Evaluating operative skills of trainees under a distance education course in general surgery in Zamboanga City, Philippines.

Joson RO, Cerrillo !, Cristobal "!. #P$ Journal %&&'( )*)+,-./0%. Evaluating Operative Skills of Trainees Under a Distance Education Course in General Surgery in Zamboanga City, !ilippines Reynaldo O. Joson, $1, $2PEd le3 !. Cerrillo, $1 "amuel !. Cristobal, $1 bstract 4rom June %&&% to $ay %&&0, a general surgery course 5as conducted by a group of $anila faculty using a distance education mode in Zamboanga City $edical Center *ZC$C+, located in far south of the Philippines. ZC$C is a tertiary government hospital 5ith a catchment of 6 million population in 7estern $indanao lacking in 8ualified trainors for general surgeons. 9he $anila faculty 5ent to ZC$C every three months for four years staying for about t5o days per trip to conduct and monitor the training program. 9he course has produced nine graduates, four practicing in Zamboanga City and five in the neighboring cities and provinces. 9he operative skills of the trainees 5ere evaluated using direct observation by the $anila faculty during their intermittent visit to ZC$C and by a board certified local trainor in the interim the $anila faculty 5ere not in to5n. 9he operative skills 5ere also evaluated via videotapes. 9he surgical trainees 5ere asked to videotape common general surgical procedures that they personally performed. 9hese videotapes, 5ithout editing, 5ere then sent to and vie5ed by the $anila faculty and e3ternal evaluators. 9his paper describes ho5 operative skills of trainees under a distance education course in general surgery in Zamboanga City 5ere evaluated. :ey 5ords, 1istance Education( "urgery( Evaluation( Operative "kills ;ntroduction 1istance education is an educational approach in 5hich ma<ority of the teaching/learning activities are done 5ith the teach and student being at a geographic distance from each other *%/ 6+. ;ntermittent face/to/face interaction bet5een the teacher and student may be done as necessary to ensure effectivity of the educational program *%/)+. t a global level, distance education is fast becoming a trend in medical education because of the reali=ation of its usefulness not only for the 5ould/be students, but also for the faculty and institutions conducting it. *-+ ;n the Philippines, a formal structured distance education in medicine is slo5ly gaining ground. ;t 5ill be incorporated in the innovative community/based medical curriculum of the Zamboanga $edical "chool 4oundation, a school established in %&&- in 7estern $indanao, 5hich is located south of $anila. 4rom June, %&&% to $ay, %&&0, a general surgery course 5as conducted by a group of $anila faculty using a distance education mode in Zamboanga City $edical Center. 9he course had produced nine graduates, four practicing in Zamboanga City and five in the neighboring cities and provinces.

skepticism commonly e3pressed by medical educators 5ith regards to distance education in medicine is that it cannot be used in courses involving surgical skills, such as in general surgery. 7ith the set/up of a distance educational program, the belief is that 9eaching and more so, evaluating operative skills of trainees are difficult, if not impossible. 9his paper describes ho5 the operative skills of trainees under a distance education course in general surgery in Zamboanga City $edical Center 5ere evaluated. 9he ob<ective of this paper is to try to determine 5hether distance education can be used in courses that involve teaching and learning of operative skills. >ackground ;nformation Zamboanga City $edical Center *ZC$C+ is a Philippine government hospital 5hich has been in e3istence even before the )nd 7orld 7ar. ;t is situated in Zamboanga City in the 5estern part of $indanao, south of $anila. t present, it is classified as a tertiary hospital 5ith a catchment of 6 million population in 7estern $indanao. ;n %&&%, 5hen the general surgery course started, the department of surgery of the hospital 5as supposed to be training t5o surgeons for the various district and provincial hospitals in 7estern $indanao. 2o5ever, due to lack of 8ualified trainors, there 5as only one board/certified general surgeon in the entire region in %&&%, no formal structured training program in general surgery could be established. #pon the re8uest for assistance by the administration of ZC$C in %&&%, the senior author, 5ho 5as based in $anila, designed a -/year general surgery course using a distance education mode. 9hus, from June %&&% to $ay %&&0, a general surgery course 5as conducted by a group of $anila faculty led by the senior author using a distance education mode. 9he $anila faculty 5ent to ZC$C every three months for four years staying for about t5o days each trip to conduct and monitor the training program. 1uring the intervals, the faculty 5ould send instructional materials for the trainees to do independent study. 9he course has produced nine graduates. 9eaching of Operative "kills 9he basic operative skills 5ere taught first. 9hese included selection and handling of surgical instruments, assisting in operations, incision, knot tying, suturing, hemostasis, anastomosis, tissue and organ removal and repair, lavage, debridement, drainage, and 5ound closure, among others. *6+ 9he trainees 5ere also taught ho5 to perform common general surgical operations such as e3cision of tumors *skin, soft tissue, breast+, drainage of abscesses, modified radical mastectomy, thyroidectomy, herniorrhaphy, celiotomy, cholecystectomy, and gastrointestinal resection and anastomosis. 9he teaching of operative skills 5as done through demonstration and return demonstration. 9he $anila faculty 5ould perform demonstration of operation during their intermittent visits to ZC$C. ;n the intervals, a local trainor *a board/certified general surgeon+ 5ould do the same either for reinforcement or for procedures not performed by the $anila faculty. Evaluation of Operative "kills

Evaluation of operative skills of the trainees 5as confined to the basic operative skills and common general surgery procedures. 9he evaluation 5as done by both the $anila and local faculty. ctual observation and indirect observation through videotapes 5ere utili=ed. 9he surgical trainees 5ere asked to videotape common general surgery procedures that they personally performed from start to finish, from draping to dressing of incisional 5ound. 9hese unedited tapes 5ere then sent to the $anila faculty for vie5ing and evaluation. rating scale 5as used in the assessment of the trainee?s operative skills. 9he general criteria used consisted of the follo5ing, %. Rational @ each operative maneuver has an indication. ). Precise @ no iatrogenic in<uries. 6. Aentle @ in handling tissues. t the end of the course, the guidelines for evaluating the technical competence of general surgical trainees as recommended by the Philippine College of "urgeons 5ere used. 9he rating scale for technical competence consisted of eight parameters, namely, patient preparation, preparation of e8uipment, general conduct of procedure, observance of basic surgical principles, technical de3terity, intraoperative <udgement, duration of procedure, and after care. 9he ratings 5ith a corresponding behavioral description consisted of the follo5ing, BO @ not observed( % @ poor( ) @ marginal( 6 @ good( and - @ e3cellent. Results of Evaluation 9he course director *the senior author+ had the opportunity to continuously interact 5ith the trainees for the entire four years in )% face/to/face interactions in Zamboanga City and in ten teleconferences. 1uring the face/to/face interactions, the senior author 5as able to evaluate the technical competence of the trainees. 9he chairman of the 1epartment of "urgery ZC$C * .C+, 5ho is a board/certified general surgeon, collaborated in the evaluation. 9he operations that 5ere formally evaluated consisted of the follo5ing, e3cisions of superficial tumors *skin, soft tissue, and breast+( herniorrhaphy( drainage of abscess( thyroidectomy( mastectomy( cholecystectomy( celiotomy( appendectomy( and gastrointestinal resection and anastomosis. Evaluation 5as based mostly on direct observation. 9he follo5ing videotaped operations 5ere submitted by the trainees for indirect evaluation, herniorrhaphy( appendectomy( cholecystectomy( and thyroidectomy. t the end of the course, the Course 1irector and the Chairman of the 1epartment of "urgery of ZC$C gave the assessment for the technical competence of each trainee as sho5n in 9able %. 9able %. ssessment of 9echnical Competence 9rainee number % ) 6 Arade :ey, % @ poor ) @ marginal 6 @ good - @ e3cellent Comments 0 ' . 6 C & 6

9o medical educators 5ho are not used to distance education, a very common reaction is, D; cannot imagine ho5 medical and surgical skills can be taught and learned through distance education.E ;n this paper, the authors describe ho5 operative skills can be taught and evaluated in a distance education course in general surgery. One has <ust to be familiar 5ith the concept of distance education to be able to understand ho5 medical and surgical skills can be taught and evaluated in distance education. reason for the misunderstanding is the belief that there is no face/to/face interaction in distance education. 9here is. lthough ma<ority of the teaching/learning activities are done 5ith the student and the teacher being at a geographic distance from each other, there are opportunities for face/to/face interaction. ;t is during these face/to/face meetings bet5een the student and the teacher that skills can be effectively taught *0+ by demonstration and evaluated by return demonstration. One can al5ays argue that the intermittent face/to/face interactions may be too short a time to teach skills. 9his is an issue that is impossible to settle. One has <ust to think of 5ays of ho5 to find Dade8uateE time for the teaching and evaluation of operative skills. Once can increase the number and length of intermittent face/to/face interactions( make use of local trainors( make use of videotapes( and other means suitable to a particular situation. "ummary 9his paper describes ho5 the operative skill of trainees under a distance education course in general surgery in Zamboanga City, Philippines 5as evaluated. ;n effect, it illustrates ho5 operative skills can be possibly evaluated in a distance education mode of training general surgeons. References %. 1odds 9, dministration of 1istance/9eaching ;nstitutions, $anual. Cambridge, BEC Print, %&C6. ). 2arden R$, 7hat is F. 1istance learningG $edical 9eacher. %H,%6&/%-0, %&CC. 6. 2olmberg >, 9he Concept of 1istance Education, ;nternational Perspectives. ;n "te5art 1, :eegan 1, and 2olmberg > *eds+. !ondon, Croo 2elm, %&C6. -. Propper R, >eard B, 1istance learning, 9he role of telemedicine. $edical Education )C, %)-/%)0, %&&-. 0. "urgical Curriculum for Aeneral "urgery. Philippine College of "urgeons, %&&0.