Evaluating the educational environment of an international animal model-based wet lab course for undergraduate students Academic research paper on "Educational sciences"

Accepted Manuscript

ANNALS OF MEDICINE &SURGERY

Evaluating the educational environment of an International animal model-based wet lab course for undergraduate students

Michail Ch. Sideris, NIHR Academic Clinical Fellow ST1 level, Apostolos E. Papalois, Thanos Athanasiou, Consultant Cardiothoracic Surgeon, Professor, Ioannis Dimitropoulos, Consultant, Korina Theodoraki, ST1 Trainee, Francois Sousa Dos Santos, ST3 Trainee, Georgios Paparoidamis, Medical Student, Nikolaos Staikoglou, Medical Student, Dimitrios Pissas, Consultant Colorectal Surgeon, Peter C. Whitfield, Consultant Neurosurgeon, Associate Professor of Neurosurgery, Alexandros Rampotas, Senior House Officer, Savvas Papagrigoriadis, Consultant Colorectal Surgeon, Senior Clinical Lecturer in Surgery, Vassilios Papalois, Consultant Transplant Surgeon, Professor of Surgery, Georgios Zografos, Professor of Surgery, Vice Rector, Director, Georgios Tsoulfas, Assistant Professor of Surgery

PII: S2049-0801(16)30141-8

DOI: 10.1016/j.amsu.2016.10.004

Reference: AMSU 504

To appear in: Annals of Medicine and Surgery

Received Date: 23 September 2016

Revised Date: 19 October 2016

Accepted Date: 19 October 2016

Please cite this article as: Sideris MC, Papalois AE, Athanasiou T, Dimitropoulos I, Theodoraki K, Dos Santos FS, Paparoidamis G, Staikoglou N, Pissas D, Whitfield PC, Rampotas A, Papagrigoriadis S, Papalois V, Zografos G, Tsoulfas G, Evaluating the educational environment of an International animal model-based wet lab course for undergraduate students, Annals of Medicine and Surgery (2016), doi: 10.1016/j.amsu.2016.10.004.

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Title:

Evaluating the educational environment of an International animal model-based wet lab course for undergraduate students.

Michail Ch. Sideris1, Apostolos E. Papalois*2, Thanos Athanasiou3, loannis Dimitropoulos4, Korina Theodoraki5, Francois Sousa Dos Santos6, Georgios Paparoidamis7, Nikolaos Staikoglou7, Dimitrios

Q Q 1 A 1 -y

Pissas , Peter C. Whitfield , Alexandros Rampotas , Savvas Papagrigoriadis , Vassilios Papalois , Georgios Zografos13, Georgios Tsoulfas14

Authors:

1.NIHR Academic Clinical Fellow ST1 level, The London Deanery, Queen Mary University London (QMUL), London, UK, Lead of the ESMSC Project - m.sideris@qmul.ac.uk

2.*Equal Contribution with 1st Author, Director of the Experimental Research Centre ELPEN, Lead of the ESMSC Project - apapalois@elpen.gr

3. Consultant Cardiothoracic Surgeon, Hammersmith and St Mary's Hospitals, Professor of Cardiovascular Sciences, Imperial College, London, UK - t.athanasiou@imperial.ac.uk

4.Consultant in Diabetes and Endocrine Medicine, Derriford Hospital, NHS, UK -ioannis.dimitropoulos@nhs.net

5. ST1 Trainee in Ophthalmology, Kent, Surrey, Sussex (KSS) Deanery - korinatheodoraki@gmail.com

6. ST3 Trainee in Obstetrics and Gynaecology, London Deanery

7. Medical Student, Aristotle University of Thessaloniki (AUTH) - nstaikoglou@gmail.com , gpaparoidamis@gmail.com

8.Consultant Colorectal Surgeon, Epsom and St Helier University Hospitals NHS Trust, London, UK -dpissas@nhs.net

9. Consultant Neurosurgeon, Associate Professor of Neurosurgery, Peninsula Medical School, Derriford Hospital, NHS, UK peter.whitfield@nhs.net

10. Senior House Officer in Renal Medicine, The Royal London Hospital, Bart's NHS Healthcare -al exis@windowslive.com

11.Consultant Colorectal Surgeon, King's College Hospital NHS Foundation Trust, Senior Clinical Lecturer in Surgery, King's College London, UK spapagrigoriadis@nhs.net

12.Consultant Transplant Surgeon, Hammersmith Hospital, London, UK, Professor of Surgery, Imperial College, London UK v.papalois@imperial.ac.uk

13. Professor of Surgery, Vice Rector, University of Athens, Director of the 1st Department of Propaedeutic Surgical, Hippocration General Hospital, Athens, Greece - gzografo@med.uoa.gr

14.Assistant Professor of Surgery, Aristotle University of Thessaloniki (AUTH) - tsoulfasg@gmail.com

Corresponding Author

Michail Ch. Sideris: NIHR Academic Clinical Fellow, The London Deanery, Queen Mary's University London (QMUL), London, UK, Lead of the Project Email: m.sideris@qmul.ac.uk ; mchsideris@gmail.com

Keywords:

Educational Environment, wet lab, Undergraduate, Basic Surgical Skills, Surgical Education Research Short Running Title:

Evaluation of ESMSC educational environment Ethics:

European and National Legislation, Directive 63/2010, PD 56/April 2013

Reference Number of the License: Michail Ch. Sideris and Apostolos Papalois 7095/05-11-2014

(revised 884 28/4/2015)

Manual of the Course:

Essential Skills in the Management of Surgical Cases - ESMSC, Scientific Publications Parisianou S.A., ISBN: 978-960-583-063-2

Authors Contribution:

Main Contribution

Michail Ch. Sideris and Apostolos E. Papalois: Equal Contribution, Lead of the Project, and Designers of the course curriculum, Main Editors of the Manual. MS drafted and edited manuscript Statistical Analysis by MS

Georgios Tsoulfas: Faculty of the Course, Lead for the In vivo Dissections (Anatomy Demonstration of the Abdomen), Conception and senior author of the Study Thanos Athanasiou, International lecturer during the course, edit of the manuscript, statistical analysis feedback

loannis Dimitropoulos, International Lecturer during course, edit of language of the manuscript

Korina Theodoraki: Faculty Member, literature search and editing of the discussion part of the manuscript

Peter C. Whitfield, International Lecturer During Course, senior advisor of the manual Alexandros Rampotas, Francois Sousa Dos Santos Members of the faculty Dimitrios Pissas, International advisory Committee of the ESMSC course Savvas Papagrigoriadis: Senior Advisor of the Course Curriculum and Manual Vassilios Papalois : Senior Advisor of the Course Curriculum and Manual Georgios Zografos : Senior Advisor of the Course Curriculum and Manual, Lead of the Scientific Committee of the Course

Georgios Paparoidamis, Nikolaos Staikoglou, medical students who set up promotion and smooth run of the course, data collection and assistants to senior assessors. GP has contributed with GT to the protocol

Acknowledgements:

Special thanks to:

Professor Shakila Thangaratinam (Professor of Maternal and Perinatal Health, Queen Mary University London) for offering feedback on the manuscript

Also to:

Experimental Research Centre ELPEN Faculty

We would like to thank all the Staff of the E.R.C. ELPEN and especially Georgios Stagias - Felasa C and Nikolaos Psychalakis - Felasa C

And the rest of the Medical Students' Committee Ismini Tsagkaraki Efstratia Georgopoulou Stefanos Karamaroudis

Funding of the Project:

Essential Skills in the Management of the Surgical Patient - ESMSC is funded by the Experimental Research Centre ELPEN, and it is provided for free to Medical Students around Europe

Conflict of Interest:

Not Applicable

Place of the Study:

Experimental Research Centre ELPEN 95 Marathonos Av., 19009, Pikermi Email: apapalois@elpen.gr

Evaluating the educational environment of an International animal model-based wet lab course for undergraduate students.

Background:

Essential Skills in the management of Surgical Cases - ESMSC is an International Combined Applied Surgical Science and Wet Lab course aimed at the undergraduate level. ESMSC combines interactive basic science workshops and case-based learning, with basic surgical training modules (BST) on Ex Vivo and In Vivo swine model. In Vivo Dissections include more advanced modules i.e. Abdominal Anatomy Dissections and Cardiac Transplant.

To evaluate the educational environment of a novel course, as well as to compare Medical students' perceptions across various groups.

Materials and Methods:

83 Delegates from King's College London (KCL) and several Hellenic Medical Schools attended the ESMSC course. The DREEM inventory was distributed upon completion of the modules.

Results:

The mean overall score for DREEM inventory was 148.05/200(99-196, SD=17.90). Cronbach's Alpha value was 0.818, indicating good internal consistency of the data. Year 3/4 Students have a significantly positive "Perception of Learning", when compared to Year 5/6 (36.43 vs. 33.75, p=0.017). KCL Students have a more positive view of the course compared to their Greek counterparts (155.19 vs. 145.62/200, p=0.034). No statistical significant difference was noted when comparing male vs. female students (p>0.05)

Conclusions:

Students seem to positively rate the ESMSC educational environment. Junior as well as KCL students appear to be more enthusiastic. Further research should focus on the optimal strategy for early involvement and motivation of various students' groups in BST.

Words: 227

Introduction

The educational environment is considered to be a crucial parameter that reflects directly onto the students' satisfaction, academic aspirations and overall perception of well-being . It is important to note that, most of the curricula are shifting toward a student-centered pattern, where evaluation of the educational environment has been possible through

various tools, that aim to objectively measure various parameters - . Recent evolution in Medical Education, diversity in the personality of Medical Students, as well as occasional misinterpretation by teachers of students' perceptions regarding the educational

environment , have underlined the need of effective evaluation of the latter . Apart from the educational environment's role in students' learning5-7, its continuous evolving character, sets the need for an objective, unbiased tool to assess the impact of various changes directly onto the educational process.

Various tools have been designed to assess educational environment ' . The Dundee Ready Education Environment Measure (DREEM)10-12 is a validated 50-statement questionnaire, which is used to effectively evaluate the educational environment. The overall evaluation is based on the aggregate scores, as well as the 5 subscales, and many authors include and comment on each of the 50 statements individually1,13. DREEM inventory has been used to evaluate various educational environments1,4,13-29, mainly in undergraduate curricula, as well as postgraduate training30.

13 31 8

Although some studies question the 5 factor structure of DREEM , , Soemantri et al conducted a systematic review on various tools, and concluded that DREEM is the most comprehensive measure of the educational environment. Nevertheless, Miles et al notes in their systematic review, that despite DREEM being an effective tool, consensus on statistical analysis and interpretation of the finding s should be reached to avoid misconceptions.

Essential Skills in the Management of Surgical Cases - ESMSC 32 is an International Combined Applied Surgical Science and wet lab course aimed specifically at the undergraduate level. It combines basic science workshops (ABGs, ECG, Shock), case-based learning on various surgical cases with basic surgical skills (BST) training on ex vivo and in vivo swine modules. In Vivo Dissections involve various basic and more advanced modules on swine model. Delegates also have the chance to be actively involved in the Cardiac Explantation under bypass In Vivo experiment as well. Ex Vivo stations include basic suturing, fundamental laparoscopic skills (FLS), Open Reduction Internal Fixation (ORIF) of long bone fractures, wound debridement and tendon repair. The unique component of ESMSC curriculum lies in the mixture of high-fidelity In Vivo SBL, with other wet or dry lab lower fidelity modules with Basic and Applied Surgical Science interactive workshops. It also offers a unique opportunity for exchange of ideas between various educational background delegates as well as faculty members and it involves, motivates and inspires students at an early stage to pursue a surgical career.

In the context of developing a novel, international, two-day course, involving intense basic, as well as more advanced skills-based training, we considered it essential to objectively evaluate the educational environment using DREEM questionnaire.

The primary aim of this study is to evaluate the overall educational environment of a novel international wet lab course (ESMSC). Additionally, we wanted to compare the overall and the subscale scores among different groups of students.

Materials and Methods

Delegates from the UK (King's College London), as well as Greek Medical Schools register their interest to attend the ESMSC course online (esmsc.gr). Selection of participants is performed via our online portal, based on CV criteria including number of publications, presentations in conferences etc. A relevant statement, where participants advocate their interest and motivation towards a surgical career, is attached to the application. The application, as well as the course is run in English, and good operational command of the language is mandatory. A panel of two senior faculty members independently assesses the applications. This is to assure that the best candidates are selected, while at the same time, homogeneity, in terms of previous exposure and background knowledge, is still maintained. This was performed on the basis to eliminate selection bias i.e. selecting only very competent students. With regards to the faculty members, all of them are proficient or native English speakers and comprise from junior to senior trainees as well as Consultants and Academics from the UK, Greece or other various countries from the EU and abroad. The ratio between delegates and faculty members is almost 1:1 to ensure highest quality teaching is assured.

Delegates were asked to fill the DREEM inventory anonymously, in the teaching room, immediately following completion of the ESMSC. Data on Demographics (Age and Sex), as well as Medical School and Year of Studies were recorded and demonstrated in Graph I.

Reliability analysis, using Cronbach's Alpha coefficient, was performed to evaluate internal consistency of the DREEM. Acceptable level of internal consistency was considered if Cronbach's Alpha is between 0.5-0.7, and good level if above 0.7 33. Interclass Correlation Coefficient (ICC) was used to evaluate the level of agreement between measurements. ICC<0.2 is considered as poor agreement, 0.21-0.40 as fair, 0.61-0.80 as good and 0.81-1.0 as very good.

Scoring, as well as Interpretation of the DREEM inventory was based on the practical guide. A 5-point Likert-type scale, ranging from Strongly Agree (SA, 4) to Strongly Disagree (SD, 0) was used for positive statements. With regards to negative statements (Questions 4, 8, 9,

17, 25, 35, 39, 48 and 50), the scale ranged from Strongly Agree (SA, 0) to Strongly Disagree (SD, 4).

The overall score, as well as the five subscale scores were used to evaluate the ESMSC educational environment. Subscale scores include "Registrars perception of Learning (RPoL)", "Registrars Perception of Course Designers (RPoCD)", "Registrars' Academic Self-Perception (RASP)", "Registrars' Perception of Atmosphere (RPoA)" and "Registrars' Social Self Perceptions (RSSP)".

Statistical Analysis

Statistical analysis of our results was performed using IBM SPSS for Macintosh version 22 (Armonk, NY, IBM Corp.). Normality of distribution for was assessed based on Shapiro-Wilk test. Independent t-test associations were used to compare means in various groups (Year 3/4 vs. Year 5/6 Students, KCL vs. Greek Students, Male vs. Female, May 2015 vs. November 2015 cohorts). One-way ANOVA was performed to compare the mean scores between Year 3-6 Medical Students, as well as between students from various Universities. Statistical significant level was set at p=0.05

Results

89 delegates attended the course and 83 filled out the DREEM inventory anonymously (response rate 83/89, 93.2%). N=46 had attended the course in May 2015 (55.4%), whereas N=37(44.6%) in November 2015. 52 delegates (62.7%) were Male students and 31 (37.3%) female. The mean age was 23.38 years old (20-30, SD=1.73) (Graph I).

21 (25.3%) came from King's College London, and 62 (74.7%) from Hellenic Medical Schools. With regards to Hellenic Medical Schools, N=15 (18.1%) were students from Athens Medical School, N=5(6.0%) from Herakleion University, N=3(3.6%) from Ioannina University, N=7(8.4%) from Larisa University, N=9(10.8%) from Patra University, N=20(24.1%) from Thessaloniki University and N=3(3.6%) from Alexandroupoli University (Graph I).

Concerning the Year of Studies, N=21 (25.3%) were Year 3 Students, N=14 (16.9%) Year 4, N=29(34.9%) Year 5 and N=19 (22.9%) Year 6. In total, N=35 (42.2%) were Year 3 or 4 and classified as Junior Medical Students, whereas N=48 (57.8%) were Year 5 or 6 classified as Senior or Final Year Medical Students. In the UK clinical rotation starts at the 3rd Year, whereas in Greece, the equivalent Year is the 4th. What is more, UK MBBS is a 5 Year course, whereas in Greece the duration of the undergraduate studies is 6 years (Graph I).

Overall Cronbach's Alpha Coefficient value was 0.818, which indicates good level of internal consistency for DREEM questionnaire. Cronbach's Alpha value for RPoL was 0.899, for RPoCD 0.766, for RASP 0.772, for RPoA 0.770, and for RSSP 0.812, which indicate good internal consistency for all the sub-scales. Overall ICC value was 0.818, which is deemed as very good level of agreement33. Shapiro-Wilk normality test showed normal distribution for overall and all subscale scores (p>0.05) except RPoA (p=0.014), though this was considered as normal using the Kolmogorov-Smirnov test (p=0.20).

The mean overall score for the DREEM inventory was 148.05/200(99-196, SD=17.90), which is classified as "More Positive than Negative" (Table I). With regards to subscale mean scores, "Registrars' Perception of Learning" scored 34.88/48(23-48, SD=5.01), which is interpreted as "A more positive perception". "Registrars' Perception of Course Organizers" mean score was 33.89/44(21-44, SD=4.70), which corresponds to "Moving in the right direction". "Registrars' Academic Self Perception" scored 23.15/32(13-32, SD=3.59) which is interpreted as "Feeling on the Positive Side". "Registrars' Perception of Atmosphere" mean score was 36.73/48(17-47, SD=4.93) which is interpreted as "A good feeling overall". Finally, "Registrars' Social Self Perceptions" mean score was 19.28/28(12-27, SD=2.95), which is classified as "Not too bad" (Table II). Individual Question Scores are listed on table I.

The minimum mean score was recorded for item 25 "The teaching over emphasizes factual learning" (mean=1.76, 1-5, SD=1.03), and the maximum for item 39 "The course organizers get angry in teaching sessions", (mean=3.46, 1.00-4.00, SD=0.73) (Table I).

Attempting a comparison between the May vs. the November Cohorts of Students, there was no statistical significant difference in the mean overall score nor in any of the sub-scale scores (p>0.05 for all associations).

Comparing Year 3/4 vs. Year 5/6 Students there was no statistically significant difference in the overall DREEM inventory score, though it was higher for Year 3/4 Students (151.77 vs. 145.33, p=0.114). However, there was a statistically significant higher score for Year 3/4 Students in terms of "Registrars' Perception of Learning" (36.43 vs. 33.75, p=0.017), (Table III). ANOVA analysis revealed that Year 3 students recorded the highest mean sub-scale and overall scores compared to any other group, and that there was an overall tendency for lower DREEM scores with advancing medical school year seniority, though this did not reach statistical significance (p>0.05) (Table IV).

When comparing KCL vs. the 7 Hellenic Medical Schools, there seems to be a difference in the overall mean DREEM inventory score: 155.19 vs. 145.62/200 (p=0.034). In terms of subscale scores, there was a statistically significant difference in the mean scores of "Registrars' Perception of Learning" (KCL vs. Greek, 37.9 vs. 33.85 respectively, p=0.003), as well as in "Registrars Social Perceptions" (KCL vs. Greek, 20.43 vs. 18.89, p=0.05) (Table V). One-way ANOVA analysis confirmed that KCL students had the highest mean overall score (p=0.002), as well as sub-scale scores (RPoL, p=0.015, RPoCO, p=0.073, RASP, p=0.003, RPoA, p=0.001, RSSP, p=0.019), compared to the 7 Hellenic Medical School Students (Table VI)

Male Medical Students reported a higher mean overall DREEM score vs. Female Students (149.29 vs. 145.97, p=0.434), though it did not reach statistical significance. No other statistical significant differences were noted with in the rest of the DREEM subscale evaluation.

Discussion

Educational environment is undoubtedly a vital parameter that reflects directly onto the students' learning5-7,34. Introducing ESMSC as a novel course32 automatically generates the need for an objective assessment of students' perception on the actual educational environment. Furthermore, the ESMSC curriculum consists of a variety of in vivo and ex vivo hands-on modules, with basic science workshops and lectures, which is considered as a fairly novel combination of learning experience. High fidelity In Vivo Simulation Based Learning (SBL) is quite uncommon in the undergraduate level, and only a few studies have reported results from in vivo based SBL courses35. Besides that, ESMSC offers the advantage of a mixture between British and Hellenic undergraduate students. This characteristic generates the opportunity to assess the views of trainees from different educational backgrounds on similar educational aspects and training methods. While relative homogeneity of the students is achieved through the online selection portal (esmsc.gr)32, ESMSC invites delegates at the level of participation in medical school clinical rotations, which results in a good variety of Year 3 to 6 Students. Thus, ESMSC could serve as an opportunity to attempt to reach conclusions on different views of students from diverse educational and stage-of-studies background, on a novel educational experience.

Despite a formal feedback report being an indicator of students' perception on an educational experience, there remains concern regarding any subjectivity; hence any

conclusions could enclose bias. Therefore, choosing a formally validated tool could confirm our observations and import answers on our question of how do different students perceive the ESMSC learning experience. The DREEM inventory seems to be the most

8 10 36

accurate tool with multiple applications in the undergraduate and postgraduate training 37. It has been generally used to assess several medical schools' profile34, or to compare following newly implemented changes, the educational environment of various

undergraduate curricula following newly implemented changes . There have been studies which use DREEM to compare different medical education institutions, students at different training stage, as well as different participant gender.

In our study, ESMSC is considered to be "a more positive than negative" educational environment, with the mean overall score (148.05 ±17.90), and compared to other reported scores in the literature6 7,4°-44, it seems to be an encouraging finding that complements the students' excellent feedback report32. Moreover, subscale scores appear to confirm the overall good impression of participants, as reflected by "A more positive Perception of learning" (34.88, ± 5.01), "Moving in the right direction" (33.89, 4.70), "Feeling on the Positive Side" (23.15, ± 3.59) etc. This confirms our primary hypothesis, that the students perceive ESMSC as a valuable educational experience, and objectively improve their performance in various skills32. Another interesting finding is that, the vast majority of mean scores, including overall, are fairly close (0,11-2.96) towards the highest class, and this generates some more interest towards achieving excellence in SBL teaching.

While SBL is widely used in the higher postgraduate training45-47, it is becoming all the more an integrated feature of various undergraduate curricula35,48,49. Our study confirms that students perceive positively this high fidelity SBL experience. There has been a discussion about integration of basic surgical skills (BSS) training as part of the undergraduate curriculum{Hamaoui, 2013 #146}, and this seems to be underlined by our delegates' perceptions on ESMSC course. As various Medical Schools are considering updating their

curricula, this could be a hint that may to be taken into consideration, whilst setting up a novel strategy for the undergraduate education.

Comparing Year 3/4 vs. Year 5/6 Students, it seems that junior students l perceive the same learning experience in an overall more positive manner (Overall-151.77 vs. 145.33, p=0.114, RPoL-36.42 vs. 33.75, p=0.017), despite (or BECAUSE of) ESMSC involving more advanced In Vivo modules. Interestingly, ANOVA analysis shows that DREEM overall and sub-scale scores tend to decline as students are moving from Year 3 to the Final Year (Graph II), although this did not reach statistical significance (p>0.05, Table IV). Demlroren et al50 reports similar patterns, where Year 3 students have the highest scores (Year 3 vs. Year 5, 123.65 vs.109.39). Al-Ayen et al51 also notes as well that Year 1 students tend to have the most positive scores compared to clinical year students. This is an interesting finding indicating that while students progress through their undergraduate studies, they potentially become less optimistic, and this should raise a question, whether more support is needed within the framework of the undergraduate curriculum in terms of continuous positive reinforcement and in particular towards graduation.

Junior students seem to be more enthusiastic, and despite the in vivo dissections' modules being more advanced, which could potentially raise difficulties in their learning process, they still seem to enjoy the course more. Furthermore, in our previous study32, we demonstrated that junior students perform similarly in the objective assessments. Therefore, we should approach these findings with a more holistic view, and question whether more hands-on skills training is required at an earlier stage to promote learning, as well as motivate students towards a more positive attitude towards their learning process.

With regards to the comparison between KCL vs. Greek Students, UK students tend to perceive most of the aspects of the course in a more positive manner ("Excellent" vs. "more positive than negative, 155.19 vs. 145.62, p=0.061). RPoL is perceived by UK students as "Teaching highly though of" vs. "A more positive perception" (37.9 vs. 33.85, p=0.003). Those findings could either be explained by the fact that KCL students were overall more junior (Year 3, N=15, 75.4%, Year 4, N=2, 9.5%, Year 5 N=4, 19.1%), or by the fact that SBL modules are a well-integrated part of UK MBBS courses, hence students are more familiar with its concepts, whilst in Greece this is evolving in the last few years. In addition to that, ESMSC is an intense course, which completely runs in English. Therefore, this may contribute to further distress for the Hellenic Students, whose undergraduate curriculum is taught in Greek. In a study examining undergraduate curriculum reforms, Finn et al24 noted that non-Irish students who did not speak English as their first language, had a more negative perception of the same education environment compared to Irish students.

ANOVA analysis concludes that KCL students have the most positive perception of the ESMSC learning environment (p=0.002, Table VI), while there is a variation noted between the Greek Institutions. For instance, students from the Athens or Thessaloniki Medical School, which are the biggest, demonstrate a more positive view of the ESMSC learning environment, compared to ones from smaller Universities i.e. Alexandroupoli or Herakleion (147.4, 150.30 vs. 135.33, 116.8 respectively, p=0.002). Despite the sample being pretty small to allow conclusions, it seems that the bigger Universities in Greece, may offer some more support to their students and hence, promote motivation in learning, as well as a

more positive view for an SBL educational environment. However, there have been some interesting studies published, that students' perception is similar, despite different ranking of Universities42,52,53

On the other hand, comparing male vs. female perceptions of the ESMSC educational environment, despite a slightly statistically non-significant higher, overall score of male students (149.2 vs. 145.2, p=0.434), there does not seem to be any difference in the gender sub-scale perception scores. Similar findings are reported by other DREEM studies14,51 in the literature.

Overall, despite the limitations of our sample, which comes from two consecutive cohorts of ESMSC course, our conclusions generate some interesting areas for future research. Firstly, as uniform standards for surgical training are implemented across Europe and the US, it would be interesting to compare students' view from more Countries and see if the overall perception on SBL training remains the same. Also, there still remains the question regarding what is the optimal stage for students to be involved in skills-based training, and how SBL can motivate students towards a surgical career. These points seem to be crucial, whilst Medical Schools' Boards seek for the optimal strategy to reform and modernize their curricula.

Conclusions

Medical Students seem to perceive the ESMSC educational environment in a positive way. Junior students tend to have a more positive view on the same learning experience compared to final year students, which should raise a question whether more SBL surgical teaching should be provided at an earlier stage, to promote motivation and learning. UK students seem to be more positively inclined towards on this novel learning environment. No significant difference was reported between male and female students' views on this course environment. These points should be taken into consideration, whilst various Medical Schools are reforming their new undergraduate training curricula.

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Table I (D )REEM Questions 1-50 mean scores)

Question N Minimu m Maxi mum Mean Std. Deviation

1 83 .00 4.00 3.3855 .71280

2 83 2.00 4.00 3.4578 .61090

3 83 .00 4.00 2.7108 .86292

4 83 .00 4.00 2.5301 1.01618

5 83 1.00 4.00 2.7952 .61997

6 83 1.00 4.00 2.9518 .71403

7 83 1.00 4.00 3.1928 .75640

8 83 .00 4.00 3.0120 1.01806

9 83 .00 4.00 2.6988 1.04456

10 83 1.00 4.00 3.2289 .70409

11 83 1.00 4.00 3.2169 .68161

12 83 .00 4.00 2.5060 1.11938

13 83 1.00 4.00 2.6265 .86547

14 83 .00 4.00 2.4458 1.20216

15 83 .00 4.00 3.2892 .83418

16 83 .00 4.00 3.1446 .78294

17 83 .00 4.00 2.9759 .99971

18 83 .00 4.00 3.0602 .75465

19 83 .00 4.00 3.2892 .84867

20 83 2.00 4.00 3.3133 .53937

21 83 .00 4.00 2.7349 .91177

22 83 1.00 4.00 2.9880 .86241

23 83 1.00 4.00 3.2530 .62163

24 83 1.00 4.00 2.9518 .88212

25 83 .00 4.00 1.7590 1.03111

26 83 1.00 4.00 2.7590 .79003

27 83 .00 4.00 2.3253 .97666

28 83 .00 4.00 2.3012 1.28533

29 83 .00 4.00 2.8193 .79854

30 83 1.00 4.00 3.0120 .75698

31 83 1.00 4.00 2.5904 .91113

32 83 .00 4.00 2.6747 .95136

33 83 1.00 4.00 3.2771 .61114

34 83 1.00 4.00 3.2530 .55969

35 83 .00 4.00 C CE 3.2892 M .89074

36 83 .00 4.00 2.7711 .68655

37 83 1.00 4.00 3.1084 .58460

38 83 1.00 4.00 3.0723 .71197

39 83 1.00 4.00 3.4699 .73811

40 83 1.00 4.00 3.3253 .58661

41 83 .00 4.00 2.7831 .91129

42 83 .00 4.00 3.1446 .76720

43 83 1.00 4.00 3.1807 .66524

44 83 1.00 4.00 3.2651 .64552

45 83 1.00 4.00 3.3253 .66458

46 83 .00 4.00 3.1807 .88545

47 83 1.00 4.00 2.7229 .88777

48 83 .00 4.00 2.7108 .89074

49 83 .00 4.00 3.3133 .67945

50 83 .00 4.00 2.8554 .98936

Total Score 83 99.00 196.00 148.04 17.90

Table I - Mean Scores for each Question (1-50), overall score

5 Sub-scale M ean Scores

Table II N Minim um Maxi mum Mean Std. Deviation

Registrar's 83 23.00 48.00 34.8795 5.00584

Perception of

Learning

Registrars' 83 21.00 44.00 33.8916 4.70343

Perception of

Course

organisers

Registrars' 83 13.00 32.00 23.1566 3.59363

Academic Self

Perception

Registrars' 83 17.00 47.00 36.7349 4.92649

Perceptions of

Atmosphere

Registrars' 83 12.00 27.00 19.2771 2.94798

Social Self

Perceptions

iauic ii — iviccui o^uics iui Eat 11 oui

Table III. Comparison between Year 3-4 vs. Year 5-6

P Mean Std. Std. Error

value Deviation Mean

DREEM Senior 0.114 145.3333 16.71963 2.41327

Overall Score Junior 151.7714 19.01715 3.21449

Registrars' Senior 0.017 33.7500 4.70174 .67864

Perception of Junior 36.4286 5.06014 .85532

Learning

Registrars' Senior 0.260 33.3750 4.25578 .61427

Perception of Junior 34.6000 5.23675 .88517

Course

organizers

Registrars' Senior 0.287 22.7917 3.47611 .50173

Academic Self Junior 23.6571 3.74121 .63238

Perception

Registrars' Senior 0.585 36.4792 4.87281 .70333

Perceptions of Junior 37.0857 5.04900 .85344

Atmosphere

Registrars' Senior 0.303 18.9792 2.61330 .37720

Social Self Junior 19.6857 3.34990 .56624

Perceptions

Table III. Comparison between Year 3-4 vs. Year 5-6

Table IV : Year 3-6 Mean Overall and Subscale Scores N Mean Std. Deviation Std. Error 95% Confidence Interval for Mean

Lower Bound Upper Bound Minimum Maximu m

DREEM Overall Score Year 3 21 152.7143 22.22418 4.84971 142.5980 162.8306 119.00 196.00

Year 4 14 150.3571 13.50560 3.60952 142.5592 158.1550 134.00 173.00

Year 5 29 145.8276 20.21504 3.75384 138.1382 153.5170 99.00 187.00

Year 6 19 144.5789 9.65698 A 2.21546 139.9244 149.2335 124.00 164.00

P value 0.345 148.0482 17.90006 1.96479 144.1396 151.9568 99.00 196.00

Registrars' Year 3 21 36.8571 5.34121 1.16555 34.4259 39.2884 29.00 48.00

Perception Year 4 14 35.7857 4.72601 1.26308 33.0570 38.5144 28.00 46.00

of Learning Year 5 29 34.2759 5.05609 .93889 32.3526 36.1991 24.00 47.00

Year 6 19 32.9474 4.10249 .94118 30.9700 34.9247 23.00 42.00

P value 0.069 34.8795 5.00584 .54946 33.7865 35.9726 23.00 48.00

Registrars' Year 3 21 33.9524 5.80927 1.26769 31.3080 36.5967 22.00 44.00

Perception Year 4 14 35.5714 4.25557 1.13735 33.1143 38.0285 26.00 43.00

of Course Year 5 29 33.7241 5.16096 .95837 31.7610 35.6873 21.00 43.00

organizers Year 6 19 32.8421 2.31572 .53126 31.7260 33.9582 27.00 36.00

P value 0.201 33.8916 4.70343 .51627 32.8645 34.9186 21.00 44.00

Registrars' Year 3 21 24.0952 3.94848 .86163 22.2979 25.8926 18.00 32.00

Academic Year 4 14 23.0000 3.44182 .91987 21.0127 24.9873 15.00 27.00

Self Year 5 29 22.8621 3.66181 .67998 21.4692 24.2549 13.00 30.00

Perception Year 6 19 22.6842 3.26688 .74947 21.1096 24.2588 16.00 31.00

P value 0.584 23.1566 3.59363 .39445 22.3719 23.9413 13.00 32.00

Registrars' Year 3 21 37.0000 5.51362 1.20317 34.4902 39.5098 ^ 28.00 46.00

Perception Year 4 14 37.2143 4.45798 1.19145 34.6403 39.7882 30.00 46.00

s of Year 5 29 36.4828 5.94991 1.10487 34.2195 38.7460 17.00 47.00

Atmospher Year 6 19 36.4737 2.63246 .60393 35.2049 37.7425 33.00 43.00

e P value 0.939 36.7349 4.92649 .54075 35.6592 37.8107 17.00 47.00

Registrars' Year 3 21 20.0952 3.49149 .76190 18.5059 21.6845 15.00 27.00

Social Self Year 4 14 19.0714 3.14922 .84166 17.2531 20.8897 14.00 24.00

Perception Year 5 29 18.8966 2.82014 .52369 17.8238 19.9693 12.00 27.00

s Year 6 19 19.1053 2.33083 .53473 17.9818 20.2287 16.00 24.00

P value 0.533 19.2771 2.94798 .32358 18.6334 19.9208 12.00 27.00

Table IV. ANOVA analysis - Year 3-6 Mean Overall and Subscale Scores

Table V KCL vs. Greek Students

KCL vs. Greek Medical School P value Mean Std. Deviation Std. Error Mean

DREEM International 0.061 155.190 20.36816 4.44470

Overall Score EPTE 5

Greek 145.629 0 16.46779 2.09141

Registrars' Perception of Learning International 0.003 37.9048 5.04881 1.10174

Greek 33.8548 4.59453 .58351

Registrars' Perception of Course organizers International 0.326 34.9048 5.69126 1.24194

Greek 33.5484 4.31800 .54839

Registrars' Academic Self Perception International 0.151 24.1905 3.80288 .82986

Greek 22.8065 3.48222 .44224

Registrars' Perceptions of Atmosphere International 0.185 38.0000 4.98999 1.08891

Greek 36.3065 4.87075 .61859

Registrars' Social Self Perceptions International 0.055 20.4286 3.15549 .68859

Greek 18.8871 2.79405 .35484

Table V - KCL vs. Greek Students DREEM mean scores

N Mean Std. Deviation Std. Error 95% Confidence Interval for Mean

Lower Bound Upper Bound Minimu m Maximum

DREEM Overall Score KCL 21 155.1905 20.36816 4.44470 145.9190 164.4620 119.00 196.00

Athens 15 147.4000 17.16641 4.43235 137.8936 156.9064 118.00 180.00

Herakleion 5 116.8000 19.54994 8.74300 92.5255 141.0745 99.00 145.00

loannina 3 148.0000 13.52775 7.81025 114.3952 181.6048 134.00 161.00

Larisa 7 146.2857 13.11125 4.95559 134.1598 158.4116 133.00 172.00

Patra 9 150.4444 11.53377 3.84459 141.5788 159.3101 132.00 173.00

Thessaloniki 20 150.3000 12.79432 2.86090 144.3121 156.2879 134.00 187.00

Alexandroupoli 3 135.3333 8.08290 4.66667 115.2543 155.4124 128.00 144.00

P value 0.002 148.0482 17.90006 1.96479 144.1396 151.9568 99.00 196.00

Registra rs' Percepti on of Learnin g KCL 21 37.9048 5.04881 1.10174 35.6066 40.2030 31.00 48.00

Athens 15 33.6000 5.75450 1.48581 30.4133 36.7867 23.00 42.00

Herakleion 5 29.2000 3.42053 1.52971 24.9529 33.4471 26.00 35.00

loannina 3 35.6667 4.72582 2.72845 23.9271 47.4062 32.00 41.00

Larisa 7 33.8571 3.43650 1.29887 30.6789 37.0354 30.00 39.00

Patra 9 34.4444 3.67801 1.22600 31.6173 37.2716 28.00 40.00

Thessaloniki 20 34.9500 4.48946 1.00387 32.8489 37.0511 28.00 47.00

Alexandroupoli 3 32.0000 2.64575 1.52753 25.4276 38.5724 29.00 34.00

P value 0.015 34.8795 5.00584 .54946 33.7865 35.9726 23.00 48.00

Registra rs' Percepti on of Course organiz ers KCL 21 34.9048 5.69126 1.24194 32.3141 37.4954 22.00 44.00

Athens 15 33.2667 4.38287 1.13165 30.8395 35.6938 24.00 41.00

Herakleion 5 27.4000 5.94138 2.65707 20.0228 34.7772 21.00 35.00

loannina 3 35.3333 4.61880 2.66667 23.8596 46.8071 30.00 38.00

Larisa 7 33.8571 4.77593 1.80513 29.4401 38.2741 29.00 43.00

Patra 9 33.8889 3.14024 1.04675 31.4751 36.3027 30.00 40.00

Thessaloniki 20 35.0000 3.38728 .75742 33.4147 36.5853 26.00 43.00

Alexandroupoli 3 32.0000 .00000 .00000 32.0000 32.0000 32.00 32.00

P value 0.073 33.8916 4.70343 .51627 32.8645 34.9186 21.00 44.00

Registra rs' Academ ic Self Percepti on KCL 21 24.1905 3.80288 .82986 22.4594 25.9215 18.00 32.00

Athens 15 23.8000 3.89505 1.00570 21.6430 25.9570 16.00 31.00

Herakleion 5 17.6000 3.43511 1.53623 13.3347 21.8653 13.00 21.00

loannina 3 23.6667 j 2.08167 1.20185 18.4955 28.8378 22.00 26.00

Larisa 7 23.5714 2.43975 .92214 21.3150 25.8278 21.00 27.00

Patra 9 23.7778 2.48886 .82962 21.8647 25.6909 20.00 27.00

Thessaloniki 20 23.2000 2.64774 .59205 21.9608 24.4392 18.00 30.00

Alexandroupoli 3 18.3333 P 3.51188 2.02759 S 9.6093 27.0573 15.00 22.00

P value 0.003 23.1566 3.59363 .39445 22.3719 23.9413 13.00 32.00

Registra KCL 21 38.0000 4.98999 1.08891 35.7286 40.2714 28.00 46.00

rs' Athens 15 37.6667 4.79086 1.23700 35.0136 40.3198 29.00 46.00

Percepti Herakleion 5 27.4000 6.22896 2.78568 19.6657 35.1343 17.00 33.00

ons of loannina 3 38.0000 3.60555 2.08167 29.0433 46.9567 34.00 41.00

Atmosp Larisa 7 34.0000 3.21455 1.21499 31.0270 36.9730 31.00 40.00

here Patra 9 37.2222 3.89801 1.29934 34.2260 40.2185 30.00 43.00

Thessaloniki 20 37.7000 3.38884 .75777 36.1140 39.2860 33.00 47.00

Alexandroupoli 3 36.0000 3.60555 2.08167 27.0433 44.9567 32.00 39.00

P value 0.001 36.7349 4.92649 .54075 35.6592 37.8107 17.00 47.00

Registra KCL 21 20.4286 3.15549 .68859 18.9922 21.8649 15.00 27.00

rs' Athens 15 18.5333 2.82506 .72943 16.9689 20.0978 14.00 24.00

Social Herakleion 5 15.8000 3.03315 1.35647 12.0338 19.5662 12.00 20.00

Self loannina 3 17.0000 2.00000 1.15470 12.0317 21.9683 15.00 19.00

Percepti Larisa 7 20.0000 2.30940 .87287 17.8642 22.1358 17.00 24.00

ons Patra 9 20.7778 2.99073 .99691 18.4789 23.0767 17.00 27.00

Thessaloniki 20 19.0000 2.44949 .54772 17.8536 20.1464 14.00 24.00

Alexandroupoli 3 18.6667 .57735 .33333 17.2324 20.1009 18.00 19.00

P value 0.019 19.2771 2.94798 .32358 18.6334 19.9208 12.00 27.00

Table VI - ANOVA Analysis of mean scores across various Universities

University

■ KCL

■ Athens

□ Herakleion

■ loannina

□ Larisa

■ Patra

■Thessaloniki □Alexandroupoli

May 2015

Graph I

- Demographics of Sample used

Mean of Registrars' Perceptions of Atmosphere

Mean of Registrars' Social Self Perceptions

Graph II. Comparison of the mean Scores of DREEM inventory based on Year of Studies

Highlights

o ESMSC is an International Surgical Science and Wet Lab course aimed at undergraduates

o Students seem to positively rate the ESMSC educational environment

o Year 3/4 Students have a significantly positive "Perception of Learning", when compared to Year 5/6

o KCL Students gave a more feedback on the course compared to their Greek counterparts

o Further research should focus on involving and motivating students early in BST