A novel video compendium of real surgical patient interactions for medical students

Objective To develop a novel video compendium of real surgical patient interactions as a tool for medical student education and to evaluate our institutional experience of its usefulness. Design Prospective development of a video compendium of real surgical patient interactions. Setting Single university affiliated hospital in Cork, Ireland. Participants Patients with illnesses relevant to the surgery curriculum and students from an Irish medical school. Results Videos were recorded of the clinical interaction between a consultant surgeon and patients, capturing focused history taking and/or clinical examination, with an associated set of explanatory notes. Fifty videos were developed with a tiered release to the clinical year medical students, via their virtual learning/education platform. Three hundred and eleven students responded to the questionnaire across 3-student year groups (311/585–53 %). Fifty-two percent of students did not have their clinical rotations affected by the COVID-19 pandemic. >90 % of students agreed that the videos helped history taking and clinical examination technique. >80 % of students agreed that the accompanying text slides reinforced key points and helped with understanding difficult topics. Eighty-five percent of students reported that the videos increased exposure to surgical patients and pathology. Eighty-five percent of students rated their experience as at least 4 out of 5. Conclusions This online educational compendium bridged a gap for students with limited clinical exposure during the COVID-19 pandemic, and has become an important resource for all clinical students. Our novel engagement with real patients sets this compendium apart from resources which use actors.


Introduction
Surgical education is a core component of the curriculum for medical students. Developing the skill set to identify, investigate, and treat surgical pathology is important for doctors at all levels of training. Significant effort is required on behalf of both medical school lecturers and students to achieve the standards required for contemporary healthcare. The cumulative exposure to surgical patients during medical school can be limited. This is due in part to surgical education being restricted to the clinical years, and to the competing demands of the academic calendar.
COVID-19 has had a marked secondary effect on the delivery of medical school education and the experience of medicals students since 2020 [1,2]. The greatest impact was In January and February 2021 when medical education was moved completely to online resources for 5-8 weeks, due to COVID restrictions [3], with minimal compensatory hospital placement added to the end of term in April/May. There have been many other interruptions to normal clinical practice due to intermittent reductions in the delivery of elective surgical care. When these circumstances are paired with student absences, or indeed consultant absences, associated with isolation periods due to COVID infection/ contact, the net effect is that there has been a significant reduction in the exposure of medical students to the treatment and management of surgical patients throughout the academic years 2019/2020, 2020/2021 and 2021/2022. It was our impression that student's clinical examination skills were declining in the years preceding COVID, though grade inflation suggested the opposite. While there are innumerable online resources for medical students to complement their education, these are often in the form of simulated patients, without real clinical findings. To augment   Data expressed as number (percentage) unless otherwise stated.
clinical experience for students, we developed a novel compendium of real surgical patient interactions. The aim of this study is to describe our creation of surgical educational videos and to evaluate the experience of students who studied them.

Ethics statement
This study was approved by the Clinical Research Ethics Committee of the Cork Teaching Hospitals.

Patients recruitment and video development
The first patients recruited for video recordings were those who attended the authors' hospital to facilitate the final year medical student short-case examinations in spring 2019. These patients had obvious clinical signs spanning a range of common surgical conditions. Subsequent patients were prospectively identified on an ad hoc basis between 2019 and 2021 in the outpatient clinic and on the surgical wards by the consultant surgeon or clinical lecturer. Patients were considered for inclusion if they described interesting symptoms, and/or had abnormal physical findings demonstrated by clinical examination, which are relevant to the curriculum. The patients selected were on the basis of the University College Cork curriculum (https://ucc-ie-public.courseleaf. com/modules/?details&code=cp5100). In the Mercy hospital, there full spectrum exposure to general surgery and vascular surgery pathology.
Patients gave written informed consent for participation in the study. A video was recorded of the encounter between the consultant surgeon and the enrolled patient. This consisted of the consultant taking a history and/or performing a focused clinical examination. In the initial part of the series the video recording was performed using university audiovisual equipment. Subsequently, to offer greater flexibility, videos were recorded with a mobile phone device. This resulted in a slight deterioration in quality, including noise pollution in the ward setting. The videos were saved and stored on a university server and subsequently published on the teaching portal, Canvas. An accompanying set of notes for each video was developed. Each of the videos was also stored on a password protected university computer. Accompanying tutorials and quizzes were developed for some of the topics over the course of the year.

Student cohort
In University College Cork, direct entry medical students undertake a 5-year program and graduate entry medical students undertake a 4-year program. Videos were released in a tiered fashion to 3rd-5th year direct entry students (DEM) and 3rd-4th year graduate entry students (GEM), through the university e-learning platform (Canvas). Videos capturing basic, common surgical conditions were made available to junior clinical students. More complex vascular content was released to students in their penultimate year, to correspond with learning objectives at that stage of the curriculum, while more complex gastro-intestinal content was reserved for final year students.

Questionnaire development and pilot
As part of a quality improvement initiative for the video compendium, a follow up questionnaire was developed. This was piloted with 258 students at the end of the 2019/20 academic year. The questionnaire was revised (Supplementary Table 1). The finalized questionnaire was developed into a "Microsoft Form" document, and was sent at the end of the 2020/21 academic year to the university email address of each student in the year groups. The questionnaire responses were anonymised at the point of data entry by each student. The results of these questionnaires were exported to a Microsoft Excel spreadsheet.

Statistical analysis
All statistical analysis was done using SPSS v26.0 (IBM Corp, Armonk NY). Categorical data was reported as median and interquartile range. Continuous data was reported as number and frequency. Questionnaire results were reported on a 5-point Likert scale (Strongly disagree, disagree, neutral, agree, strongly agree).

Results
Fifty videos were developed over a 3-year period, encompassing general surgery, gastrointestinal surgery, and vascular surgery. The videos and accompanying text slides were organized into topics according to the surgery curriculum. The list of topics/ videos is shown in Table 1. There were 16 videos released to the DEM3/GEM2 students, 35 videos released to the DEM4/GEM3, and 40 videos released to the DEM5/GEM4 students. The average length of all videos was 8 min (Gastrointestinal surgery 8.5 min, vascular surgery 10 min, miscellaneous 6 min).
>90 % of students agreed that the videos helped history taking and clinical examination technique. A small proportion (8 %) of the students agreed or strongly agreed that the videos were either ambiguous or confusing (Fig. 1a). To enhance the video compendium, an accompanying set of notes were developed. >80 % of students agreed or strongly agreed that the notes were useful to reinforce key points, and to give additional detail regarding difficult concepts. <8 % of students found the text slides distracted from the clinical video (Fig. 1b). Student use of tutorials and quizzes are shown in Supplementary Table 2. The Gastrointestinal Tract surgery tutorial was the most used among both 4th DEM/3rd GEM (31 %-53/172) and final med students (52 %-107/ 206). The Peri-operative care quiz was the most used among both 4th DEM/3rd GEM (46 %-79/172) and final med students (14 %-29/206).
Among all student groups, the majority agreed or strongly agreed that the videos helped with preparation for clinical examinations, and with exposure to surgical patients (Fig. 1c). As a point of critique, students did express an interest for the topics to contain quizzes or a selfassessment component (73 %). Consequently, some quizzes have subsequently been added to the package of resources. Students also agreed or strongly agreed (73 %) that the videos should describe more detail regarding investigation and management of the video topics. To avoid overcrowding the notes that accompany video recordings of patient interactions, a parallel set of recorded tutorials were created to give background detail including anatomy, physiology, investigations and treatment. In contrast, students did not think that more explicit learning objectives needed to be included. Interestingly, only a small majority of students (51 %) would want the videos available for download. Eightyfive percent of the overall student group rated the videos at least 4 out of 5.
More students in the DEM5/GEM4 year groups agreed or strongly agreed that the videos helped in identifying the appropriate questions when taking a history (97 % vs. 88 %, p = 0.022), and improved Similarly, the DEM5/GEM4 groups agreed that the videos improved preparation for exams (88%vs. 74 %, p = 0.005) and expanded exposure to surgical patients (93 % vs. 81 %, p = 0.004) compared to the other year groups. The overall experience of DEM5/GEM4 students was higher than that of the other year groups (p = 0.029) ( Table 3).

Discussion
Surgery is a core component of every medical students' training. However, given the limitations of the calendar year and the commitments to fulfil coursework in other specialties, the exposure to surgical patients is inherently limited. The lack of structure during surgical rotations has previously been noted [4].
This online compendium of surgical education videos was created to supplement the education of medical students in the authors' institution. Each of the educational videos consisted of a consultant surgeon taking a history and/or performing clinical examination with a set of additional explanatory notes. Although this resource was in development prior to the COVID 19 pandemic, it became a principal component of surgical education, at times for whole year groups excluded from the hospital environment and at other times for isolating individual medical students. The feedback from the students across all three student year groups was predominantly positive, highlighting the major role that a novel education tool, such as real patient recordings, can have for medical students.
Clinical medical education is typically delivered through different media including textbooks, lectures, and bedside teaching. In our medical school, students are given a list of recommended textbooks at the start of the academic year. Although textbooks are a valuable resource and reference for students, high yield condensed resources are important to students given the time commitments with clinical attachments. With this series of video recordings, students get the opportunity to see real patients being assessed and examined by a consultant. This helps to broaden students' exposure to patients that they may not have seen on rotations, due to time limitations. The accompanying notes are valued by students firstly as an aid to interpretation of the patient's history and clinical examination findings; secondly as an example of how verbal communications might be translated into written notes for the patient records and thirdly; to add clarity to complex issues.
The use of e-learning needs to be carefully designed and integrated into medical education. This video compendium was developed in a planned manner to encompass the surgical curriculum. In a study from an American University, an eLearning program was developed during the pandemic, but the medical student group that was surveyed felt that it was too rapidly set up and was fragmented in its content. Interestingly the students expressed a desire for real cases to follow [1]. This is a considerable advantage of the real patient video compendium, which helps to bridge some of the limitations of current e-learning platforms.
A considerable proportion of students had a positive experience with the video compendium and this effect spanned across year groups. Final year medical students are not only preparing for real patients interaction in their end of year examinations, but also for real patient interactions in the workplace. The other year groups have OSCEs, with role players in their end of year "clinical examination." Not unexpectedly, the final year groups had a strong positive experience of the video compendium compared to the other year groups. Interestingly, a large proportion of students watched the videos on a number of occasions, supporting their use as a revision tool. A similar learning platform was created for paediatrics in another Irish university that encompassed online lectures and scenarios, clinical examination videos, discussion forums and video conferencing tutorials [5]. This, too, was well received by students and was held to be a very beneficial resource to prepare for exams and for clinical practice. A previous web-based platform for problem based learning was developed in our institution and was found to improve the examination results of final year medical students in our university [6]. SD/D/N-Strongly Disagree/Disagree/Neutral, A/SA-Agree/Strongly Agree. Boldface indicates statistical significance.
Given the success of this education tool with medical students, there is significant potential for the videos to be made available to post graduate general practice and surgical trainees. The videos were exclusively available on the university e-learning platform, but there is potential for it to be shared among other universities. The results of the survey suggest that a recorded real patient interaction has compelling benefit to medical student education and this approach could be broadened out to other specialties.

Funding sources
There is no funding source to declare.

Ethics approval
Ethical approval was granted by the Clinical Research Ethics Committee of the Cork Teaching Hospitals.

Funding statement
There was no external funding for this study.

Declaration of competing interest
The authors declare no conflict of interest.