of a combination of lectures and laboratory sessions) from the second semester of the second year of the curriculum to the first semester of the first year. To accommodate other classes required during the first year, the laboratory portion of the course was decreased from six 3-hour laboratory sessions during the semester to six 2-hour sessions.
Because of the decrease in laboratory contact hours and the perceived need for greater surgical skills training, the CVM decided at the same time to introduce an OCSL, with the first sessions offered during the spring semester in 2011. The OCSL was designed to provide students multiple opportunities to build and refine their surgical skills.
Description of the OCSL
The OCSL was developed as a voluntary learning opportunity for students in all 4 years of the veterinary curriculum. Laboratory sessions were offered at times during the week that did not conflict with core curriculum courses. Individual sessions were 3 hours long, but students could come and go as they pleased. Attendance was tracked with a sign-in sheet.
Only 4 laboratory sessions were offered during the spring semester of 2011, but sessions were conducted on a weekly and eventually biweekly basis during subsequent semesters. Laboratory sessions were conducted in a vacated space in the veterinary teaching hospital. Students were allowed to practice whatever surgical skills and procedures they desired during the sessions.
During each OCSL session, a variety of surgical training models and cadavers were available for students to practice with. Simple models for students to practice suturing, pedicle ligation, and IV catheter placement were made from surplus hospital stock and inexpensive materials readily available from hardware and craft stores. In addition, 5 to 7 whole or prosected cadavers were typically available for student use during each session. Large animal cadavers were primarily obtained through donation to the veterinary teaching hospital. Canine and feline cadavers were obtained through the CVM's contract with animal control agencies in Washington state under which animals judged to be unadoptable by individual animal control agencies were euthanized at the agencies in accordance with AVMA and institutional animal care and use guidelines and transported to WSU CVM fresh-frozen. Fresh cadavers from other teaching laboratories were also used when available. All cadaver use adhered to AVMA and institutional animal care and use guidelines for humane use of animals. No animals were euthanized specifically for use in the OCSL.
Staffing of the OCSL sessions evolved over time. Initially, staffing for each session was provided by 1 of 4 faculty surgeons who circulated periodically to assist students. The second year, staffing responsibilities were shifted to paid student TAs selected on the basis of approachability and ability to give clear and effective feedback, as assessed through a cover letter, resume, and working interview. In support of their role, student TAs were provided additional training by a diplomate of the American College of Veterinary Surgeons. Additionally, a faculty surgeon attended each laboratory session for brief periods to address learning challenges, mentor the TAs, and provide in-the-moment teaching. Currently, TAs consist of a mix of second- and third-year students. As the program has evolved, the total TA numbers have increased from 7 in 2011 to 11 in 2015. In general, 3 TAs are present for each 3-hour shift.
The primary surgeon holding ultimate responsibility for the OCSL would regularly send emails to all students reminding them of upcoming OCSL sessions, providing information on opportunities and goals for future laboratory sessions, and recommending background resources for students. For example, a laboratory focused on gastrointestinal surgery would start with an email containing an interesting statistic about the importance of timeliness in surgery followed by some information regarding resources available for the laboratory for that session and an overview of the suggested activities. First-year students would be encouraged to practice inverting suture patterns on segments of intestine and checking for leakage. They would be encouraged to have a TA or upper classman instruct them on performing a purse-string pattern to add to their skill set beyond what was taught in the formal curriculum. Second-year students would be encouraged to review suture patterns and to think about how to maintain strict asepsis when opening bowel. They would be given segments of bowel sitting on a white cotton background with intraluminal foreign bodies coated in dyed lube to test their ability to maintain control of contamination during the laboratory. Third-year students would be challenged to perform a resection and anastomosis and would be given pointers to consider to avoid common errors. Finally, fourth-year students would be encouraged to practice procedures they had observed or were interested in performing.
Program Assessment
A variety of survey-based methods were used to measure the impact and effectiveness of the OCSL. At the start and end of the spring semester of 2011, for example, students from the class of 2013 (ie, students completing their second year of the veterinary curriculum who were the first class to complete the introductory surgery course during their first year) were sent a survey that, among other things, asked them to score, on a scale from 0 (no working knowledge) to 10 (true excellence), their level of skill performing an intradermal suture pattern, a Lembert inverting suture pattern, and 1- and 2-handed hand ties. Overall, 43 of the 94 (46%) students responded. Mean scores were 3.9, 2.1, and 3.4, respectively, at the start of the semester and 7, 6.5, and 7.1, respectively, at the end of the semester, indicating substantial perceived improvement in skill level. In addition, all 43 respondents agreed or strongly agreed with the statement that the OCSL had helped them develop their surgical skills.
Forty-two of 95 (44%) members of the class of 2014 responded to an open-text question included in their electronic course evaluation at the end of the fall semester of 2011, with analysis of the written comments suggesting that they found the student TAs and the OCSL beneficial for their development of surgery skills and provided ideas for improvement to the physical space to enhance the learning opportunities. Since the fall semester of 2012, the formal course evaluations have contained questions related to the utility and benefit of the TAs and the OCSL. These evaluations have uniformly been positive and appreciative of the opportunity and have provided evidence of student support to garner future administrative and financial support. During exit interviews with graduating seniors, the OCSL has been credited as a source of confidence and additional clinical experience.
Attendance at OCSL sessions increased from a mean of 9 students/session during the spring semester of 2011 to 30 students/session during the fall semester of 2011, 24 students/session during the spring semester of 2012, and 35 students/session during the fall semester of 2012. Since then, there has been a progressive increase in the number of students attending OCSL sessions. During the 2015 academic calendar, > 50 students took advantage of the OCSL each week, with busy weeks easily exceeding 100 students.
The greatest cost of these instructional opportunities was often faculty time. As an illustration, the total cost for the OCSL during the spring semester of 2011 was $18,700, which accounted for faculty time. Total cost for the OCSL was $15,800 for the fall semester of 2011 and $12,700 for the spring semester of 2012. This included the faculty time for TA training, TA salaries, disposable materials (suture, drapes, etc that exceed the donated supply of expired items), and processing surgical instruments. As the OCSL has expanded, the costs have increased in proportion with the number of hours the TAs worked and the amount of disposable materials needed by greater numbers of students.
Conceptual Framework
The OCSL was designed and implemented with several key educational theories in mind, including the concepts of deliberate practice, self-reflection, and PAL.
Deliberate practice
One of the foundational concepts for the creation of the OCSL was the importance of deliberate practice, as defined by Ericsson,12 for the sake of long-term mastery over short-term memory.
Ericsson12 has suggested that practice alone is insufficient in the long-term mastery of a skill and that deliberate practice is needed. Four specific factors differentiate practice from deliberate practice: identifying well-defined goals, providing motivation to improve, providing feedback, and providing opportunities for repetition and refinement of skills.12 With regard to the OCSL, the concept of identifying well-defined goals was incorporated through the emails sent by the surgeon with primary responsibility for the OCSL, who would suggest specific goals for individual laboratory sessions. These goals were subsequently reiterated by the student TAs during the session. The concept of providing motivation to improve was not specifically incorporated within the OCSL because it was assumed that individuals who took the initiative to attend voluntary laboratory sessions already had sufficient motivation to improve. However, students who reported decreased levels of stress during their third-year live-animal surgical classes and greater opportunities for hands-on experience during externships as a result of time spent in the OCSL may, through these word-of-mouth interactions, have motivated other students to attend.
In-the-moment feedback was consistently present throughout OCSL sessions and was enhanced with the addition of student TAs. Finally, in the fall of 2012, the number of OCSL sessions was increased to 2 a week to minimize conflicts with courses and laboratories and allow students more opportunities to attend. The OCSL is promoted as an environment where students could engage in deliberate practice with the goal of attaining a higher proficiency in surgical skills, thus potentially becoming more skilled, profitable, and employable following graduation.13,14
Self-reflection
While engaging in deliberate practice, learners must also develop self-policing abilities to achieve long-term mastery of skills. Gunderman,15 for example, has stressed that if learners do not develop the skills of self-reflection and self-policing, they are less prepared to learn from their practice. Thus, encouragement of self-policing among laboratory participants became a deliberate feature of TA-student interactions.
PAL
Given limited faculty availability to staff laboratory sessions and because of a desire to encourage development of a collegial learning environment, PAL, defined as “people from similar social groupings who are not professional teachers helping each other to learn and learning themselves by teaching,”16 was adopted as a key part of the OCSL. Specifically, a near-PAL approach was adopted,17 in that student TAs who were second- and third-year students would provide feedback to students from all 4 class years.
The utility of PAL has been demonstrated in several studies.17–21 Specifically, PAL has been demonstrated to benefit the student teachers, the student learners, and the institution itself. With regard to the OCSL, student TAs enhanced their own learning as a result of the additional instruction, coaching, and feedback they received. Additional benefits that have been reported for student teachers involved in PAL include improvements in the student teachers' teaching and communication skills,18,22 and anecdotal evidence from student TAs for the OCSL supported these findings. The OCSL environment was experiential and mirrored aspects of the professional working environment. Student TAs reported feeling as though they had made deeper connections between the lecture-based curriculum and the surgical skills needed at graduation, indicating a deeper level learning, as has also been reported previously for other PAL programs.23,24 Through both experiential and active learning, the TAs were able to create a more meaningful learning experience for themselves and those who attend the OCSL.
Students who participated in the OCSL sessions reported that their skills improved throughout the semester, which was consistent with previously reported effects of PAL.20 Field et al18 concluded that PAL modules were an efficient method of providing students with more time and hands-on opportunities to practice clinical skills and reinforce basic principles. Beard et al19 reported that students were more motivated to practice surgical skills after PAL sessions. With PAL, motivation is manifested not only in students who function as peer teachers, but also in the students they are teaching. In assessing the impact of the OCSL, students have consistently reported that the presence of the student TAs had a positive impact on their learning experience. Likely, a key to the positive impact on student learning was immediate feedback.25 As discussed previously, low-stress, real-time feedback is of particular value in developing clinical skills.26
Importantly, use of student TAs for OCSL sessions was less expensive than paying a faculty member to provide instruction and resulted in a higher teacher-to-student ratio. Peer-assisted learning can improve the efficiency and effectiveness of many types of instruction by prioritizing faculty members' time and effort.20,25 With increased clinical skills practice, students entered their clinical year more prepared and with a broader foundation in clinically relevant surgical skills. Greater student preparation meant clinicians could provide them with more advanced surgical training and wider application of knowledge and skill.
Despite their limited clinical expertise and exposure, it appeared that student TAs, when provided with proper training and oversight, were capable of providing a surgical skill foundation comparable to that provided by clinical faculty. Congruence theory explains why this may be the case, as it tells us that teachers with a knowledge base congruent to that of their students are more effective at imparting concepts than an expert with a more expansive knowledge base.27,28
Peer-assisted learning also appeared to be beneficial to the school culture. Learning from student TAs increased cooperative learning on the parts of both participants and TAs. Distinct from PAL, cooperative learning occurs when small groups of students work collaboratively toward a common goal29 and has been shown to have numerous positive effects on both skill retention and student achievement.30 In a veterinary professional curriculum, it is also critical to fostering a sense of professional culture. As the newest members of a small profession, it is important that veterinary students appreciate and rely on their peers as colleagues as soon as possible. The relaxed, cooperative atmosphere of the OCSL engendered opportunities for students to identify each other as peers and equals, regardless of class year. Cooperative learning among students has also been shown to allow development of communication skills critical to future professional success, such as giving feedback and managing performance.31
Program Challenges
As with any new program, implementing the OCSL was not without its challenges. Early difficulties involved securing administrative support, obtaining financing and a suitable facility, encouraging student attendance, and providing sufficient evidence to justify continuation. Administration skepticism was overcome by documenting students' desire for additional clinical skills development, citing relevant literature, engaging a motivated surgeon and instructional staff who believed in the need for more skill development, and engaging in continuing dialogue with administrators.
Motivating students to take ownership of their education and seek extracurricular sources of knowledge and experience is an ongoing concern. Student participant feedback has been used to determine how frequently to offer laboratory sessions, how to structure individual sessions to capture student interest, and how to incentivize regular clinical skills practice. Balancing a focus on foundational skills with the addition of new material has allowed students to tailor their own education.
Implementation of the OCSL at the WSU CVM has been beneficial to students, faculty, and the institution overall. Early challenges of space, staffing, and funding were predictable, and WSU CVM experiences can serve as a model for approaches to overcome them. Further, some of the most beneficial aspects of the OCSL, such as PAL, active learning, and collaborative behaviors, evolved in response to these early challenges. This model may be applicable to teaching any set of clinical skills in the veterinary curriculum. Additional research is warranted on the effects of this type of learning on student performance on a longer-term basis. Furthermore, a clear set of standards by which to monitor outcomes should be developed. Providing an environment that fosters learning will make the process by which we train surgical skills a transparent, efficient process benefitting students, the institution, and the profession.
Acknowledgments
Presented in part at the International Veterinary Simulation in Teaching Conference in Calgary, AB, Canada, August 2012.
The authors thank Dr. John Gay for assistance with statistical analyses.
ABBREVIATIONS
| CVM | College of Veterinary Medicine |
| OCSL | Optional clinical skills laboratory |
| PAL | Peer-assisted learning |
| TA | Teaching assistant |
| WSU | Washington State University |
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