The humane alternatives to harmful animal use in biomedical education have been designed by professional educators and scientists, and their educational efficacy is clearly demonstrated by the fact that nearly every comparative study has shown that students using humane alternatives perform at least as well as those trained via harmful animal use. At least 33 papers sourced from the biomedical and educational literature, covering all educational levels and disciplines, describe studies that have compared the ability of humane alternatives to impart knowledge or clinical or surgical skills. 39.4% (13/33) demonstrated that alternative students achieved superior learning outcomes, or achieved equivalent results more quickly, allowing time for additional learning. 51.5% (17/33) demonstrated equivalent educational efficacy, and only 9.1% (3/33) demonstrated inferior educational efficacy of humane alternatives. The design of one of the latter studies has been substantially criticized. 74 additional papers are also provided in which comparison with harmful animal use did not occur, demonstrating further educational efficacy, as well as staff time and cost savings and other important advantages of humane teaching methods.

Educational efficacy

Papers demonstrating superior educational efficacy of humane alternatives (13)

Abutarbush Sameeh M., Naylor Jonathan M., Parchoma Gale, D'Eon Marcel, Petrie Lyall & Carruthers Terry. Evaluation of traditional instruction versus a self-learning computer module in teaching veterinary students how to pass a nasogastric tube in the horse. Journal of Veterinary Medical Education 2006;33(3):447-54.

Objective – To evaluate the effectiveness of a self-learning computer module (SLCM) versus traditional instruction in teaching how to pass a nasogastric tube (NG) in the horse.

Design – a double-blind, monocentric study.

Sample population – 52 third-year students in the DVM program were randomly assigned to two groups: traditional instruction (N = 25) or SLCM instruction (N = 27).

Procedure – Traditional instruction consisted of an instructor and live demonstration; SCLM students were given a CD-ROM each. Both sessions lasted one hour. The students were then united in one session to practice passing the NG tube. Their performance was videotaped and evaluated by two evaluators. Students were then given a multiple-choice knowledge quiz. One week later, a second demonstration of the same procedure by the two methods was administered, and students were allowed to choose either method of instruction. A Likert-scale questionnaire about their comfort, their confidence, and the appropriateness of the teaching method was given after the second demonstration. Data were analyzed by non-parametric tests. A focus-group study was conducted to determine students’ perception of each teaching method. Nine participants in the experiment volunteered for these focus-group sessions. The sessions were audiotaped and transcribed.

Results – Students in the SLCM group performed significantly better on the test of knowledge than traditionally instructed students. The questionnaire found significant perceived benefits to computer-based instruction, including a preference for the computer-based module, better learning, and greater preparedness. In hands-on skill, time to pass the NG tube on the successful attempt was significantly shorter in the SLCM group than in the traditionally instructed group. The data from focus-group sessions suggest that while participants expressed satisfaction with both modes of instruction, the SLCM group reported somewhat higher levels of confidence in their skills prior to performing the procedure. Whereas the traditional group reported a strong preference for continued live demonstrations of the procedure, the SLCM group stated that the computer-assisted module alone provided them with effective instruction.

Conclusion – computer-assisted learning is an acceptable and effective method of training students to pass an NG tube with potential welfare, proficiency, and knowledge advantages.

Fawver, A.L., C.E. Branch, L. Trentham, B.T. Robertson & S.D., Beckett. A comparison of interactive videodisc instruction with live animal laboratories. American Journal of Physiology 1990;259(Advances in Physiology Education 4):S11–14.

This study compared interactive videodisc-simulated laboratories with two types of traditional labs: a traditional general cardiovascular physiology participation lab and a traditional fibrillation/positive pressure ventilation demonstration lab. The two laboratory sections (a total of 85 first-year veterinary medical students) were divided into 12 lab groups of 3-4 students per lab section. These groups were randomly assigned to either a traditional live animal laboratory or an interactive videodisc-simulated laboratory to compare the effectiveness and efficiency of these methods in teaching physiology. A 22-item, multiple-choice/short answer test was given to all students after the laboratories. In both the participation and the demonstration laboratories, there were no significant differences between group test scores of the interactive videodisc groups and the live animal laboratory groups, but there were differences in time spent by both students and instructors. It was concluded that the interactive videodisc-simulated lab was as effective as the traditional live-animal labs and was more time efficient than the traditional participation lab.

Fowler, H.S. & E.J. Brosius. A research study on the values gained from dissection of animals in secondary school biology. Science Education 1968;52(2):55–7.

High school students who watched films of animal dissections (earthworm, crayfish, frog, perch) demonstrated greater factual knowledge of these animals than did students who performed dissections on them.

Griffon DJ, Cronin P, Kirby B, Cottrell DF. Evaluation of a hemostasis model for teaching ovariohysterectomy in veterinary surgery. Vet Surg 2000;29(4):309-16. Department of Veterinary Clinical Studies, Easter Bush Veterinary Centre and the School of Cognitive Science, The University of Edinburgh, Scotland.

OBJECTIVE: To evaluate the efficacy of a reusable plastic model mimicking the anatomy and hemodynamics of the canine female genital tract for teaching basic surgical skills and ovariohysterectomy. SAMPLE POPULATION: 40 veterinary students of the class of 1998. STUDY DESIGN: Prospective study. METHODS: Students' confidence level and experience in private practice was evaluated via questionnaire before training. Students in 2 groups performed an ovariohysterectomy on cadavers (group C, n = 20) or on the model (Group M, n = 20) for 2 hours. Students' psychomotor and basic surgical skills were objectively assessed by the following tests: ligation of a foam cylinder, passing a needle through the eyelets of an electronic suture board, and ligating latex tubing. Results were compared before and after training and within and between groups. The ability of students to perform an ovariohysterectomy in a live dog after training was compared between groups with a scoring system. RESULTS: Students in both groups had similar surgical experience and basic skills before training. The results of the psychomotor and basic surgical skills tests were better in group M after training than group C. The improvement of each student in performing these tasks also increased when students were trained with the model. Scores assigned to students performing an ovariohysterectomy in a live dog were higher in group M (31.45 +/- 1.15) than in group C (20.7 +/- 1.42). CONCLUSION: The model was more effective than cadavers in teaching basic surgical skills and ovariohysterectomy in dogs.

Henman, M.C., & G.D.H. Leach. An alternative method for pharmacology laboratory class instruction using biovideograph videotape recordings. British Journal of Pharmacology 1983;80:591P.

Undergraduate pharmacology students using biovideograph performed significantly better on post-laboratory tests than those participating in the organ-based laboratories.

Johnson A.L. & J.A. Farmer. Evaluation of traditional and alternative models in psychomotor laboratories for veterinary surgery. Journal of Veterinary Medical Education 1989;16(1):11–14.

Inanimate models effectively taught basic psychomotor skills, and had the advantage over live animals that they could be used repeatedly, enhancing the acquisition of motor proficiency.

Leonard W. H. A comparison of student performance following instruction by interactive videodisc versus conventional laboratory. Journal of Research in Science Teaching 1992;29(1):93–102.

In the use of videodisc or traditional laboratories, no significant difference was found for biology undergraduate students' laboratory grades. However, the videodisc group required one-half the time.

McCollum T.L. 1987. The effect of animal dissections on student acquisition of knowledge of and attitudes toward the animals dissected. Unpublished Doctoral Dissertation, University of Cincinnati.

Approximately 175 high school biology students taught frog structure, function, and adaptation via lecture performed better on a post-test than did approximately 175 high school biology students taught by doing a frog dissection.

More, D. & C.L. Ralph. A test of effectiveness of courseware in a college biology class. J. Educational Technology Systems 1992;21:79–84.

Biology knowledge of about 92 undergraduate biology students using computer courseware increased more than did that of approximately 92 students using traditional animal-based laboratories.

Olsen D, Bauer MS, Seim HB, Salman MD. Evaluation of a hemostasis model for teaching basic surgical skills. Vet Surg 1996;25(1):49-58. Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, USA.

The need for alternative methods of teaching veterinary medicine and surgery has increased in recent years because of increasing costs and changing public opinion. For these reasons a hemostasis model was developed that mimics the arteries and veins of the peripheral vascular system, and can be used to teach the basic skills involved in blood vessel ligation and division. This study evaluated the effectiveness of the fluid hemostasis model compared with using live animals for teaching these skills. Forty sophomore veterinary students participated in the study. Two groups of 20 students each received identical instruction in the basic techniques required for vessel ligation and division. The students then completed various exercises using inanimate models to objectively evaluate their psychomotor skills. Both groups then practiced the techniques for equal time periods; one group used the hemostasis model and the other performed a splenectomy on live dogs. After the practice session, the students were videotaped (for later evaluation), as they performed vessel ligations and divisions. The students then repeated the exercises using the inanimate models for evaluation of skills improvement. Questionnaire responses before and after the project were obtained to determine the students' views on the need for inanimate models for teaching purposes. Results of this study indicate that the hemostasis model was as effective as live animals for teaching the basic skills involved in blood vessel ligation. The students' opinions regarding the use of properly designed inanimate models for teaching these skills were dramatically changed.

[The model group had a lower number of errors and lower time to complete exercises; more students in the model group tied square knots and tight ligatures, and instrument grip was rated better for the model group.]

Phelps, J.L., J.O. Nilsestuen & S. Hosemann 1992. Assessment of effectiveness of videodisc replacement of a live animal physiology laboratory. Distinguished Papers Monograph, American Association for Respiratory Care.

Nursing students who studied using an interactive video program on cardiac output principles performed better on a post-test than did students taught by lecture and live animal physiology laboratory.

Samsel, R.W., G.A. Schmidt, J.B. Hall, L.D.H. Wood, S.G. Shroff & P.T. Schumacker. Cardiovascular physiology teaching: computer simulations vs. animal demonstrations. Advances in Physiology Education 1994;11:S36–46.

The roots of physiology lie in laboratory observation, and physiology courses continue to rely on laboratory observation to provide students with practical information to correlate with their developing base of conceptual knowledge. To this end, animal laboratories provide a functioning example of interactions among organ systems and a source of data for student analysis. However, there are continuing objections to using animals for teaching, and animal labs are costly in time and effort. As an alternative laboratory tool, computer software can simulate the operation of multiple organ systems: responses to interventions illustrate intrinsic organ behavior and integrated systems physiology. Advantages of software over animal studies include alteration of variables that are not easily changed in vivo, repeated interventions, and cost-effective hands-on student access. Nevertheless, simulations miss intangible aspects of experimental physiology, and results depend critically on the assumptions of the model. We used both computer and animal demonstrations in teaching cardiovascular physiology to first-year medical students. The students rated both highly, but the computer-based session received a higher rating. We believe that both forms of teaching have educational merit. At the introductory level, the computer appears to provide an effective alternative.

Velle S & Hal T. Virtual Frog Dissection—Reality Check? 1999. Unpublished. In Cross TR & Cross VE. Scalpel of mouse: a statistical comparison of real and virtual frog dissections. The Amer Biol Teacher 2004;66(6):408-11.

A study was conducted using 64 ninth grade students in Wisconsin. Two classes, led by different teachers, were utilized. The class of Teacher A dissected real frogs, while the class of Teacher B performed a virtual dissection. Students in both classes followed the same laboratory outline and submitted the same laboratory report. At the end of the lab, both classes were given two tests. One test was virtual; the other used real frogs. Students who had completed the virtual dissection performed better on both tests. Cross & Cross (2004) commented that the teacher conducting the virtual dissection was a veteran of 20 years in the classroom, while the teacher working with the students dissecting real frogs was a first year biology intern, and that the method by which the performances were judged was not indicated.

Papers demonstrating equivalent educational efficacy of humane alternatives (17)

Bauer, M.S., N. Glickman, L. Glickman, J.P. Toombs & P. Bill. Evaluation of the effectiveness of a cadaver laboratory during a fourth-year veterinary surgery rotation. Journal of Veterinary Medical Education 1992;19(2):77–84.

Learning outcomes were similar between two groups of fourth-year veterinary students, one who were taught surgery using a terminal and cadaver laboratory format, the other taught using survival laboratories.

See also: Bauer MS, Glickman N, Salisbury SK, Toombs JP, Prostredny JM. Surgical vs terminal animal laboratories to teach small animal surgery. Journal of Veterinary Medical Education 1992;19(2):54-58.

Carpenter LG, Piermattei DL, Salman MD, Orton EC, Nelson AW, Smeak DD, Jennings PB Jr, Taylor RA. A comparison of surgical training with live anesthetized dogs and cadavers. Vet Surg 1991;20(6):373-8. Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, USA.

[Although the abstract does not specify the source of the cadavers, use of ethically-sourced cadavers, from animal that have been euthanased for medical reasons, or died naturally or in accidents, is possible. Hence the cadavers were considered the more humane option.]

Cadavers were compared with live anesthetized dogs for their effectiveness as models for surgical training of veterinary medical students. One group of students was trained using cadavers, and a peer group was trained using live anesthetized dogs. Both groups then performed an intestinal anastomosis using a live subject. The time to completion of the procedure was recorded. The anastomoses and celiotomy closures were evaluated. Each anastomosis was isolated and pressure tested. Reviewers blindly scored each surgical team's performance based on actual inspection of the surgical site and on viewing videotapes of the procedure. The participants' attitudes toward the use of live animals in teaching and research were documented before and after training. No statistically significant differences could be detected between the two groups. The results suggest that some substitution of cadavers for live dogs in surgical training might be feasible.

Clarke KA. The use of microcomputer simulations in undergraduate neurophysiology experiments. Alternatives to Laboratory Animals 1987;14:134-40.

One undergraduate student cohort (group) performed a physiological frog experiment on an isolated sciatic nerve preparation, while another cohort used a computer simulation of the same experiment. There was no significant difference between student cohorts in marks derived for the laboratory report, the standard form of assessment for a wet lab.

[i.e., similar to Dewhurst et al. 1988].

Cohen, P.S. & M. Block. Replacement of laboratory animals in an introductory psychology laboratory. Humane Innovations and Alternatives 1991;5:221–5.

Undergraduate students who studied feral pigeons in a city park scored equally well on evaluations as did students who studied operant conditioning with rats in a traditional lab.

Dewhurst DG, Brown GJ, Meehan AS. Microcom­puter simulations of laboratory experiments in physiology. Alternatives to Laboratory Animals 1988;15:280-9.

One undergraduate student cohort (group) performed a physiological frog experiment on an isolated sciatic nerve preparation, while another cohort used a computer simulation of the same experiment. There was no significant difference between student cohorts in marks derived for the laboratory report, the standard form of assessment for a wet lab.

[i.e., similar to Clark 1987].

Dewhurst DG, Hardcastle J, Hardcastle PT, Stuart E. Comparison of a computer simulation program and a traditional laboratory practical class for teaching the principles of intestinal absorption. Am J Physiol 1994;267(6 Pt 3):S95-104. Faculty of Health and Social Care, Leeds Metropolitan University, United Kingdom.

[Six undergraduate students working independently with a computer program gained equal knowledge, at one-fifth the cost, as eight supervised students using freshly killed rats.]

Here we describe an evaluation of the effectiveness, compared with a traditional laboratory, of an interactive computer-assisted learning (CAL) program, which simulates a series of experiments performed using isolated, everted sacs of rat small intestine. The program is aimed at undergraduate students of physiology and is designed to offer an alternative student-centered learning approach to the traditional laboratory-based practical class. The evaluative study compared two groups of second-year [UK] undergraduate students studying a module on epithelial transport: one group worked independently using the CAL program and associated learning materials, and the other group followed a conventional practical class approach, working in the laboratory under supervision. Knowledge gain of each group was measured by means of a test consisting of a range of question types (e.g., short-answer factual, calculation, interpretation) given to students before and after the module. Student attitude to both approaches was assessed by questionnaire, and the resource requirements were also compared. It was found that the knowledge gain of both groups of students was the same [and interestingly, the tutors who ran this teaching session did not identify laboratory/animal skills as primary learning objectives], that students had a positive attitude toward using CAL programs of this type [students using the CAL program became more positive about the experience after using it], and that the cost of the conventional laboratory-based approach was five times greater [the computer program was used with a printed workbook but no tutor support, whereas the wet lab required full tutor and some technical support]. The potential for integrating CAL programs into the undergraduate curriculum is discussed.

Dewhurst, D.G. & A.S. Meehan. Evaluation of the use of computer simulations of experiments in teaching undergraduate students. British J. Pharm. Proc. 1993;Suppl. 108:238.

Undergraduate students using computer simulations performed equally well as students using traditional approaches in physiology and pharmacology laboratories.

Downie, R. & J. Meadows. Experience with a dissection opt-out scheme in university level biology. Journal of Biological Education 1995;29(3):187–94.

Cumulative examination results of 308 undergraduate biology students who studied model rats were the same as those of 2,605 students who performed rat dissections.

Greenfield CL, Johnson AL, Shaeffer D & Hungerford LL. Comparison of surgical skills of students trained with models or live animals. Veterinary Surgery 1994;23(5):402.

Greenfield CL, Johnson AL, Schaeffer DJ, Hungerford LL. Comparison of surgical skills of veterinary students trained using models or live animals. J Am Vet Med Assoc 1995;206(12):1840-5. Department of Veterinary Clinical Medicine, College of Veterinary Medicine, University of Illinois, Urbana 61801, USA.

Surgical skills of veterinary students were evaluated following training with dogs and cats, or soft tissue organ models; performance of each group was equivalent.

Hughes IE. Do computer simulations of laboratory practicals meet learning needs? Trends in Pharmacological Sciences 2001;22(2):71-4. School of Biomedical Sciences, University of Leeds, LS2 9JT, Leeds, UK.

[The academic performance of students doing wet practicals (where students set up and manipulated their own tissue preparations, prepared their own solutions and calculated and prepared the drug doses and concentrations to be used) was compared with the performance of students using computer simulations. In each of five separate laboratory exercises, the performance of the students who used computer simulations was statistically significantly superior to that of the students who participated in the wet labs. However, examination results were equivalent or poorer when assessing details of the wet labs.]

There is a variety of pressures on pharmacology teachers to replace real laboratory practicals with simulations but do they help students achieve the required learning objectives? In this article, the marks obtained by students in a variety of assessments using 'wet' or simulated practicals are analysed. Poorer performance in practical write-ups by students doing 'wet' practicals compared with those doing simulations can be explained by the quality of the data that the students obtain. In examinations, students perform equally well except with questions that are related to the experimental details of 'wet' practicals; students taught using such 'wet' practicals perform better in response to these questions.

Kinzie, M.B., R. Strauss & J. Foss. The effects of an interactive dissection simulation on the performance and achievement of high school biology students. Journal of Research in Science Teaching 1993;30(8):989–1000.

Findings suggest that an interactive videodisc was at least as effective as actual dissection in promoting high school student learning of frog anatomy and dissection procedures.

Leathard, H.L. & D.G. Dewhurst. Comparison of the cost effectiveness of a computer-assisted learning program with a tutored demonstration to teach intestinal motility to medical students. ALT-J 1995;3(1):118–25.

No significant difference was found in the performances of preclinical medical students who used a traditional live animal laboratory and those who used a computer simulation on intestinal motility.

Lieb, M.J. 1985. Dissection: A valuable motivational tool or a trauma to the high school student? Unpublished Thesis, Master of Education, National College of Education, Evanston, Illinois.

Post-test scores were equivalent for high school students who dissected earthworms and those who received a classroom lecture on earthworm anatomy.

Pavletic, M.M., A. Schwartz, J. Berg, & D. Knapp. An assessment of the outcome of the alternative medical and surgical laboratory program at Tufts University. JAVMA 1994;205(1):97–100.

The school of Veterinary Medicine had made it the rule that all dogs undergoing major surgical procedures in its small animal teaching laboratories should be killed at the end of the procedure. However in 1988 12 students formally submitted a proposal requesting formation of an alternative small animal medical and surgical procedures course that would not include euthanasia of dogs, as they felt that it was morally wrong. An alternative training programme was developed to satisfy the moral concerns of the students, yet maintain the quality of their education. Cadavers were used of terminally ill or dead pets which were donated by the owners for the education of veterinary students, and were frozen until required. These students also spent 4 supplemental weeks in small animal surgery, 1 week in small animal medicine and 1 week in intensive care. Using this alternative training it was found that the use of cadavers during the 3rd year laboratory programme, when supplemented with additional clinical training during the 4th year, can provide training comparable to that provided in a conventional laboratory programme.

[Pavletic and others (1994) studied new graduates from the Tufts University veterinary class of 1990. The class included 12 students who had participated in an alternative small animal medical and surgical procedures course. These students and 36 of their conventionally-trained counterparts were assessed by questionnaires sent to their employers. Employers were asked to rate the competency of the new graduates at the time of hiring and 12 months later. It was found that there was no significant difference on either occasion in the abilities of the conventional and alternative graduates to perform common surgical, medical and diagnostic procedures; in their attitudes towards performing orthopaedic or soft tissue surgery; confidence in performing the listed procedures; or ability to perform those procedures without assistance.]

Strauss, R.T. and Kinzie, M.B. Student achievement and attitudes in a pilot study comparing an interactive videodisc simulation to conventional dissection. The American Biology Teacher 1994;56(7):398–402.

Two groups of high school students performed equally on a test following either animal dissection or interactive videodisc simulation.

White, K.K., L.G. Wheaton & S.A. Greene. Curriculum change related to live animal use: a four-year surgical curriculum. Journal of Veterinary Medical Education 1992;19:6–10.

After hesitancy in their first live tissue surgery, veterinary students from an alternative surgical laboratory program performed on par with students with a standard laboratory experience.

Papers demonstrating inferior educational efficacy of humane alternatives (3)

Cross TR & Cross VE. Scalpel or mouse: a statistical comparison of real and virtual frog dissections. The Amer Biol Teacher 2004;66(6):408-11.

Over a two-year period, four classes of eleventh and twelfth grade high school AP Biology students were tested, none of whom had previously dissected a frog. 36 students dissected real frogs, while 38 dissected virtual frogs using the ‘Biolab Frog Dissection’ computer simulation. The students were given two days to complete their assignments, after which their identification and knowledge of the functions of organs and tissues was examined. The first year (two classes), all students were tested only via a laboratory practical using real frogs. The second year (two additional classes), students were tested in laboratory practicals using both real and virtual frogs. Students dissecting real frogs performed significantly better on the laboratory practicals utilizing real frogs. No significant difference was observed in the virtual laboratory practical test scores, however.

Matthews, D. Comparison of MacPig to fetal pig dissection in college biology. The American Biology Teacher 1998;60(3):228–9.

Eight biology undergraduate students who dissected fetal pigs scored significantly higher on an oral test with prosected fetal pigs than did twelve students who studied on a computerized pig (MacPig).

Balcombe J. The American Biology Teacher. 1998;60(8):555-6. Criticized the study because MacPig is not advanced enough for college level biology instruction, to which Matthews replied, adding nothing further of substance: Matthews D. Efficacy of fetal pig dissection alternatives questioned. The American Biology Teacher 1998b;61(2):88.

Smeak DD, Hill LN, Beck ML, Shaffer CA, Birchard SJ. Evaluation of an autotutorial-simulator program for instruction of hollow organ closure. Vet Surg 1994;23(6):519-28. Department of Veterinary Clinical Sciences, Ohio State University College of Veterinary Medicine, Columbus.

Forty students were randomly assigned into two study groups (traditional, T; and simulator, S) of 20 students each for a core operative practice laboratory. Students were randomly paired and their group assignment and identity remained anonymous to the evaluators throughout the study. Questionnaires were distributed to students to evaluate prior surgical experience and obtain learning resource use information. Before the evaluation sessions, both groups were given identical learning resource opportunities except students in Group S received hollow organ simulators and practice materials for gastrotomy closure. All students were forewarned that surgical instruction would not be available during the evaluation sessions. In the first live animal evaluation session, all student pairs were videotaped after which stomachs were harvested for gross evaluation of the surgical site. Group T performed an additional gastrotomy for video and gross evaluation 2 weeks later. Questionnaire, and gross and video evaluation results were compared statistically between groups and sessions. The hollow organ model did not suitably simulate live stomach tissue; the material was more fragile and stiff and suture cut-out was a problem even with appropriate suture tension and technique. The model was effective for teaching needle placement, instrument usage, creating proper tissue inversion, and methods to minimize instrument handling of tissue during gastrotomy closure. Prior practice with models did not boost student confidence during their live gastrotomy session. The autotutorials (ATs) were well received by students but did not sufficiently address how to manage mucosal eversion, suture tension, and bleeding encountered during live gastrotomy. AT viewing time positively correlated with mean total video score for Group T during both sessions. None of the students had prior experience performing hollow organ closure and no significant difference in experience level was evident between groups. Mean closure time was not significantly different between groups for session one (Group T, mean, 31.5 minutes, range, 18.4 to 53.4; Group S, mean, 28.2 minutes, range, 16.8 to 36), but was significantly reduced for session two (Group T, mean, 21.3 minutes, range, 13.9 to 31). This AT/simulator program does not significantly influence students' overall gastrotomy closure technique; gross and video evaluation scores were not significantly different between groups. Without instructor supervision, an additional gastrotomy experience did not improve surgical technique appreciably for Group T; however, these students performed the second procedure with more confidence and speed.

Other relevant papers (e.g., comparisons not involving harmful animal use) (74)

Ahmad, Asyia; Alnoah, Zaid; Kochman, Michael L.; Krevsky, Benjamin; Peikin, Steven R.; Mercogliano, Giancarlo; Bailey, Marie; Boynton, Robert and Reynolds, James C. Philadelphia GI Training Group; Philadelphia, PA, Camden, NJ, Wynnewood, PA. Endoscopic simulator enhances training of colonoscopy in a randomized, prospective, blinded trial. Gastrointestinal Endoscopy 2003;57(5):S1499.

The aim of this single blind, randomized, prospective, multi-center study was to determine the impact of using an endoscopic simulator (AccuTouch Endoscopy Simulator, Immersion Medical, Gaithersburg, MD) for the acquisition of skills to perform colonoscopy. Conclusion: The use of this endoscopic simulator enhanced the performance of colonoscopies by GI fellows within the first two months of training.

Allen SW & Chambers JN. Computer-assisted instruction of fundamental surgical motor skills. Journal of Veterinary Medical Education 1997;24(1):2-5.

A computer-assisted learning program, "The Surgical Techniques Auto-Tutorial Program," was developed for use as an introductory training tool of fundamental surgical motor skills such as instrument handling and knot tying. The program was well received by veterinary medical students. Although computer-assisted instruction was as effective as traditional methods in helping the students develop and retain some skill, direct instructor contact was necessary for the retention of other skills such as knot tying. It is concluded that when followed by instructor contact laboratories allowing feedback and reinforcement of operative skills, computer-assisted instruction was found to be a helpful introductory training tool for the development of fundamental surgical motor skills.

Anon. New endoscopy simulator helps train for needle aspiration. Laparoscopic Surgery Update. 2001;9(6):69.

Baillie, S.; Crossan, A.; Reid, S.; Brewster, S. Preliminary development and evaluation of a bovine rectal palpation simulator for training veterinary students. Cattle Practice 2003;11(2):101-6.

A computer based teaching tool has been developed using haptic technology to train veterinary students to examine the bovine reproductive tract, simulating rectal palpation. The student receives touch feedback from a haptic device while palpating virtual objects. The teacher can visualise the student's actions on a screen and give training and guidance. The teaching protocol is divided into several levels to support the progressive development of skills. Preclinical students are trained to orientate themselves in the three dimensional anatomical environment, to develop the correct exploratory technique and to identify key structures. More experienced students can be trained to reinforce, and further develop, existing skills. The properties of the virtual scene were assessed by veterinary surgeons. Evaluation of the teaching tool was conducted with fourteen veterinary students. After being trained with the device, each student carried out rectal examinations and assessed the effect of haptic training. The evaluation results, although preliminary, support haptic training as a possible method for enhancing the teaching of bovine rectal palpation.

Baillie S. Crossan A. Brewster S. Mellor D. Reid S Validation of a bovine rectal palpation simulator for training veterinary students. Studies in Health Technology & Informatics 2005;111:33-6.

Bovine rectal palpation is a necessary skill for a veterinary student to learn. However, lack of resources and welfare issues currently restrict the amount of training available to students in this procedure. Here we present a virtual reality based teaching tool -- the Bovine Rectal Palpation Simulator -- that has been developed as a supplement to existing training methods. When using the simulator, the student palpates virtual objects representing the bovine reproductive tract, receiving feedback from a PHANToM haptic device (inside a fibreglass model of a cow), while the teacher follows the student's actions on the monitor and gives instruction. We present a validation experiment that compares the performance of a group of traditionally trained students with a group whose training was supplemented with a simulator training session. The subsequent performance in the real task, when examining cows for the first time, was assessed with the results showing a significantly better performance for the simulator group.

Baillie S. Mellor DJ. Brewster SA. Reid SW. Integrating a bovine rectal palpation simulator into an undergraduate veterinary curriculum. Journal of Veterinary Medical Education 2005;32(1):79-85.

There are problems associated with teaching bovine rectal palpation to undergraduate veterinary students. The students need opportunities to examine enough cows to develop the required skills, but increasing student numbers and limitations on access to cows have made this more and more difficult to achieve. A virtual reality-based teaching tool, the Bovine Rectal Palpation Simulator, has been developed as a supplement to existing training methods. The student palpates computer generated virtual models of the bovine reproductive tract while interacting with a haptic (touch feedback) device. During training sessions, the instructor follows the student's actions inside the virtual cow on the computer screen and gives instruction. A trial integration of the simulator into the fourth-year bovine reproduction course was undertaken at the University of Glasgow Veterinary School during the 2003/2004 academic year. Students were offered two training sessions, and feedback was gathered using questionnaires. In the first session, all students were taught a range of basic skills using a standardized teaching protocol. The second training session was customized to each student's learning needs and included practice in dealing with a range of on-farm scenarios. Student feedback indicated that the training had been useful for learning various aspects of bovine rectal palpation and provided information that helped in the further development of the simulator as a teaching tool.

Bauer MS, Glickman N., Salisbury SK, Toombs JP & Prostredny JM. Survival vs. terminal animal laboratories to teach small animal surgery. Journal of Veterinary Medical Education 1992;19(2):54-8.

Bro-Nielsen M. Tasto JL. Cunningham R. Merril GL. PreOp endoscopic simulator: a PC-based immersive training system for bronchoscopy. Studies in Health Technology & Informatics. 62:76-82, 1999.

The high cost of simulators that offer adequate realism for training has been a major challenge for the simulation community. The cost of the computers alone has been too high for most training institutions to afford. We have met this challenge by developing the PreOp Endoscopic Simulator, our second generation of low-cost medical simulators. The PreOp system integrates multimedia, 3D graphics simulation, and force feedback technology on a PC. This paper discusses the challenges of this project and the trade-offs and solutions that we developed to overcome them. We discuss our process of analyzing and prioritizing the medical tasks necessary to correctly perform flexible bronchoscopy. In addition, we illustrate how we blended together simulation and multimedia technology to ensure adequate immersion and training efficacy, while keeping the system cost to a minimum.

Buchanan M.F., Carter W.C., Cowgill L.M., Hurley D.J., Lewis S.J., MacLeod J.N., Melton T.R., Moore J.N., Pessah I., Roberson M., Robertson T.P., Smith M.L. & Vandenplas M.L. Using 3D animations to teach intracellular signal transduction mechanisms: taking the arrows out of cells. Journal of Veterinary Medical Education 2005;32(1):72-8. College of Veterinary Medicine, University of Georgia, Athens, GA 30602, USA.

Traditional methods of teaching intracellular biological processes and pathways use figures or flowcharts with the names of molecules linked with arrows. Many veterinary students, presented with such material, simply memorize the names or chemical structures of the molecules and are then likely to forget the material once the examination is completed. To address this problem, the authors designed, created, and field-tested new teaching media that incorporate realistic three-dimensional (3D) animations depicting the dynamic changes that occur in intracellular molecules during cellular activation. Testing found that veterinary students taught using traditional teaching media (e.g., lectures, handouts, textbooks) are proficient in memorizing the names and order of intracellular molecules but unable to appreciate the interactions between these elements or their spatial relationships within cells. In contrast, more than 90% of veterinary students taught using 3D animations not only recall the facts about the intracellular elements but also develop accurate mental images of the interactions among these molecules and their spatial relationships. These findings strongly suggest that the comprehension of complex biological processes by veterinary students can be enhanced by the use of dynamic 3D depictions of these processes in the classroom.

Chaer RA. Derubertis BG. Lin SC. Bush HL. Karwowski JK. Birk D. Morrissey NJ. Faries PL. McKinsey JF. Kent KC. Simulation improves resident performance in catheter-based intervention: results of a randomized, controlled study. Annals of Surgery 2006;244(3):343-52.

OBJECTIVES: Surgical simulation has been shown to enhance the training of general surgery residents. Since catheter-based techniques have become an important part of the vascular surgeon's armamentarium, we explored whether simulation might impact the acquisition of catheter skills by surgical residents. METHODS: Twenty general surgery residents received didactic training in the techniques of catheter intervention. Residents were then randomized with 10 receiving additional training with the Procedicus, computer-based, haptic simulator. All 20 residents then participated in 2 consecutive mentored catheter-based interventions for lower extremity occlusive disease in an OR/angiography suite. Resident performance was graded by attending surgeons blinded to the resident's training status, using 18 procedural steps as well as a global rating scale. RESULTS: There were no differences between the 2 resident groups with regard to demographics or scores on a visuospatial test administered at study outset. Overall, residents exposed to simulation scored higher than controls during the first angio/OR intervention: procedural steps (simulation/control) (50 +/- 6 vs. 33 +/- 9, P = 0.0015); global rating scale (30 +/- 7 vs. 19 +/- 5, P = 0.0052). The advantage provided by simulator training persisted with the second intervention (53 +/- 6 vs. 36 +/- 7, P = 0.0006); global rating scale (33 +/- 6 vs. 21 +/- 6, P = 0.0015). Moreover, simulation training, particularly for the second intervention, led to enhancement in almost all of the individual measures of performance. CONCLUSION: Simulation is a valid tool for instructing surgical residents and fellows in basic endovascular techniques and should be incorporated into surgical training programs. Moreover, simulators may also benefit the large number of vascular surgeons who seek retraining in catheter-based intervention.

Clark JA. Volchok JA. Hazey JW. Sadighi PJ. Fanelli RD. Initial experience using an endoscopic simulator to train surgical residents in flexible endoscopy in a community medical center residency program. Current Surgery 2005;62(1):59-63.

INTRODUCTION: The importance of training surgical residents in GI endoscopy has been recognized for years. Despite advice from SAGES and the RRC, few programs have managed to incorporate effective flexible endoscopy training into their curriculum, making it difficult for their graduates to be credentialed in GI endoscopy. Prior to October 2001, our residents obtained their entire clinical experience in the endoscopy unit with staff surgical endoscopists. Attendance was inconsistent because of their many other responsibilities, and residents often used much of their clinical endoscopic exposure gaining basic familiarity with the equipment, precluding the development of therapeutic facility. Since October 2001, we have used the Simbionix endoscopic simulator to supplement resident training in GI endoscopy. With the advent of virtual-reality simulators, and studies validating their effectiveness in teaching fundamental technical skills, we report our initial success in implementing a formal GI endoscopy curriculum using a virtual reality endoscopic simulator to provide basic experience before the clinical endoscopic experience begins. METHODS: Residents are given monthly assignments of simulated cases on the GI Mentor simulator. Junior residents complete the diagnostic case modules; senior residents complete the therapeutic modules. Data were accumulated over the course of two years with a total of five PGY-I and eight senior surgical residents completing assigned cases on the simulator. Objective criteria were measured from their performance on the simulator to determine the efficiency of the examination for each case completed. RESULTS: Preliminary data collected over the course of two years indicates that residents improve the efficiency of their endoscopic examinations over time as measured by objective criteria. Junior surgery residents attained an aggregate average of 59% efficiency in their examinations whereas senior surgical residents who had previous experience with the simulator, attained an aggregate efficiency of 80%. CONCLUSIONS: A formal flexible endoscopy curriculum enhances surgical resident training and positively impacts careers in general and gastrointestinal surgery. Endoscopic simulators allow surgical residents to master the technical aspects of GI endoscopy quickly, thereby permitting them more benefit from their clinical exposure in the endoscopy unit. We anticipate that our formal curriculum in GI endoscopy training will prepare our graduates well for careers that include flexible endoscopy as a component of their clinical practices, and position them to be credentialled in GI endoscopy upon graduation.

Dev P, Montgomery K, Senger S, Heinrichs WL, Srivastava S & Waldron K. Simulated medical learning environments on the Internet. Journal of the American Medical Informatics Association. 2002;9(5):437-47.

Learning anatomy and surgical procedures requires both a conceptual understanding of three-dimensional anatomy and a hands-on manipulation of tools and tissue. Such virtual resources are not available widely, are expensive, and may be culturally disallowed. Simulation technology, using high-performance computers and graphics, permits realistic real-time display of anatomy. Haptics technology supports the ability to probe and feel this virtual anatomy through the use of virtual tools. The Internet permits world-wide access to resources. We have brought together high-performance servers and high-bandwidth communication using the Next Generation Internet and complex bimanual haptics to simulate a tool-based learning environment for wide use. This article presents the technologic basis of this environment and some evaluation of its use in the gross anatomy course at Stanford University.

Dewhurst, D.G. & L. Jenkinson. The impact of computer-based alternatives on the use of animals in undergraduate teaching. ATLA 1995;23:521–30.

Use of computer packages saved teaching staff time, were less expensive, were an effective and enjoyable mode of undergraduate biomedical student learning, and significantly reduced animal use.

Dhein CR & Memon M. On-line continuing education at the College of Veterinary Medicine, Washington State University. Journal of Veterinary Medical Education (Special issue: Continuing veterinary education) 2003;30(1):41-6.

The use of on-line continuing education overcomes the potential obstacles of time and distance and reduces the expenses associated with continuing education. The asynchronous nature of the delivery system allows participants to spend as much or little time with the materials as they choose, allows them to start and stop when they wish (within the access duration) and gives them the ability to access the materials repeatedly during the available time-frame. The on-line format breaks geographic barriers, making it an excellent tool for international education. Our experiences at Washington State University with on-line continuing education support the view that there is demand for on-line education from veterinary medical professionals, as well as from animal owners. The on-line delivery system that has evolved at Washington State University has been well received by the majority of participants. The design of the delivery system has been kept consistent and relatively simple, in order to allow use by participants using a wide variety of computers and methods of Internet access. The team approach used in the development of these courses proved effective and provided for more expedient development of new courses. The content provider was not required to use advanced technical skills to participate. The site designer used templates created by an experienced computer programmer to build the site. The format used in our on-line education programs has also been used in our veterinary curriculum. The didactic components of two small animal specialties are currently taught by content experts outside our college, using the format developed for distance education. The education continuum, from veterinary school to the self-directed, lifelong learning of a practicing veterinarian, is enhanced by exposure to distance education in the veterinary curriculum.

Di Giulio E, Fregonese D, Casetti T, Cestari R, Chilovi F, D'Ambra G, Di Matteo G, Ficano L & Delle Fave G. Training with a computer-based simulator achieves basic manual skills required for upper endoscopy: a randomized controlled trial. Gastrointestinal Endoscopy 2004;60(2):196-200.

Dyson DH. Non-linear, visual-rich supplemental material designed for an introductory course in veterinary anaesthesia. Journal of Veterinary Medical Education 2003;30(4):360-3.

A possible reason for superficial learning in an introductory anaesthesia course was considered to be a lack of visual reinforcement at the time of examination preparation. Students had limited access to live animal laboratories and clinical cases during the course, reducing their ability to depend on experiential learning. In an attempt to improve student learning, simple presentation software was used to develop a supplemental CD. The design involved multiple PowerPoint presentations that incorporated text, pictures, videos and self-assessments. Non-linear exploration of the topics covered was made possible by extensive use of hyperlinks within and between presentations, moving the student to definitions, background material, videos, advanced details and previously covered information. Comments received from students on a prototype were positive overall, and improvements were made related to their feedback. Other supplemental materials and lecture presentations can easily incorporate the techniques described here.

Edmond CV Jr. Impact of the endoscopic sinus surgical simulator on operating room performance. Laryngoscope 2002;112(7 Pt 1):1148-58.

OBJECTIVES/HYPOTHESIS: The aim of this study is to evaluate an endoscopic sinus surgical simulator (ESS) as a training device and to introduce a methodology to assess its impact on actual operating room performance. STUDY DESIGN: Prospective evaluation of the endoscopic sinus surgical simulator as a trainer. METHODS: Ten junior and senior ear, nose and throat residents served as subjects, some of whom had prior training with the simulator. The evaluation team collected several measures, which were analyzed for a statistical correlation, including simulator scores, operating room performance rating, ratings of videotaped operating room procedures, and surgical competency rating. RESULTS: These findings suggest the ESS simulator positively affects initial operating room performance across all measures as judged by senior surgeons rating anonymous videotapes of those procedures. The two simulation-trained residents were rated consistently better than the other two residents across all measures. These differences approached statistical significance for two items: anterior ethmoidectomy (P =.06; P CONCLUSIONS: The endoscopic sinus surgical simulator is a valid training device and appears to positively impact operating room performance among junior otolaryngology residents.

Ellaway R. Pettigrew G. Rhind S. Dewhurst D. The Edinburgh Electronic Veterinary Curriculum: an online program-wide learning and support environment for veterinary education. Journal of Veterinary Medical Education 2005;32(1):38-46.

The Edinburgh Electronic Veterinary Curriculum (EEVeC) is a purpose-built virtual learning support environment for the veterinary medicine program at the University of Edinburgh. It is Web based and adapted from a system developed for the human medical curriculum. It is built around a set of databases and learning objects and incorporates features such as course materials, personalized timetables, staff and student contact pages, a notice board, and discussion forums. The EEVeC also contains global or generic resources such as information on quality enhancement and research options. Many of these features contribute to the aim of building a learning community, but a challenge has been to introduce specific features that enhance student learning. One of these is a searchable lecture database in which learning activities such as quizzes and computer-aided learning exercises (CALs) can be embedded to supplement a synopsis of the lecture and address the key needs of integration and reinforcement of learning. Statistics of use indicate extensive student activity during evenings and weekends, with a pattern of increased usage over the years as more features become available and staff and students progressively engage with the system. An essential feature of EEVeC is its flexibility and the way in which it is evolving to meet the changing needs of the teaching program.

Erickson, H.H. & V.L. Clegg. Active learning in cardiovascular physiology. In Modell, H.I., & Michael, J.A. (Eds). Promoting Active Learning in the Life Science Classroom. Annals of the New York Academy of Sciences 1993;701;107–8.

Of fourteen learning methods for basic cardiac teaching and ECG interpretation, computer-based active learning was rated the highest in veterinary student evaluations.

Galle U & Bubna-Littitz H. Model for teaching venous puncture techniques in the dog. Possibility for reducing stress to living experimental animals in student teaching. [German] Zentralblatt fur Veterinarmedizin, A 1983;30(10):796-9.

For obtaining practice in intravenous injection or bleeding in the dog a practice model is described which has given good results. A formalin-fixed preparation of a canine extremity in which the cephalic vein is replaced by a silicon tube is simple and cheap to set up and has the advantage of simulating the living animal. Using this model, the correct technique for injection and the reduced number of venous puncture attempts in the live animal can reduce to a minimum the stress imposed on experimental dogs.

Garuda, Sanjay; Keshavarzian, Ali; Losurdo, John; Brown, Michael D.; Rush Presbyterian St. Luke's Medical Center, Chicago, IL. Efficacy of a computer-assisted endoscopic simulator in training residents in flexible sigmoidoscopy. Presented as a poster abstract at the 2002 ACG.

Use of a simulator (AccuTouch Endoscopy Simulator, Immersion Medical, Gaithersburg, MD) reduced the number of procedures required to reach competency.

Grantcharov TP. Kristiansen VB. Bendix J. Bardram L. Rosenberg J. Funch-Jensen P. Randomized clinical trial of virtual reality simulation for laparoscopic skills training. British Journal of Surgery 2004;91(2):146-50.

BACKGROUND: This study examined the impact of virtual reality (VR) surgical simulation on improvement of psychomotor skills relevant to the performance of laparoscopic cholecystectomy. METHODS: Sixteen surgical trainees performed a laparoscopic cholecystectomy on patients in the operating room (OR). The participants were then randomized to receive VR training (ten repetitions of all six tasks on the Minimally Invasive Surgical Trainer-Virtual Reality (MIST-VR)) or no training. Subsequently, all subjects performed a further laparoscopic cholecystectomy in the OR. Both operative procedures were recorded on videotape, and assessed by two independent and blinded observers using predefined objective criteria. Time to complete the procedure, error score and economy of movement score were assessed during the laparoscopic procedure in the OR. RESULTS: No differences in baseline variables were found between the two groups. Surgeons who received VR training performed laparoscopic cholecystectomy significantly faster than the control group (P=0.021). Furthermore, those who had VR training showed significantly greater improvement in error (P=0.003) and economy of movement (P=0.003) scores. CONCLUSION: Surgeons who received VR simulator training showed significantly greater improvement in performance in the OR than those in the control group. VR surgical simulation is therefore a valid tool for training of laparoscopic psychomotor skills and could be incorporated into surgical training programmes.

Guy, J.F. & A.J. Frisby. Using interactive videodiscs to teach gross anatomy to undergraduates at Ohio State University. Academic Medicine 1992;67:132–3.

To determine whether interactive-videodisc lessons can effectively replace some of the labor-intensive laboratories in human gross anatomy, pre-nursing and allied-medical-professions undergraduates at The Ohio State University were randomly assigned to either a traditional cadaver-demonstration lab or an interactive-videodisc computer lab covering the same material. In a one-unit pilot study in the autumn quarter of 1989 (involving 190 students) and a full-quarter course in the spring quarter of 1991 (283 students), the performances of the computer-lab students were not significantly different from those of the students in the traditional cadaver-demonstration-lab groups.

Hadzimahmutovic Z. Healy DL. Tsaltas J. Lawrence AS. Brown TIH. Flanagan B. Gynaecological endoscopy training simulators. Gynaecological Endoscopy 1999;8(3):129-35.

Objective: To introduce the concept of simulator training to gynaecological surgeons and to inform them of the current state of worldwide research into the development of a laparoscopic simulator. Attributes: Virtual-reality technology enables the surgeon not only to perform diagnostic procedures, but also to practice entire surgical operations on a mannikin, while observing and interacting with a realistic computer-generated gynaecological environment on-screen. The benefits of such simulator training are twofold: surgeons will be at a higher point on the learning curve before their first operation on a patient, and patients should enjoy better quality of care. Research: Great confidence in the potential of virtual-reality technology in gynaecology, and medicine in general, has generated considerable international interest. As a result, much research and development effort is going into the creation of a gynaecological endoscopy simulator. Although several laparoscopic simulators are near their completion stage, there are no commercially available systems as yet. Medical education: A plan for the successful implementation of simulator training in gynaecology through preceptorship and credentialling programs, is outlined. Use of simulator training in gynaecology and other medical fields, is expected to become mole popular with further advances in technology.

Hall RE, Plant JR, Bands CJ, Wall AR, Kang J & Hall CA. Human patient simulation is effective for teaching paramedic students endotracheal intubation. Academic Emergency Medicine 2005;12(9):850-5.

OBJECTIVES: The primary purpose of this study was to determine whether the endotracheal intubation (ETI) success rate is different among paramedic students trained on a human patient simulator versus on human subjects in the operating room (OR). METHODS: Paramedic students (n = 36) with no prior ETI training received identical didactic and mannequin teaching. After randomization, students were trained for ten hours on a patient simulator (SIM) or with 15 intubations on human subjects in the OR. All students then underwent a formalized test of 15 intubations in the OR. The primary outcome was the rate of successful intubation. Secondary outcomes were the success rate at first attempt and the complication rate. The study was powered to detect a 10% difference for the overall success rate (alpha = 0.05, beta = 0.20). RESULTS: The overall intubation success rate was 87.8% in the SIM group and 84.8% in the OR group (difference of 3.0% [95% confidence interval {CI} = -4.2% to 10.1%; p = 0.42]). The success rate on the first attempt was 84.4% in the SIM group and 80.0% in the OR group (difference of 4.4% [95% CI = -3.4% to 12.3%; p = 0.27]). The complication rate was 6.3% in the SIM group and 4.4% in the OR group (difference of 1.9% [95% CI = -2.9% to 6.6%; p = 0.44]). CONCLUSIONS: When tested in the OR, paramedic students who were trained in ETI on a simulator are as effective as students who trained on human subjects. The results support using simulators to teach ETI.

Hariri S. Rawn C. Srivastava S. Youngblood P. Ladd A. Evaluation of a surgical simulator for learning clinical anatomy. Medical Education 2004;38(8):896-902.

BACKGROUND: New techniques in imaging and surgery have made 3-dimensional anatomical knowledge an increasingly important goal of medical education. This study compared the efficacy of 2 supplemental, self-study methods for learning shoulder joint anatomy to determine which method provides for greater transfer of learning to the clinical setting. METHODS: Two groups of medical students studied shoulder joint anatomy using either a second-generation virtual reality surgical simulator or images from a textbook. They were then asked to identify anatomical structures of the shoulder joint as they appeared in a videotape of a live arthroscopic procedure. RESULTS: The mean identification scores, out of a possible score of 7, were 3.1 +/- 1.3 for the simulator group and 2.9 +/- 1.5 for the textbook group (P = 0.70). Student ratings of the 2 methods on a 5-point Likert scale were significantly different. The simulator group rated the simulator more highly as an effective learning tool than the textbook group rated the textbook (means of 3.2 +/- 0.7 and 2.6 +/- 0.5, respectively, P = 0.02). Furthermore, the simulator group indicated that they were more likely to use the simulator as a learning tool if it were available to them than the textbook group was willing to use the textbook (means of 4.0 +/- 1.2 and 3.0 +/- 0.9, respectively, P = 0.02). CONCLUSION: Our results show that this surgical simulator is at least as effective as textbook images for learning anatomy and could enhance student learning through increased motivation. These findings provide insight into simulator development and strategies for learning anatomy. Possible explanations and future research directions are discussed.

Hawkins EC, Hansen B & Bunch BL. Use of animation-enhanced video clips for teaching abnormal breathing patterns. Journal of Veterinary Medical Education (Special issue: Continuing veterinary education) 2003;30(1):73-7.

The ability to characterize disease of the respiratory tract accurately based on breathing, pattern is helpful for the development of differential diagnoses and an efficient diagnostic plan and critical for the stabilization of patients in respiratory distress. Veterinary students do not have sufficient clinical experience to observe personally all types of respiratory diseases and their resultant abnormal breathing patterns. We developed a teaching tool, the animated breathing pattern videotape (ABV), to fill this gap. The ABV is a collection of video clips of small animal patients with normal and abnormal breathing patterns on a conventional videotape of approximately 20 minutes duration. Each video clip is shown for 20 to 40 seconds, followed by the same clip with superimposed animation of rib and diaphragm motion, followed by the initial clip again, without overlying animation. The ABV has since been used in teaching, third-year veterinary students, interns, residents, practicing veterinarians, and veterinary technicians. Student evaluations and responses to questionnaires by interns, residents, practicing veterinarians, veterinary technicians, and peer reviewers have been uniformly positive.

Hilmi OJ. White PS. McGurty DW. Oluwole M. Bronchoscopy training: is simulated surgery effective? Clinical Otolaryngology & Allied Sciences. 27(4):267-9, 2002 Aug.

Intensive surgical skills courses have become an essential part of surgical skill acquisition for surgeons in training. There is a need to monitor the value of these courses in terms of skill attainment. The aim of this study was to determine the effectiveness of skills-laboratory-based training in rigid bronchoscopy and bronchial foreign body removal. Bronchoscopies were recorded, analysed and categorized by a single observer according to time to completion and four predetermined parameters of surgical error. An overall quality score was obtained by simple summation of the number of errors and determined as acceptable or unacceptable (scoring 0 or 1 respectively). The data was analysed using a t-test for paired groups.

Hines SA, Collins PL, Quitadamo IJ, Brahler CJ, Knudson CD and Crouch GJ. ATLes: the strategic application of Web-based technology to address learning objectives and enhance classroom discussion in a veterinary pathology course. Journal of Veterinary Medical Education 2005;32(1):103-12.

A case-based program called ATLes (Adaptive Teaching and Learning Environments) was designed for use in a systemic pathology course and implemented over a four-year period. Second-year veterinary students working in small collaborative learning groups used the program prior to their weekly pathology laboratory. The goals of ATLes were to better address specific learning objectives in the course (notably the appreciation of pathophysiology), to solve previously identified problems associated with information overload and information sorting that commonly occur as part of discovery-based processes, and to enhance classroom discussion. The program was also designed to model and allow students to practice the problem-oriented approach to clinical cases, thereby enabling them to study pathology in a relevant clinical context. Features included opportunities for students to obtain additional information on the case by requesting specific laboratory tests and/or diagnostic procedures. However, students were also required to justify their diagnostic plans and to provide mechanistic analyses. The use of ATLes met most of these objectives. Student acceptance was high, and students favorably reviewed the online ''Content Links'' that made useful information more readily accessible and level appropriate. Students came to the lab better prepared to engage in an in-depth and high-quality discussion and were better able to connect clinical problems to underlying changes in tissue (lesions). However, many students indicated that the required time on task prior to lab might have been excessive relative to what they thought they learned. The classroom discussion, although improved, was not elevated to the expected level-most likely reflecting other missing elements of the learning environment, including the existing student culture and the students' current discussion skills. This article briefly discusses the lessons learned from ATLes and how similar case-based exercises might be combined with other approaches to enhance and enliven classroom discussions in the veterinary curriculum.

Hochberger J. Matthes K. Maiss J. Koebnick C. Hahn EG. Cohen J. Training with the compactEASIE biologic endoscopy simulator significantly improves hemostatic technical skill of gastroenterology fellows: a randomized controlled comparison with clinical endoscopy training alone.[see comment]. Gastrointestinal Endoscopy 2005;61(2):204-15.

BACKGROUND: The Erlangen Active Simulator for Interventional Endoscopy (EASIE) was introduced in 1997 for interventional endoscopy training. compactEASIE developed in 1998 is a modified, light-weight version of the original model. Objective evidence of the benefits of training with these models is limited. A randomized controlled study, therefore, was conducted to compare the effects of intensive 7-month, hands-on training in hemostatic techniques by using the compactEASIE model (in addition to clinical endoscopic training) vs. pure clinical training in endoscopic hemostatic methods. METHODS: Thirty-seven fellows in gastroenterology in New York City area training programs were enrolled. Baseline skills were assessed on the simulator for the following techniques: manual skills, injection and electrocoagulation, hemoclip application, and variceal ligation. Twenty-eight fellows were then randomized into two comparable groups. Those randomized to Group A received purely clinical training in endoscopic hemostatic techniques at their hospitals. Those in Group B, in addition, were trained by experienced tutors in 3 full-day hemostasis workshops over 7 months. Both groups underwent a final evaluation on the compactEASIE simulator conducted by their tutors and additional evaluators who were blinded to the method of training. Initial and final evaluation scores were compared for each group and between groups. Outcomes of actual clinical hemostatic procedures performed during the study period also were analyzed. RESULTS: Ten of 14 fellows randomized to Group A (standard training) and 13 of 14 in Group B (intensive training) returned for the final evaluation. For Group B, scores for all techniques were significantly improved. In Group A, a significant improvement was noted for variceal ligation alone. CONCLUSIONS: compactEASIE simulator training (3 sessions over 7 months), together with clinical endoscopic training resulted in objective improvement in the performance by fellows of all 4 endoscopic hemostatic techniques, whereas significant improvement was noted for variceal ligation alone for fellows who had standard clinical training. In clinical practice, fellows who had intensive simulator/clinical training had a significantly higher success rate and a nonsignificant reduction in the frequency of occurrence of complications.

Holmberg DL, Cockshutt JR & Basher AWP. Use of a dog abdominal surrogate for teaching surgery. Journal of Veterinary Medical Education 1993;20(2):61-2.

The DASIE (dog abdominal surrogate for instructional exercises) was well received by students. It was considered to be an effective, low stress method of preparing for live animal surgery. Its use has reduced the need for animals in teaching abdominal surgery. This follows the philosophical trend of today's society in its demands for non-living teaching models. The use, is therefore suggested, of an abdominal surrogate as an aesthetically acceptable alternative to live animal or cadaver surgery for some introductory surgical laboratory classes.

Holt RI, Miklaszewicz P, Cranston IC, Russell-Jones D, Rees PJ, Sonksen PH. Computer assisted learning is an effective way of teaching endocrinology. Clin Endocrinol (Oxf) 2001;55(4):537-42. Department of Medicine, Guy's, King's & St Thomas' School of Medicine, St Thomas' Hospital, Lambeth Palace Road, London, UK.

OBJECTIVES: Computers are a part of everyday life and offer an exciting way of learning. The aim of our study was to determine the effectiveness of teaching undergraduate endocrinology using a Computer Assisted Learning (CAL) programme. DESIGN AND SUBJECTS: One hundred and eighty-five first year clinical medical students were randomly assigned either to attend a series of conventional lectures (n = 77) or to have the same material available through a CAL programme. MEASUREMENTS: A multiple choice question examination was performed before and after the course. Lecture attendance and individual usage of the computer system were recorded. Students were asked to fill in an evaluation form at the end of the study. RESULTS: There was no significant difference in the first examination scores between the groups. Both groups improved their scores after the course. Students spent longer performing CAL than attending lectures. Those who scored lowest in the first examination spent the most time on the CAL course. Those who spent the most time on the CAL course showed the largest improvement in examination score. Thirty-six out of the 42 students, who completed an evaluation of the CAL programme, rated it better than the standard lectures. CONCLUSIONS: Computer assisted learning is an effective way of increasing knowledge in teaching undergraduate endocrinology. The course was easy to run and was valued more highly than conventional lectures. The module is now running routinely in the year 3 clinical firms at St Thomas' and has resulted in an increase in knowledge in the end of firm assessment.

Howe LM. Boothe HW Jr. Hartsfield SM. Student assessment of the educational benefits of using a CD-ROM for instruction of basic surgical skills. Journal of Veterinary Medical Education 2005;32(1):138-43.

RATIONALE FOR STUDY: At Texas A&M University, introductory-level surgical lecture and laboratory notes were converted to a CD-ROM format that included illustrative photographs as well as instructional videos demonstrating the basic surgical skills that all students were required to master. The CD-ROM was distributed to all students in place of traditional paper notes in the second-year surgical class in the professional veterinary curriculum. The study reported here was designed to evaluate the educational benefits of the use of the CD-ROM in place of traditional paper notes by examining the attitudes and practices of students before and after exposure to the CD-ROM format. METHODOLOGY: An anonymous survey was distributed to students in the second-year introductory surgery course on the first day of class and again on the last day of class. Responses to questions were tabulated, response frequencies determined, and Chi-square analysis performed to determine differences between initial and final responses. RESULTS: On the final survey, 89 per cent of students responded that the instructional videos definitely helped them prepare for the laboratory, and 77 per cent responded that they were more likely to practice techniques learned from the CD-ROM videos than those learned from traditional study materials. The majority of students believed that the CD-ROM improved both the course (60 per cent) and their learning experience (62 per cent) as compared to traditional paper notes. CONCLUSIONS: Including instructional videos on the CD-ROM enhanced the educational experience of the students by promoting preparedness for laboratories and promoting practice of techniques learned from the videos outside of the laboratory.

Howe LM & Slater MR. Student assessment of the educational benefits of a prepubertal gonadectomy program (preliminary findings). Journal of Veterinary Medical Education 1997;24(1):12-7.

Texas A&M University recently established two prepubertal gonadectomy programmes in association with area humane organizations as an addition to its required elective surgery rotation for 4th-year veterinary medical students. Results of a student questionnaire indicate that the addition of these programs enhances their education experience in several ways including: refinement of surgical skills in certain areas including gentle tissue handling and hand-eye coordination, exposure and practice in perioperative and anaesthetic management of paediatric patients, increased awareness of the functions, goals, and activities of humane organizations and increased understanding of the pet overpopulation problem and the unique role of the veterinarian in combating

Huang, S.D. & J. Aloi. The impact of using interactive video in teaching general biology. The American Biology Teacher 1991;53(5):281–4.

Biology undergraduate students using a computer-assisted interactive videodisc system which included dissection simulations performed significantly better than students who had not used the computer-aided instruction.

Jones, N.A., R.P. Olafson, & J. Sutin. Evaluation of a gross anatomy program without dissection. Journal of Medical Education 1978;53:198–205.

Freshman medical students have been participating in an experimental multimedia gross anatomy program at Emory University for five years. The program includes audiovisuals, computer-assisted instruction, and tutorial sessions using prosected specimens. No lectures are given nor is dissection permitted. Experimental and traditional groups were compared by intramural written and practical examinations and by an extramural written examination prepared by the National Board of Medical Examiners and the Association of Anatomy Chairmen. Study of 35 intramural examinations given to five classes showed students in the traditional course with significantly higher performance in three examinations and students in the experimental course with significantly higher performance in six examinations. Neither group's performance was significantly higher on any extramural examination. It was concluded that, as measured by conventional examinations, students in the multimedia program with prosection tutorials learned human anatomy as well as those in the traditional lecture-dissection program.

Josephson Eleanor M., Moore Larry J. An electronic instructor for gross anatomy dissection. Journal of Veterinary Medical Education 2006;33(3):465-73. Correspondence:

Gross anatomy is time consuming to teach and to learn. Because the process of dissection takes up so much student time, assistance in the form of an in-lab instructional DVD program might improve student performance. The DVD could be viewed with a portable device by individual dissection groups at their tables. Groups could dissect at their own pace, with access to step-by-step demonstrations and answers to frequently asked anatomical questions. We created an instructional DVD program demonstrating dissection of the canine ventral neck and thoracic limb. The effect on student exam scores of using the DVD versus not using it was measured in a controlled, two-sample study using incoming first-year veterinary students as volunteers. Volunteers were told the study was of two different dissection methods; the DVD was not specifically mentioned until after the students were separated into two groups (Blue/DVD group and Orange/No DVD group), and then only to volunteers in the Blue group. Except for the DVD, the two groups had the same resources. The difference in scores on an exam given after a single dissection period did not differ sufficiently to conclude that DVD use raised the mean score; however, 73% of the DVD group scored 60% or higher, while only 38% of the No DVD group scored 60% or higher. The difference in mean scores overall was 2.3 points out of a possible 49, suggesting that the DVD helped students, especially those with lower scores, to earn two to three more points than they would have otherwise.

Kumar Amarendhra M, Murtaugh Robert, Brown Donald, Ballas True, Clancy Elizabeth, Patronek Gary. Client donation program for acquiring dogs and cats to teach veterinary gross anatomy. Journal of Veterinary Medical Education 2001;28(2):73–77. Department of Biomedical Sciences, School of Veterinary Medicine, Tufts University, 200 Westboro Road, N. Grafton, MA 01536, USA.

A donor program for procuring dogs and cats to meet the needs of anatomical instruction was initiated six years ago at Tufts University School of Veterinary Medicine. The program was initiated in order to comply with state regulations that preclude the use of shelter animals and to satisfy ethical objections of students and faculty. The donor program has successfully met the animal needs for teaching gross anatomy and, in addition, provides opportunities to integrate clinical perspectives and ethics beginning from the first year of veterinary education.

[This excellent paper describes the educational memorial program (EMP) (body donation program) at Tufts Uni vet school, which successfully supplies all cadaver needs for teaching gross anatomy (donated cadavers are also used in teaching medical procedures and clinical skills). The euthanasia brochure and client consent forms are given, as are detailed technical embalming instructions. Tables of student opinions (90% in support) and comments (strongly supportive) are given, and rebuttals of common objections by academics to setting up EMPs (e.g. too labour intensive) are given, based on the Tufts experience. This article strongly supports the establishment of an EMP.]

Li Y. Brodlie K. Phillips N. Web-based VR training simulator for percutaneous rhizotomy. Studies in Health Technology & Informatics 2000;70:175-81.

Virtual Reality offers great potential for surgical training--yet is typically limited by the dedicated and expensive equipment required. Web-based VR has the potential to offer a much cheaper alternative, in which simulations of fundamental techniques are downloaded from a server to run within a web browser. The equipment requirement is modest--an Internet-connected PC or small workstation--and the simulation can be accessed worldwide. In a collaboration between computer scientists and neurosurgeons, we have studied the use of web-based VR to train neurosurgeons in Percutaneous Rhizotomy--a treatment for the intractable facial pain which occurs in trigeminal neuralgia. This involves the insertion of a needle so as to puncture the foramen ovale, and lesion the nerve. Our simulation uses VRML to provide a 3D visualization environment, but the work immediately exposes a key limitation of VRML for surgical simulation. VRML does not support collision detection between objects--only between viewpoint and object. Thus collision between needle and skull cannot be detected and fed back to the trainee. We have developed a novel solution in which the training simulation has linked views: a normal view, plus a view as seen from the tip of the needle. Collision detection is captured in the needle view, and fed back to the viewer. A happy consequence of this approach has been the chance to aid the trainee with this additional view from needle tip, which helps locate the foramen ovale. The technology to achieve this is Java software communicating with the VRML worlds through the External Authoring Interface (EAI). The training simulator is available on the Web, with accompanying tutorial on its use. A major advantage of web-based VR is that the techniques generalize to a whole range of surgical simulations. Thus we have been able to use exactly the same approach as described above for neurosurgery, to develop a shoulder arthroscopy simulator--where again collision detection, and the view from the scope, are fundamental.

Lilienfield LS, Broering NC. Computers as teachers: learning from animations. Am J Physiol 1994;266(6 Pt 3):S47-54. Department of Physiology and Biophysics, Georgetown University Medical Center, Washington, District of Columbia 20007.

The effectiveness of an interactive multimedia computer program, the "Electronic Textbook in Human Physiology," in improving the knowledge of students studying cardiovascular physiology was determined from scores on tests given before and immediately after completion of a two-hour animation program on the Cardiac Cycle and Introduction to Electrocardiography and by comparison of performance on a final examination taken later with their unexposed (control) classmates. Unsigned comments on the use of the program were obtained from all participants and were universally laudatory. A marked and significant improvement in the immediate posttest compared with the pretest scores was found. More importantly, the students who had used the computer program achieved a significantly higher grade in the cardiovascular section of the final exam than their (control) classmates. Several possible explanations of the results are offered; the most likely one is that the use of the computer program facilitated learning. The implications of this, especially for curriculum planning, are discussed.

Linton A., Schoenfeld-Tacher R. & Whalen L.R. Developing and implementing an assessment method to evaluate a virtual canine anatomy program. Journal of Veterinary Medical Education 2005;32(2):249-54. Department of Biomedical Sciences at Colorado State University, W103 Anatomy/Zoology, BMS-Anatomy, CSU, 1617 Campus Delivery, Fort Collins, CO, 80523-1617, USA.

A computer-based anatomy program, Virtual Canine Anatomy: The Head, was incorporated into a first-year veterinary dissection laboratory two years ago to address challenges inherent in the traditional pedagogical approach. The program uses specimen photographs, QuickTime Virtual Reality, and interactive features to help students study the dissection, osteology, and radiology of the canine head. Photographs of each phase of dissection are displayed in the program, along with dissection instructions. Students can click on anatomical structures in each photograph to highlight the selected structure and display a complete description of it. Related structures and views are accessible through hyperlinks. This study was designed to measure student and faculty attitudes toward the instructional software, to gauge its effect on student achievement, and to propose evaluation methodology and instrumentation for similar projects. Observations, interviews, focus groups, surveys, and test results were used for this assessment. Results suggest positive student and faculty attitudes toward the program. Students felt the program met their needs, increased their confidence and efficiency, and was easy to use. Both students and instructors felt the program was beneficial during dissection. There was no significant change in student achievement on course tests. Future research will measure the program's effect on student-instructor interactions.

Long V. Kalloo AN. AccuTouch Endoscopy Simulator: development, applications and early experience. Gastrointestinal Endoscopy Clinics of North America 2006;16(3):479-87.

These studies suggest that there are several potential advantages to use of the AccuTouch simulators, including (1) improvement of the endoscopic training of trainees before patient contact, (2) possible evaluation for procedural competency, and (3) possible cost savings, increasing the productivity of faculty while the trainees are developing competency using the trainers. Other potential advantages might include the training of endoscopists in new diagnostic and therapeutic techniques and even new devices before patient contact. With continued improvement in software and hardware, endoscopic simulators will become an integral part of endoscopic training programs.

Madorin S. Iwasiw C. The effects of computer-assisted instruction on the self-efficacy of baccalaureate nursing students. Journal of Nursing Education 1999;38(6): 282-5.

As computer-assisted instruction (CAI) use has increased during the past few years, nurse educators have expressed concern regarding its effectiveness. The purpose of this quasiexperimental study was to determine if completion of a computerized simulation about a surgical patient increased baccalaureate nursing students' self-efficacy about caring for surgical patients in the clinical environment. Such an association is desirable because increased levels of self-efficacy have been associated with increased motivation, goal-setting, and achievement. A nonprobability, convenience sample (N = 23) of second-year baccalaureate nursing students was assigned randomly to experimental and control groups. The self-efficacy of the experimental group was measured three times: on an initial pretest; following the intervention of a computer simulation; and after an 8-week clinical rotation. The self-efficacy of the control group was measured on an initial pretest and after the 8-week rotation. Higher preclinical self-efficacy scores (p<.01) of the experimental group support the use of CAI as an important aspect of clinical education. Implications for nursing education, practice, and research are addressed. Computer-assisted instruction (CAI) has been available for several decades; however, its use in nursing education has escalated during the past few years. This intensified interest is the result of a decrease in the cost of computer hardware and an increase in the availability of relevant educational software (Wright, 1995). Cutbacks to educational funding, along with the rising costs of clinical teaching, have motivated studies of this method of nursing education. The purpose of this pilot study was to determine if completion of a supplemental computerized simulation about a surgical patient increased baccalaureate nursing students' self-efficacy about caring for surgical patients in the clinical area. The exploration of a link between CAI and self-efficacy focused on the processes of learning, thereby extending the literature.

Maiss J. Wiesnet J. Proeschel A. Matthes K. Prat F. Cohen J. Chaussade S. Sautereau D. Naegel A. Krauss N. Peters A. Hahn EG. Hochberger J. Objective benefit of a 1-day training course in endoscopic hemostasis using the "compactEASIE" endoscopy simulator. Endoscopy 2005;37(6):552-8.

BACKGROUND AND STUDY AIMS: The Erlangen Active Simulator for Interventional Endoscopy (EASIE) was introduced in 1997 as a training model for interventional endoscopy. Objective evidence of the benefits of training with this model has not previously been published. As part of two long-term projects, the benefits of a 1-day training course with the "compactEASIE" simulator were evaluated. MATERIALS AND METHODS: Fourteen American and 18 French gastroenterology fellows were enrolled. These fellows were participants in the intensive groups performing training in endoscopic hemostasis, with a total number of 28 fellows in New York and 36 in France. Gastrointestinal endoscopy faculty members in New York and France evaluated and timed the fellows in four disciplines to establish baseline skills (manual skills; injection and coagulation; Hemoclip application; and variceal ligation) with the compactEASIE simulator. The trainees were reevaluated after an intensive 1-day course (with two or three fellows and one instructor per station), also including preparation and assistance for each procedure. The assessment (overall and parts) was done by expert tutors using an ordinal scale ranging from 1 to 10 (1 = poorest, 10 = best), recording also mistakes and performance time. The compactEASIE simulator, equipped with an upper gastrointestinal organ package and an artificial blood perfusion system, was used as the training tool. RESULTS: A highly significant improvement ( P CONCLUSIONS: A 1-day training course on endoscopic hemostasis using the compactEASIE simulator is capable of improving the performance of hemostasis procedures. Long-term effects of repeated training sessions are currently subject of collaborative studies in New York and France.

Marescaux J, Mutter D, Soler L, Vix M & Leroy J. [The Virtual University applied to telesurgery: from tele-education to tele-manipulation]. [French] Bulletin de l Academie Nationale de Medecine 1999;183(3):509-21. Discussion 521-2.

The advent of new computer technologies appears as a revolution of surgical teaching, as well as the planning and realisation of surgical procedures. The introduction of a camera into the body of a patient, allowing the visual display of the operative procedure through the use of miniaturised camera constitutes the greatest alteration that the surgical world has experienced at the end of this century: mini-invasive surgery is born. This revolution was announces further changes: the development of telecommunication devices applied to medicine (tele-education, teletraining, telementoring, teleproctoring and tele-accreditation) constitutes the basis of cybersurgery or virtual reality allowing the merging of the concepts of telepresence and telemanipulation. These new concepts were developed at the European Institute of TeleSurgery of Strasbourg. The TESUS project developed the use of surgical images and data transmission through the realisation of international multi-site video conferences between surgeons. The WEBS project created the first Virtual University concept placing surgical techniques at the surgeon's disposal through Internet. The HESSOS project uses virtual reality as a surgical simulation system. The MASTER project allows to develop the concept of distant telemanipulation. It is now possible to face surgical teaching outside of the restricted University frame and to conceive teaching on a world level, offering to the practitioner unimaginable possibilities of formation, training and planning of surgical procedures.

Marescaux J, Mutter D, Soler L, Vix M & Leroy J. [The virtual university applied to telesurgery: from tele-education to telemanipulation]. [French] Chirurgie 1999;124(3):232-9.

The advent of new computer technologies can appear as a revolution in surgical teaching, as well as in the planing and realization of surgical procedures. The introduction of a camera into the body of a patient, allowing the visual display of the operative procedure through the use of a miniaturized camera, constitutes the greatest change that the surgical world has experienced at the end of this century: mini-invasive surgery is born. This revolution also predicts further changes: the development of telecommunication devices applied to medicine (tele-education, tele-training, tele-mentoring, tele-proctoring and tele-accreditation), constitutes the basis of cybersurgery or virtual reality allowing the merging of the concepts of tele-presence and telemanipulation. These new concepts were developed at the European Institute of TeleSurgery at Strasbourg. The TESUS project developed the use of surgical images and data transmission through the realization of international multi-site video conferences between surgeons. The WEBS project created the first virtual university concept by placing surgical techniques at the surgeon's disposal through the Internet. The HESSOS project uses virtual reality as a surgical simulation system. The MASTER project allows the development of the concept of distant telemanipulation. It is now possible to face surgical teaching outside of the restricted University framework, and to conceive teaching on a world-wide level, offering the practitioner unimaginable possibilities of formation, training and the planning of surgical procedures.

Modell JH, Cantwell S, Hardcastle J, Robertson S, Pablo L. Using the human patient simulator to educate students of veterinary medicine. J Vet Med Educ 2002 Summer;29(2):111-6. University of Florida College of Medicine / University of Florida College of Veterinary Medicine, Gainesville, FL 32610, USA.

INTRODUCTION: The human patient simulator has proved to be an effective educational device for teaching physicians and paramedical personnel. METHODOLOGY: To determine whether veterinary medicine students would benefit from similar educational sessions, 90 students each took a turn being the patient's clinician as real-life scenarios were played out on the simulator. The students induced and maintained anesthesia on their patient and monitored vital signs. Several critical events were presented for the students to diagnose and treat as they occurred. All students submitted a written evaluation of the course upon completion. The last 40 students were randomly divided into two groups of 20 students each. The students in Group I experienced the simulator before their clerkship examination, and those in Group II took the examination before their simulator experience. RESULTS: The students rapidly gained confidence in treating their simulated patient. This carried over to the clinical setting, where they appeared to be more confident when anesthetizing live patients. The simulator experience brought together much of the previous didactic material that they had been exposed to so they could appreciate its clinical relevance. The overwhelming response to the simulator experience was positive. The students in Group I had a significantly higher score on the clerkship examination dealing with concepts reviewed by simulation than those in Group II, who engaged in self-study instead of the simulation exercise (p < 0.001). CONCLUSION: We conclude that the human patient simulator was a valuable learning tool for students of veterinary medicine. It was exciting for the students to work with, made them deal with "real-life" scenarios, permitted them to learn without subjecting live patients to complications, enabled them to retrace their steps when their therapy did not correct the simulated patient's problems, and facilitated correlation of their basic science knowledge with clinical data, thus accelerating their ability to handle complex clinical problems in healthy and diseased patients.

Montgomery K. Burgess L. Dev P. Heinrichs L. Project hydra--a new paradigm of internet-based surgical simulation. Studies in Health Technology & Informatics 2006; 119:399-403.

Computer-based surgical simulation systems have produced tremendous benefits and demonstrated validity as a better method for many areas of surgical skills acquisition. However, despite these benefits, broad proliferation of these systems has continued to be elusive. While in large part this lag in adoption of this technology is due to social factors (organizational momentum, curriculum integration difficulties, etc), the cost of computer-based simulation systems has certainly remained a major deterrent toward broad deployment. Instead, what if it were possible to eliminate the cost of the large computer completely from the system, yet provide a much more extensive and detailed simulation than currently available? Finally, what if a simulation with even greater detail over a wider anatomical area were possible? This is the genesis of Project Hydra- a shared simulation supercomputer were made available for free and all that is required to access it is a low-end Internet-connected computer and, optionally, interaction/haptics devices as needed for the particular task. This would enable supercomputer-class simulation at every desktop with much greater fidelity than any user could individually afford and provide an online community for simulation research and application. Further, Internet-based simulation provides for many other benefits as well. By the user merely plugging optional, additional hardware into their existing, low-end PC and using the Internet as a means of simulation dissemination, distribution, and delivery means that the user can have immediate access to simulation updates/upgrades and download/access new content (didactic curriculum and cases). Further, this ease of access and use could lead to accelerated adoption and use of simulation within the medical curriculum and this access is provided anywhere in the world 24 x 7. In addition, once connected, a server-based simulation system would be a natural point for performing easy, automated clinical studies of surgical performance and skills.

Montgomery K. Sorokin A. Lionetti G. Schendel S. A surgical simulator for cleft lip planning and repair. Studies in Health Technology & Informatics 2003;94:204-9.

The objective of this project was to develop a computer-based surgical simulation system for cleft lip planning and repair. This system allows the user to interact with a virtual patient to perform the traditional steps of cleft-lip repair. The system interfaces to force-feedback (haptic) devices to track the user's motion and provide feedback during the procedure, while performing real-time soft-tissue simulation. An eleven-day old unilateral cleft-lip and palate patient was previously CT scanned for ancillary diagnostic purposes using standard imaging protocols and 1mm slices. High-resolution 3D meshes were automatically generated from this data using the ROVE software created in our lab. The resulting 3D meshes of bone and soft-tissue were instilled with physical properties of soft tissues for purposes of simulation. Once these preprocessing steps were completed, the patient's bone and soft-tissue data are presented on the computer screen in stereo and the user can freely view, rotate, and otherwise interact with the patient's data in real-time. The user is prompted to select anatomical landmarks on the patient data for preoperative planning purposes, then their locations are compared against that of a "gold standard" and a score, derived from their deviation from that standard and time required, is generated. The user can then move a haptic stylus and guide the motion of the virtual cutting tool. The soft tissues can thus be incised using this virtual cutting tool, moved using virtual forceps, and fused in order to perform any of the major procedures for cleft-lip repair. Real-time soft tissue deformation of the mesh realistically simulates normal tissues and haptic-rate (>1kHz) force-feedback is provided. The surgical result of the procedure can then be immediately visualized and the entire training process can be repeated at will. A short evaluation study was also performed. Two groups (nonmedical and plastic surgery residents) of six-people each performed the anatomical marking task of the simulator four times. Results showed that the plastic surgery residents scored consistently better than the people without medical background. Every person's score increased with practice, and the length of time needed to complete the eleven markings decreased. The data was compiled and showed which specific markers consistently took users the longest to identify as well as which locations were hardest to accurately mark. Our findings suggest that the simulator is a valuable training tool, giving residents a way to practice anatomical identification for cleft lip surgery without the risks associated with training on a live patient. Educators can also use the simulator to examine which markers are consistently problematic, and modify their training to address these needs.

Mori T, Asano K, Kadosawa T, Motizuki M, Nishimura R & Maruo K. Evaluation of a dog abdominal surrogate model for teaching basic surgical skills by veterinary students. [Japanese] Journal of the Japan Veterinary Medical Association 2006;59(2):122-5.

A dog abdominal surrogate model for instructional exercises was evaluated to determine acceptance, by cooperation of two hundred and fifty-one fourth-year veterinary students at four universities in Japan. After practicing a celiotomy and intestinal anastomosis using the model, students' responses to a questionnaire were analyzed. Most students thought that the model was effective for acquiring basic surgical skills (99.2%) and necessary prior to surgical practice using live animals (96.8%). The major advantages of practical training using the model were effectiveness for acquiring basic surgical skills (40.8%), easy understanding of the structure (38.4%), reducing the need for live animals (21.6%) and multiple usage (14.8%). Meanwhile, more than half students (57.6%) suggested potential improvements of the materials and design of the model. The surrogate model used in the present study was well received by the students. We suggest that the model would be an acceptable alternative to live animals for certain basic surgical procedures.

Panait L. Rafiq A. Tomulescu V. Boanca C. Popescu I. Carbonell A. Merrell RC. Telementoring versus on-site mentoring in virtual reality-based surgical training. Surgical Endoscopy. 20(1):113-8, 2006 Jan.

BACKGROUND: Telementoring can be an adjunct to surgical training using virtual reality surgical simulation. Telementoring is hypothesized to be as effective as a local mentor for surgical skills training. METHODS: In this study, 20 Romanian medical students trained using a virtual reality surgical simulator (LapSim) with a telementor or local mentor. All the students watched an instructional module at the beginning of the exercise. The telementor, in the United States, interacted by videoconferencing. Before and after training sessions, tool path length and time for task completion were measured. RESULTS: Instructional media and training with mentoring resulted in similar levels of performance between locally mentored and telementored groups. Right- and left-hand path length and time decreased significantly within each group from the initial to the final evaluation (p CONCLUSIONS: Integration of instructional media with telementoring can be as effective for the development of surgical skills as local mentoring.

Phillips NI. John NW. Web-based surgical simulation for ventricular catheterization. Neurosurgery 2000;46(4):933-6; discussion 936-7.

We have used new developments in computer technology and the Internet to create a small program that simulates catheterization of the lateral ventricle. The program can run on most personal computers connected to the Internet. The program allows trainee surgeons to practice the technique with varying degrees of visual feedback--and no risk to the patient. It allows them to learn both the technique and the associated anatomy. The trainees can be assessed while performing the procedure. This is a small, early-stage application of virtual reality in surgical education. There is a demand for surgical training techniques that expose the patient to no risk; the use of computers is appropriate to meet this demand. The technique presented here requires further development; in particular, it needs a standardized assessment element that will allow it to be tested by established surgeons and trainees. The real test of a good training technique is how well it discriminates between trainee and trainer.

Pinckney Rhonda D., Martha J. Mealy, Chester B. Thomas, Peter S. MacWilliams. Impact of a Computer-Based Auto-Tutorial Program on Parasitology Test Scores of Four Consecutive Classes of Veterinary Medical Students. J Vet Med Educ 2001;28(3):136-9.

A "Hard and Soft Tick" auto-tutorial that integrates basic knowledge of the parasite biology with practical aspects of tick identification, clinical presentation, pathology, disease transmission, treatment, and control was developed at the University of Wisconsin-Madison School of Veterinary Medicine. The purpose of this study was to assess impact of the auto-tutorial on parasitology test scores in four classes (1999, 2000, 2001, and 2002) of veterinary students. The analysis revealed a small but significant increase (p = 0.054) in mean percentage examination scores for students who used the tutorial over those who did not.

Prentice, E.D., W.K. Metcalf, T.H. Quinn, J.G. Sharp, R.H. Jensen & E.A. Holyoke. Stereoscopic anatomy: evaluation of a new teaching system in human gross anatomy. Journal of Medical Education 1977;52:758–63.

Traditionally, human gross anatomy teaching has revolved around anatomical dissection. Unfortunately, during the last decade a number of medical schools have experienced a decrease in the number of hours allotted to gross anatomy instruction compounded by a shortage of anatomical donors. This, in turn, has served to increase the difficulties of providing students with truly effective anatomical instruction. To help overcome this problem, a stereoscopic slide-based auto-instructional program has been developed as a substitute for dissection. Evaluation data suggest that this program, while having minor limitations in terms of anatomical orientation, does provide a viable alternative to dissection.

Richardson EF, Gregory CR & Sucre E. Enhancement of the surgical education of fourth year veterinary students by participation in juvenile ovariohysterectomy and castration program. Veterinary Surgery 1994;23(5):415.

Rogers DA, Regehr G, Yeh KA, Howdieshell TR. Computer-assisted learning versus a lecture and feedback seminar for teaching a basic surgical technical skill. Am J Surg 1998;175(6):508-10. Department of Surgery, Medical College of Georgia, Augusta 30912-4070, USA.

BACKGROUND: Rapid improvements in computer technology allow us to consider the use of computer-assisted learning (CAL) for teaching technical skills in surgical training. The objective of this study was to compare in a prospective, randomized fashion, CAL with a lecture and feedback seminar (LFS) for the purpose of teaching a basic surgical skill. METHODS: Freshman medical students were randomly assigned to spend 1 hour in either a CAL or LFS session. Both sessions were designed to teach them to tie a two-handed square knot. Students in both groups were given knot tying boards and those in the CAL group were asked to interact with the CAL program. Students in the LFS group were given a slide presentation and were given individualized feedback as they practiced this skill. At the end of the session the students were videotaped tying two complete knots. The tapes were independently analyzed, in a blinded fashion, by three surgeons. The total time for the task was recorded, the knots were evaluated for squareness, and each subject was scored for the quality of performance. RESULTS: Data from 82 subjects were available for the final analysis. Comparison of the two groups demonstrated no significant difference between the proportion of subjects who were able to tie a square knot. There was no difference between the average time required to perform the task. The CAL group had significantly lower quality of performance (t = 5.37, P <0.0001). CONCLUSIONS: CAL and LFS were equally effective in conveying the cognitive information associated with this skill. However, the significantly lower performance score demonstrates that the students in the CAL group did not attain a proficiency in this skill equal to the students in the LFS group. Comments by the students suggest that the lack of feedback in this model of CAL was the significant difference between these two educational methods.

Rudas P. Hypermedia in veterinary education. [Conference Paper] In Hencsey G. & Renner G. (Eds.) Proceedings of 3rd Annual International Conference and Exhibition on CAD/CAM/CAE/CIM. Applications for Manufacturing and Productivity. Budapest, Hungary: World Comput. Graphics Assoc. 28-30 Sep. 1993. 212-8.

Several veterinary educational organisations have formulated declarations about the need for decreasing information overload and increasing teaching efficiency. At the same time university policies have changed under the pressure of decreasing funding and increasing requirements of the society. Teacher/student ratio is decreasing, quality research is demanding more and more time and effort. These facts have changed our thinking about the way we teach. Lecture with its unidirectional information is not anymore the optimal solution for effective teaching. Therefore teaching of concept and skill together can only be done efficiently in an interactive environment. The paper considers how interactive multimedia and hypermedia seems to be a solution to these problems (0 References).

Sedlack, Robert E. and Kolars, Joseph C. Department of Gastroenterology, Mayo Clinic, Rochester, MN. The effects of computer simulator training on patient-based sigmoidoscopy by residents. Gastrointestinal Endoscopy 2003;57(5): S1495.

For the first time, computer-based sigmoidoscopy simulator training demonstrates a direct patient benefit-reduced discomfort during flexible sigmoidoscopy. Study performed on an AccuTouch Endoscopy Simulator (Immersion Medical, Gaithersburg, MD).

Sedlack RE. Kolars JC. Alexander JA. Computer simulation training enhances patient comfort during endoscopy. Clinical Gastroenterology & Hepatology 2004;2(4):348-52.

BACKGROUND & AIMS: Computer-based endoscopy simulator (CBES) training's impact on patient-based outcomes has never been examined. This study examines whether the endoscopy skills of trainees are improved and patient discomfort is reduced as a result of CBES training. METHODS: From July 2001-June 2002, 38 residents received either 1 week of patient-based training (PBT) alone in flexible sigmoidoscopy (FS) or 3 hours of simulator-based training (SBT) before a week of training in FS. Patients completed questionnaires grading the discomfort experienced during endoscopy (1, no pain; 10, worst pain of life). In addition, residents' performance was graded by the supervising staff and themselves with 8 performance parameters by using a 1-10 Likert scale (1, strongly agree; 5, neutral; 10, strongly disagree). RESULTS: Nineteen SBT and 19 PBT residents performed 150 and 175 FS, respectively. During this same period, staff completed 585 FS. The median patient discomfort score for SBT residents was significantly less than for PBT residents, 3 (25%-75% interquartile range [IQR], 2-5) vs. 4 (IQR, 2-6) (P CONCLUSIONS: Increased patient comfort resulted from simulation training, demonstrating that CBES training has a direct benefit to the patient. Although no measurable impact on residents' performance skills was observed, we do demonstrate that residents perceive themselves as having acquired greater endoscopic skills in contrast to staff evaluations.

Seymour NE. Gallagher AG. Roman SA. O'Brien MK. Bansal VK. Andersen DK. Satava RM. Virtual reality training improves operating room performance: results of a randomized, double-blinded study. Annals of Surgery 2002;236(4):458-63; discussion 2002 Oct.:463-4.

OBJECTIVE: To demonstrate that virtual reality (VR) training transfers technical skills to the operating room (OR) environment. SUMMARY BACKGROUND DATA: The use of VR surgical simulation to train skills and reduce error risk in the OR has never been demonstrated in a prospective, randomized, blinded study. METHODS: Sixteen surgical residents (PGY 1-4) had baseline psychomotor abilities assessed, then were randomized to either VR training (MIST VR simulator diathermy task) until expert criterion levels established by experienced laparoscopists were achieved (n = 8), or control non-VR-trained (n = 8). All subjects performed laparoscopic cholecystectomy with an attending surgeon blinded to training status. Videotapes of gallbladder dissection were reviewed independently by two investigators blinded to subject identity and training, and scored for eight predefined errors for each procedure minute (interrater reliability of error assessment r > 0.80). RESULTS: No differences in baseline assessments were found between groups. Gallbladder dissection was 29% faster for VR-trained residents. Non-VR-trained residents were nine times more likely to transiently fail to make progress (P CONCLUSIONS: The use of VR surgical simulation to reach specific target criteria significantly improved the OR performance of residents during laparoscopic cholecystectomy. This validation of transfer of training skills from VR to OR sets the stage for more sophisticated uses of VR in assessment, training, error reduction, and certification of surgeons.

Silva RMG, da Matera JM & Ribeiro AACM. Evaluation of the surgical technique teaching method using chemically preserved cadavers. [Portuguese] Revista de Educacao Continuada do CRMV-SP 2003;6(1/3):95-102.

Objective: To assess surgical training using chemically-preserved cadavers in the Surgical Techniques and Orthopaedics classes of "Faculdade de Medicina Veterinaria e Zootecnia da Universidade de Sao Paulo" (College of Veterinary Medicine and Zootechnics of the University of Sao Paulo) - (FMVZ/USP), Sao Paulo, SP, Brazil, as an alternative method to use in the place of live animals in classrooms. Materials and Methods: A modified Larssen solution that preserves the characteristics of the animals' colour, the consistency and texture of tissues, and the flexibility of joints as similar as possible to those found in live animals was used. Cadavers with body weight between 1-25 kg, of different sexes and species, were cleaned and received a lavage of the vascular circuit with hot physiologic solution and a second lavage with modified Larssen solution at a volume corresponding to 5% of the cadaver body weight. At a second stage, fixing solution was injected into the cadaver, the volume of which corresponded to 10% of cadaver weight. After fixation, cardavers were cryopreserved in cold chambers with temperatures between -20 to -16 degrees C. Acceptance of the use of cadavers as a teaching method was assessed using a survey questionnaire distributed among students of the Surgical Techniques and Orthopaedics classes in 2001, 2003 and 2003. Results and Conclusions: Based on responses of students to the questionnaires it was possible to conclude that the described teaching methodology of using cadavers is well accepted. The use of modified Larssen solution to chemically preserve the cadavers allows for intense and adequate training of surgical techniques during the course. The said practice allows the repeated use of cadavers, decreasing the number of animals needed for classroom purposes.

Simpson RM & Meuten DJ. Development of a teaching laboratory aid for instruction of fine needle aspiration biopsy cytology technique. Veterinary Clinical Pathology 1992;21(2):40-4.

An aspiration biopsy cytology teaching aid was developed by placing portions of fresh organ tissue from routine submissions to the pathology laboratory into a specimen container partially filled with chilled normal saline solution. Specimens were stored immersed in saline at 4 degrees C for up to 48 h. Prior to the cytopathology teaching laboratory period, the specimen container was removed from storage and covered with a latex diaphragm. Instructors responsible for teaching cytodiagnostic techniques used this ex vivo aspiration biopsy cytology device for instruction of fine needle aspiration biopsy, specimen processing, and microscopy. In the teaching laboratory, puncture of the diaphragm and aspiration of a tissue sample with hypodermic needle and syringe was instructed to, and practiced by, numerous trainees simultaneously using clinical operative technique without the need for live animals. Trainees prepared and stained cytology smears as well as evaluated and interpreted specimens in a single, realistic exercise. It was concluded such training experience may improve ability of trainees to procure diagnostic-quality biopsy specimens for cytodiagnosis of lesions from clinical patients.

Specht PC. Computer graphics interface to a complex simulation. P R Health Sci J 1988;7(2):184-8. Pharmacology Department, School of Medicine, University of Puerto Rico, San Juan.

The program "Cardio VascularCat" is a simulation of a laboratory experiment on the cardiovascular system of the cat, for students of physiology or pharmacology. There are two important innovations in this version, utilizing the "Macintosh environment": 1) The functioning of the program is highly interactive with the student. Any manipulation almost immediately produces some result in the (simulated) experimental animal. 2) The input from the student, and the output to the student, are handled in simple and intuitive ways. The mouse and menu system are utilized to simplify the control of the program. The keyboard is eliminated. The Macintosh graphics capabilities provide for an output display that is easily and quickly interpreted by the student. The program has been tested with a small sample of medical students. As measured by an objective test, the results are equivalent to learning from a textbook. An attitude survey revealed that the Macintosh program is clearly superior for reinforcement and review.

Smeak DD, Beck ML, Shaffer CA, Gregg CG. Evaluation of video tape and a simulator for instruction of basic surgical skills. Vet Surg 1991;20(1):30-6. Department of Veterinary Clinical Sciences, Ohio State University College of Veterinary Medicine, Columbus.

Twenty first-year veterinary students with no prior participatory experience in surgery were randomly paired and assigned into two study groups. Ten students (group V) viewed a hemostatic technique video tape until they thought they could competently perform and assist in performing a hand-tied ligature on a blood vessel in a live animal. Ten students (group VS) were also given a simulator for technique practice. Paired students were video recorded and blindly evaluated on their ability to perform and assist proper ligation of a bleeding vessel. Inexpensive hemostasis models were very helpful for teaching students essential surgeon and assistant skills involved in hand-tied ligature placement. Students who practiced with simulators performed significantly better as surgeon and assistant, and in total psychomotor skill evaluation, then students watching the video only. Students using simulators performed ligation with significantly more accuracy and tended to be more expeditious at this task. Further training is needed for students to acquire skills necessary for efficient bleeding vessel exposure and isolation.

Strom P. Kjellin A. Hedman L. Johnson E. Wredmark T. Fellander-Tsai L. Validation and learning in the Procedicus KSA virtual reality surgical simulator. Surgical Endoscopy 2003;17(2):227-31.

BACKGROUND: Advanced simulator training within medicine is a rapidly growing field. Virtual reality simulators are being introduced as cost-saving educational tools, which also lead to increased patient safety. METHODS: Fifteen medical students were included in the study. For 10 medical students performance was monitored, before and after 1 h of training, in two endoscopic simulators (the Procedicus KSA with haptic feedback and anatomical graphics and the established MIST simulator without this haptic feedback and graphics). Five medical students performed 50 tests in the Procedicus KSA in order to analyze learning curves. One of these five medical students performed multiple training sessions during 2 weeks and performed more than 300 tests. RESULTS: There was a significant improvement after 1 h of training regarding time, movement economy, and total score. The results in the two simulators were highly correlated. CONCLUSION: Our results show that the use of surgical simulators as a pedagogical tool in medical student training is encouraging. It shows rapid learning curves and our suggestion is to introduce endoscopic simulator training in undergraduate medical education during the course in surgery when motivation is high and before the development of "negative stereotypes" and incorrect practices.

Summers AN, Rinehart GC, Simpson D, Redlich PN. Acquisition of surgical skills: a randomized trial of didactic, videotape, and computer-based training. Surgery 1999;126(2):330-6. Department of Surgery (Plastic Surgery and General Surgery), Medical College of Wisconsin, Milwaukee, USA.

BACKGROUND: Although computer-based training (CBT) can enhance didactic instruction, few studies have assessed the efficacy of CBT for basic surgical skills training. This study compares CBT with traditional methods of basic surgical skills training. METHODS: Sixty-nine naive medical students were randomized into 3 treatment groups for basic surgical skills instruction: didactic, videotape, or CBT. All instructional material contained the same pictures, text, and audio. With use of a multiple-choice question examination and a series of performance stations, students were objectively assessed before, immediately after, and 1 month after skills instruction. Raters were blinded to treatment modality during the follow-up evaluation. RESULTS: There were no significant differences among the groups before treatment. After treatment, the didactic group scored higher on the multiple-choice question examination. In contrast, the videotape and CBT groups demonstrated statistically significant (P < .01) enhancement of technical skills compared with the didactic group. After 1 month, a calculated performance quotient revealed statistically significant (P < .01) improvement only in the CBT group. The amount of time students spent practicing their skills was not significantly different among the groups. CONCLUSIONS: CBT is as effective as, and possibly more efficient, than traditional methods of basic surgical skills training for medical students.

Szinicz G, Beller S & Zerz A. [Role of the pulsatile organ perfusion surgical simulator in surgery education]. [German] Langenbecks Archiv fur Chirurgie - Supplement – Kongressband 1997;114:687-93.

The operation simulator with pulsatile organ perfusion ("POP trainer") simulates the blood supply of organs or organ complexes and was developed for the training in both minimally invasive and conventional surgery. With the redesigned new POP-trainer, even complex operations, such as colorectal and antireflux procedures can be practised. Due to perfect quality of simulation, simple handling and economic aspects, the POP trainer serves to intensify the training of surgeons, simultaneously decreasing the number of animal experiments.

Tsai CL, Heinrichs WL. Acquisition of Eye-hand Coordination Skills for Videoendoscopic Surgery. J Am Assoc Gynecol Laparosc 1994;1(4, Part 2):S37. Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford Endoscopy Center for Training and Technology, 750 Welch Road, Stanford, CA 94305.

Evaluation of eye-hand coordination skills in relation to experiential human factors may lead to improved instruction for videoendoscopic surgical skills acquisition. Twenty-nine subjects (medical students or residents in surgical specialties) volunteered to perform three exercises of increasing complexity in an "inanimate" trainer system that simulated the eye-hand coordination tasks inherent in a laboratory videoendoscopic surgical environment. Fourteen subjects participated in a biweekly practice program of 4 weeks duration using an inanimate trainer. Fifteen subjects had no practice on the laparoscopic trainer during the 4 weeks. Both groups were tested after demonstration on three exercises at the beginning and end of a 4 week period and all performed the procedures in solitude. Both groups of subjects increased performance levels (time and accuracy) over the four weeks, but improvement was significantly greater for the practicing subjects. After eight sessions, convergence of performance levels was observed, but plateauing of performance levels was not evident, even with the simple paradigms evaluated. To investigate what factors contribute to learning, subjects were assessed with respect to their surgical experiences, personality, and self-evaluated motor skills. Subjects with prior endoscopic surgical experience, interest in mechanical activities (as measured by the Strong Interest Inventory), or regular engagement in video game play tended to be more skillful initially, but demonstrated less improvement in performance levels after practice than subjects who had lower levels of experience, interest, or video game play. Manual dexterity (as measured by the Purdue Pegboard Manual Dexterity Test) was positively related to the degree of observed improvement. We conclude that "inanimate" videoendoscopic paradigms offer relatively inexpensive and useful training exercises for acquiring basic eye-hand coordination skills. Relevance for animate laboratory skills requirements are probable but can only be inferred. Subjects with manual dexterity skills used in video games may perform better initially in the inanimate videoendoscopic situation but this advantage is shortlived.

Tsai MD. Hsieh MS. Jou SB. Virtual reality orthopedic surgery simulator. Computers in Biology & Medicine 2001;31(5):333-51.

This paper describes a highly interactive virtual reality orthopedic surgery simulator. The simulator allows surgeons to use various surgical instruments to operate on virtual rigid anatomic structures, such bones, prostheses and bone grafts, to simulate every procedure on the rigid structures for complex orthopedic surgeries, including arthroplasty, corrective or open osteotomy, open reduction of fractures and amputation. A comparative study of the simulator with paper simulation was performed and showed that interns and residents found the simulator to be a useful learning tool, and that visiting doctors could use it effectively for planning verification and rehearsal of operations.

Uribe JI. Ralph WM Jr. Glaser AY. Fried MP. Learning curves, acquisition, and retention of skills trained with the endoscopic sinus surgery simulator. American Journal of Rhinology 2004;18(2):87-92.

BACKGROUND: As an initial step in evaluating the effectiveness of training otolaryngology residents on an endoscopic sinus surgery simulator (ES3), we have assessed the ability of the ES3 to train persons inexperienced in sinus surgery (medical students) to perform certain simulated procedural tasks needed in endoscopic sinus surgery (ESS). METHODS: A total of 26 medical students were enrolled and trained on the ES3 following a preset protocol in the three levels of difficulty and complexity (novice, intermediate, and advanced modes). RESULTS: In the novice mode (three-dimensional abstract images are used to teach the use of endoscopic surgical equipment), medical students displayed a steep learning curve within three to five trials on the simulator and after an additional four to five trials, they reached a plateau in their learning curves to within 90% of that of experienced sinus surgeons. In the intermediate mode (ESS is performed on a simulated patient with teaching aids), medical students were able to reach a plateau in their learning curves to within 80% of that of experienced surgeons. This performance was sustained in the advanced mode (simulated sinus surgery without teaching aids). We observed that medical students, who had novice or intermediate mode training interrupted with an interval of 11-60 days, were able to resume their training without deviation from their prior learning curves. CONCLUSION: Intensive, proctored training on the ES3 can train inexperienced persons to perform simulated ESS within a reasonable approximation of the performance of experienced sinus surgeons on the ES3 and the training that an inexperienced person receives on the simulator is not short term but is retained over a period of at least 2 months.

Waldhalm SJ. Bushby PA. Bringing information technology into the veterinary curriculum. Seminars in Veterinary Medicine & Surgery (Small Animal) 1996;11(2):96-9.

The personal computer has been available to medical education for many years, but the role of the computer has changed. We have required students to purchase a personal computer since 1984, and used this tool in several ways throughout the intervening years. Our experience has shown that students and faculty derive greatest benefit from personal computers as information retrieval and communication devices. Requiring students to purchase computers has many benefits including student attitudes, employer's perception of computer literacy, and institutional access to current technological advancements in hardware and software.

Watterson JD. Beiko DT. Kuan JK. Denstedt JD. Randomized prospective blinded study validating acquistion of ureteroscopy skills using computer based virtual reality endourological simulator. Journal of Urology 2002;168(5):1928-32.

PURPOSE: Surgical simulation has emerged in the last decade as a potential tool for aiding acquisition of technical skills, including anesthesia protocols, trauma management, cardiac catheterization and laparoscopy. We evaluate and validate the use of a computer based ureteroscopy simulator (URO Mentor, Simbionix Ltd., Lod, Israel) in the acquisition of basic ureteroscopic skills. MATERIALS AND METHODS: We assessed 20 novice trainees for the ability to perform basic ureteroscopic tasks on a computer based ureteroscopy simulator. Participants were randomized to receive individualized mentored instruction or no additional training, and subsequently underwent post-testing. Pre-training and post-training improvement in performance was assessed by objective simulator based measurements. Subjective overall performance was rated using a validated endourological global rating scale by an observer blinded to subject training status. RESULTS: Demographics and pre-test scores were similar between groups. Post-testing revealed a significant effect of training on objective and subjective measurements. Spearman rank correlation demonstrated a significant association between objective simulator based measurements and the endourological global rating scale. CONCLUSIONS: Use of a computer based ureteroscopy simulator resulted in rapid acquisition of ureteroscopic skills in trainees with no prior surgical training. Results of this study demonstrate the use of a virtual reality ureteroscopy simulator in endourological training. Correlation of simulator based measurements with a previously validated endourological global rating scale provides initial validation of the ureteroscopy simulator for the assessment of ureteroscopic skills.

Whithear KG. Browning GF. Brightling P. McNaught C. Veterinary education in the era of information technology. Australian Veterinary Journal. 1994;71(4):106-8.

A major innovation in the delivery of the veterinary curriculum is being implemented at The University of Melbourne using the subject of systematic bacteriology and mycology as a pilot project. Students receive course information as interactive, multimedia databases. These consist of text and an associated library of catalogued digital images, movies and sounds. The databases employ a hypermedia information system to achieve efficient integration within and between subjects. The new delivery method encourages greater autonomy and more active learning roles for students than occurs in traditionally taught courses. Students will use their databases as the principal resource of information for undergraduate studies. A unique feature of this system for delivering the curriculum is that students will modify and expand their databases during the course. The ultimate aim is for students at graduation to receive, on disc, a copy of their own databases, adapted by themselves to their particular future professional needs. As graduate veterinarians they will continue to use their databases as a major resource for information and learning, thus providing continuity from undergraduate to continuing postgraduate education.

[facilitates more active learning, greater autonomy, life-long learning].

Wilhelm DM. Ogan K. Roehrborn CG. Cadeddu JA. Pearle MS. Assessment of basic endoscopic performance using a virtual reality simulator.[see comment]. Journal of the American College of Surgeons 2002;195(5):675-81.

BACKGROUND: The objective of this study was to evaluate the effect of supervised training using a state-of-the-art virtual reality (VR) genitourinary endoscopy simulator on the basic endoscopic skills of novice endoscopists. STUDY DESIGN: We evaluated 21 medical students performing an initial VR case scenario (pretest) requiring rigid cystoscopy, flexible ureteroscopy with laser lithotripsy, and basket retrieval of a proximal ureteral stone. All students were evaluated with objective parameters assessed by the VR simulator and by two experienced evaluators using a global rating scale. Students were then randomized to a control group receiving no further training or a training group, which received five supervised training sessions using the VR simulator. All students were then evaluated again in the same manner using the same case scenario (posttest). RESULTS: Comparing the results of pre- and posttests, no major differences were demonstrated for any variable in the control group. In the trained group, posttest results revealed statistically significant improvement from baseline in the following parameters: total procedure time (p = 0.002), time to introduce a ureteral guidewire (p = 0.039), self-evaluation (p CONCLUSIONS: Students trained on the VR simulator demonstrated statistically significant improvement on repeat testing, but the control group showed no improvement. Endourologic training using VR simulation facilitates performance of basic endourologic tasks and might translate into better performance in the operating room.