A Systematic Review of Educational Mobile-Applications (Apps) for Surgery Residents: Simulation and Beyond

Mobile App Use in Clinical Care for Cleft Patients in the UK and Republic of Ireland

ObjectiveTo establish whether mobile applications (apps) are used as part of routine care for patients with cleft lip and palate in the UK and Republic of Ireland and to determine what role apps could play in the delivery of care.DesignA 5-question survey was designed by the authors and disseminated via Clinical Standards Advisory Groups (CSAGs), professional contacts, and the following presentation of preliminary results at the Craniofacial Society of Great Britain and Ireland's annual conference (2024). Responses were collected between April 5 and May 9, 2024.SettingUnited Kingdom (UK) and Republic of Ireland.ParticipantsProfessionals working in cleft care.InterventionsN/aMain outcome measuresCurrent app use, desirable functions in a cleft app, and views on the need for future app development in cleft care.ResultsSeventy-one responses, from 10 different roles working in cleft care. Twenty-one percent of respondents used apps in clinical practice. Respondents named 23 different apps that they used. Of those not using apps, 22% had failed to find the appropriate app. Eighty-two percent of those who had not looked believed there is a role for apps in cleft care. The most common suggested functions for a cleft app were therapy/treatment (85%), patient information (75%), and clinical education/training (59%).ConclusionsMany healthcare professionals use a variety of apps in the delivery of cleft care. There is an appetite among cleft professionals in the UK and the Republic of Ireland for a cleft-specific application. Work is required to establish an evidence base for app use in cleft care.

Identifying Research Priorities in Digital Education for Health Care: Umbrella Review and Modified Delphi Method Study

BACKGROUND

In recent years, the use of digital technology in the education of health care professionals has surged, partly driven by the COVID-19 pandemic. However, there is still a need for focused research to establish evidence of its effectiveness.

OBJECTIVE

This study aimed to define the gaps in the evidence for the efficacy of digital education and to identify priority areas where future research has the potential to contribute to our understanding and use of digital education.

METHODS

We used a 2-stage approach to identify research priorities. First, an umbrella review of the recent literature (published between 2020 and 2023) was performed to identify and build on existing work. Second, expert consensus on the priority research questions was obtained using a modified Delphi method.

RESULTS

A total of 8857 potentially relevant papers were identified. Using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) methodology, we included 217 papers for full review. All papers were either systematic reviews or meta-analyses. A total of 151 research recommendations were extracted from the 217 papers. These were analyzed, recategorized, and consolidated to create a final list of 63 questions. From these, a modified Delphi process with 42 experts was used to produce the top-five rated research priorities: (1) How do we measure the learning transfer from digital education into the clinical setting? (2) How can we optimize the use of artificial intelligence, machine learning, and deep learning to facilitate education and training? (3) What are the methodological requirements for high-quality rigorous studies assessing the outcomes of digital health education? (4) How does the design of digital education interventions (eg, format and modality) in health professionals' education and training curriculum affect learning outcomes? and (5) How should learning outcomes in the field of health professions' digital education be defined and standardized?

CONCLUSIONS

This review provides a prioritized list of research gaps in digital education in health care, which will be of use to researchers, educators, education providers, and funding agencies. Additional proposals are discussed regarding the next steps needed to advance this agenda, aiming to promote meaningful and practical research on the use of digital technologies and drive excellence in health care education.

Implementation of a Digital Health Technology Platform Improves Neurosurgical Resident Communication Skills

INTRODUCTION

Surgical residency lacks standardized curricula for teaching interpersonal and communication skills. We evaluated the utility of a digital health communication platform, Playback Health, that generates audiovisual recordings of patient-provider interactions as a tool for junior neurosurgical resident education.

METHODS

Junior (postgraduate year (PGY)-2 and PGY-3) neurosurgical residents rated their comfort working with five attending neurosurgeons (one of whom implemented Playback Health) across 10 categories, grouped into three overarching domains encompassing knowledge base, technical skills, and interpersonal skills on a 10-point Likert scale. Ratings were performed at the beginning of the rotation at the hospital as a baseline and then every two months for a total duration of six months.

RESULTS

At baseline, resident ratings of their comfort working with each physician did not differ significantly between the four Playback Non-Users and the Playback User. Regarding knowledge base, significant improvements arose at the four- and six-month time points regarding imaging knowledge (p = 0.045 and p = 0.003, respectively) and preoperative management (p = 0.024 and p = 0.003, respectively), and additionally for intraoperative knowledge at four months (p = 0.021) and postoperative management knowledge (p = 0.002). Among interpersonal skills, there was a significant difference with the physician who implemented Playback Health compared to Playback Non-Users as early as two months across both categories evaluated (understanding of patient concerns and expectations (p = 0.028) and understanding of patient's support structure (p = 0.005)). This difference was sustained across four- and six-month time points.

CONCLUSIONS

The implementation of a platform that generates customized audiovisual content during routine patient-provider interactions may be a valuable tool for resident education, particularly regarding interpersonal skills and understanding of patient specific concerns and support structures.

Pilot Study to Improve Resident Experience on Vascular Surgery by Standardizing Dissemination of Operative Steps

OBJECTIVE

Many surgical residencies have passed along attendings preferences and procedural knowledge as a highly utilized but informal resource. The objective was to assess the effect of providing operative steps and attending preferences on surgical resident performance.

DESIGN

This was a prospective observational study with a survey-based design.

SETTING

We created and shared vascular surgery operative steps including institutional and attending preferences with junior residents at the Massachusetts General Hospital.

PARTICIPANTS

There were a total of 31 residents who completed a survey to assess self-perception of performance in operative knowledge and Accreditation Council for Graduate Medical Education (ACGME) Milestone criteria.

RESULTS

Advice from colleagues was the most utilized resource, followed by web-based materials. Of the web-based materials, almost all residents utilized Google searches over other web-based resources designed to specifically help surgical trainees. The vascular surgery resource was used by 90% of residents more than 3 times per week to prepare for operative cases. There was significant improvement in patient positioning, instrument selection, operative field exposure, anatomy, sequence of procedure, procedure choices, and peri-operative care knowledge.

CONCLUSIONS

Development of institutional resources that specifically capture attending surgeon procedural variations can improve resident performance, encourage resident autonomy, and provide a catalog of approaches to challenging operative situations.

e-Health education for patients and health professionals in the field of vascular disease

e-Health, defined as "the use of new information and communication technologies (ICT) to improve or support health and health care," has grown in popularity over recent years as a cost-efficient, rapidly adaptable tool to deliver health care education to a wide audience. In the field of vascular disease, for which early detection and risk factor management may greatly influence patient outcomes, application of e-Health educational resources may provide innovative solutions to facilitate evidence-based and patient-centered care provision of care; to enable patients to take a more active role in the management of their long-term vascular health conditions; and to augment their preparation for, and recovery from, surgical procedures.

Rapid Design of a Student-Centred App for Musculoskeletal Clinical Skills: An Example of a Theoretically Informed Approach to Developing Apps for Learning

Background and need for innovation

The process to design mobile apps for learning are infrequently reported and focus more on evaluation than process. This lack of clear process for health professional education mobile apps may explain the lack of quality mobile apps to support medical student learning.

Goal of innovation

The goal of this project was to develop a student informed ready for production wireframe model of a minimally viable mobile app to support learning of musculoskeletal (MSK) clinical skills.

Steps taken for development and implementation of innovation

The Information Systems Research (ISR) framework and Design Thinking were combined for the mobile app design. The process followed the cycles and modes of the combined framework to; systematically review available apps, use a focus group to identify attributes of the app valued by students, define the initial plan for the mobile app, develop an app prototype, and test and refine it with students.

Outcomes of innovation

The student focus group data had five themes: 1) interactive usability, 2) environment, 3) clear and concise layout, 4) anatomy and pathology, 5) cultural safety and 'red flags'. The prototyping of the app went through three cycles of student review and improvement to produce a final design ready for app development.

Critical reflection on our process

We used a student-centred approach guided by design frameworks to design a minimally viable product mobile app to support learning of MSK clinical skills in ten weeks with a small team. The framework supported nonlinear, iterative, rapid prototyping. Student data converged and diverged with the MSK teaching methods literature. Of note our students requested cultural safety learning in the app design, suggesting mobile apps could support cultural safety learning.

Evaluation of Educational Feedback in Urology Training: A Survey-Based Assessment of Trainees and Program Directors

OBJECTIVE

Our objective was to evaluate current satisfaction with the feedback provided during post-graduate urological training, including the quality and frequency of feedback, with participants consisting of both trainees and program directors. Additionally, we aimed to identify areas for future improvement in resident and fellow-level urological training.

METHODS

Graduating residents, fellows, and program directors from accredited residency/fellowship programs in the United States were surveyed. A total of 575 surveys were sent out. Information on feedback frequency, quality, form, and satisfaction was collected using applicable multiple-choice responses and a five-point Likert scale. An open-ended question gathered suggestions for improving current feedback processes. A chi-square test of independence was used to compare the responses to individual questions.

RESULTS

Ninety-two respondents answered our survey: 22 residents, 18 fellows, 25 residency program directors (PDs), and 27 fellowship PDs. The distribution of age, race, and gender categories was not significantly different between PDs and trainees. However, there was a significant difference in their subspecialties and American Urological Association (AUA) sections. The majority of fellowship PDs, residency PDs, fellows, and residents (88 total) reported verbal feedback as the predominant method within their practice. This was followed by written (68 total), electronic (54 total), and app-based feedback (19 total).

CONCLUSION

Our study suggests that there may be a need for ongoing improvement or standardization of feedback mechanisms in the field of urological training and highlights the perceived discrepancies between learners and educators.

Virtual Simulation of Intra-operative Decision-Making for Open Abdominal Aortic Aneurysm Repair: A Mixed Methods Analysis

OBJECTIVE

To create and pilot test a novel open abdominal aortic aneurysm (AAA) repair virtual simulation focused on intraoperative decision-making. To identify if the simulation replicated real-time intra-operative decision-making and discover how learners' respond to this type of simulation.

DESIGN

An explanatory sequential mixed methods study. We developed a step-by-step outline of major intra-operative decision points within a standard open AAA repair. Perioperative and intraoperative decision-making trees were developed and coded into an online virtual simulation. The simulation was piloted. Quantitative data was collected from the simulation platform. We then performed a qualitative thematic analysis on feedback from interviewed participants.

SETTING

Four academic general and vascular surgical training programs across the US.

PARTICIPANTS

Seventeen vascular and general surgery trainees and 6 vascular surgery faculty.

RESULTS

Participants spent on average 27 minutes (range: 8-45 minutes) interacting with the interface. 93% of participants reported feeling they were making real intraoperative decisions. 85% said it added to their knowledge base. 96% requested additional simulations. 22 interviews were completed: 241 primary codes were collapsed into 21 parent codes, and 6 emerging themes identified. Themes included the benefit of how (1) "Virtual Learning Could Standardize the Training Experience"; how (2) "Dealing with the Unexpected" as a trainee is an important part of surgical education growth, and that this (3) "Choose Your Own Adventure" virtual format simulates this intraoperative growth experience. Participants requested a (4) "Looping Feature Feedback Diagram" for future simulation iterations and highlighted that (5) "Fancier is Not Necessarily More Educational." Finally, many trainees wondered about (6) "The Attending Impact" from the simulation: if faculty would notice a difference between trainees who did vs did not utilize the simulation for case preparation.

CONCLUSIONS

Operative simulation training should focus on both technical skills and intra-operative decision-making, particularly "dealing with the unexpected." The learners' responses indicate that a low-fidelity, scalable, virtual platform can effectively deliver knowledge and allow for intra-operative decision-making practice in a remote learning environment.

Mobile applications in medical education: A systematic review and meta-analysis

Objective

This review evaluates the effectiveness of smartphone applications in improving academic performance and clinical practice among healthcare professionals and students.

Methods

This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Articles were retrieved from PubMed, Scopus, and Cochrane library through a comprehensive search strategy. Studies that included medical, dental, nursing, allied healthcare professional, undergraduates, postgraduates, and interns from the same disciplines who used mobile applications for their academic learning and/or daily clinical practice were considered.

Results

52 studies with a total of 4057 learner participants were included in this review. 33 studies (15 RCTs, 1 cluster RCT, 7 quasi-experimental studies, 9 interventional cohort studies and 1 cross-sectional study) reported that mobile applications were an effective tool that contributed to a significant improvement in the knowledge level of the participants. The pooled effect of 15 studies with 962 participants showed that the knowledge score improved significantly in the group using mobile applications when compared to the group who did not use mobile applications (SMD = 0.94, 95% CI = 0.57 to1.31, P<0.00001). 19 studies (11 RCTs, 3 quasi-experimental studies and 5 interventional cohort studies) reported that mobile applications were effective in significantly improving skills among the participants.

Conclusion

Mobile applications are effective tools in enhancing knowledge and skills. They can be considered as effective adjunct tools in medical education by considering their low expense, high versatility, reduced dependency on regional or site boundaries, online and offline, simulation, and flexible learning features of mobile apps.

A data-driven performance dashboard for surgical dissection

Surgical error and resulting complication have significant patient and economic consequences. Inappropriate exertion of tool-tissue force is a common variable for such error, that can be objectively monitored by sensorized tools. The rich digital output establishes a powerful skill assessment and sharing platform for surgical performance and training. Here we present SmartForceps data app incorporating an Expert Room environment for tracking and analysing the objective performance and surgical finesse through multiple interfaces specific for surgeons and data scientists. The app is enriched by incoming geospatial information, data distribution for engineered features, performance dashboard compared to expert surgeon, and interactive skill prediction and task recognition tools to develop artificial intelligence models. The study launches the concept of democratizing surgical data through a connectivity interface between surgeons with a broad and deep capability of geographic reach through mobile devices with highly interactive infographics and tools for performance monitoring, comparison, and improvement.

Application of Universal Design for Learning (UDL) Principles to Surgical Education During the COVID-19 Pandemic

OBJECTIVE

During the COVID-19 pandemic in 2020, we have faced unprecedented challenges in the delivery of surgical education. At the time of writing, changes to the structure and nature of the surgical workforce are occurring rapidly, even daily. Surgical educators are utilizing remote learning solutions, including flipped classroom approaches, online educational materials, telemedicine, and simulations, to continue education for surgical residents despite cancelations of face-to-face instruction. Our objective is to delineate an interdisciplinary strategy, utilizing the principles of Universal Design for Learning (UDL), by which we can optimize learning during this pandemic.

DESIGN

This perspective describes the UDL framework which can be used to situate solutions to issues with delivery of surgical education during this pandemic within the broader view of strategic inclusive instructional design to meet diverse learning needs..

CONCLUSION

The principles of UDL can inform curricular and pedagogical changes in surgical education that may be employed during a time of social distancing, isolation, and quarantine. UDL involves planning flexibility into curricular design from the outset, recognizing that learners are varied in their learning preferences and capabilities, motivational characteristics, and environmental constraints. Viewing the design of remote learning opportunities through the UDL lens aims to remove barriers to learning during this pandemic by targeting three areas: expansion of the means that information is communicated, ways that learners are supported and motivated, and approaches to assessing learning through available distance learning technologies.