Immersive medium for early clinical exposure - knowledge acquisition, spatial orientation and the unexpected role of annotation in 360° VR photos.

Aim: 360° VR photos could be a low-threshold possibility to increase early clinical exposure. Apart from granting insights into local routines and premises, the medium should facilitate knowledge acquisition and spatial orientation depending on its design. This assumption, however, is not yet substantiated empirically. Thus, three hypotheses were tested in consideration of Mayer's modality principle: 1) Providing 360° VR photos as visual reference improves retention and comprehension of information. 2) The annotation of text boxes in 360° VR photos compromises spatial orientation and presence. 3) Annotated audio commentary is superior to annotated text boxes in terms of cognitive load and knowledge acquisition. Methods: Using head-mounted displays, students of human (N=53) and dental medicine (N=8) completed one of three virtual tours through a surgical unit, which were created with 360° VR photos. In the first two variants, information about the facilities, medical devices and clinical procedures was annotated either as text boxes or audio commentary comprising 67 words on average (SD=6.67). In the third variant, the same information was given separately on a printed handout before the virtual tour. Taking user experience and individual learner characteristics into account, differences between conditions were measured regarding retention, comprehension, spatial orientation, cognitive load, and presence. Results: Concerning retention and comprehension of information, annotated text boxes outperformed annotated audio commentary and the handout condition. Although annotated audio commentary exhibited the lowest knowledge test scores, students preferred listening over reading. Students with an interest in VR and 360° media reported higher levels of enjoyment and presence. Regarding spatial orientation and presence, no significant group differences were found. Conclusions: 360° VR photos can convey information and a sense of spatial orientation effectively in the same learning scenario. For students, their use is both enjoyable and instructive. Unexpectedly, the ideal mode of annotation is not dictated by Mayer's modality principle. For information like in this study, annotated text boxes are better for knowledge acquisition than the subjectively preferred audio commentary. This finding is probably contingent on the length and the quality of the annotated text. To identify boundary conditions and to validate the findings, more research is required on the design and educational use of 360° VR photos.

Visions and reality: the idea of competence-oriented assessment for German medical students is not yet realised in licensing examinations.

Objective: Competence orientation, often based on the CanMEDS model, has become an important goal for modern curricula in medical education. The National Competence Based Catalogue of Learning Objectives for Undergraduate Medical Education (NKLM) has been adopted in Germany. However, it is currently unknown whether the vision of competence orientation has also reached the licensing examination procedures. Methods: Therefore, a prospective, descriptive, single-centre, exemplary study design was applied to evaluate 4051 questions/tasks (from 28 examiners at 7 two-day licensing oral-practical exams) for undergraduate medical students at the University of Ulm. The oral and practical questions/tasks as well as the real bedside assessment were assigned to specific competence roles (NKLM section I), categories (NKLM section II) and taxonomy levels of learning domains. Results: Numerous questions/tasks were set per candidate (day 1/2: 70±24/86±19 questions) in the licensing oral-practical exam. Competence roles beyond the "medical expert" were scarcely considered. Furthermore, practical and communication skills at the bedside were hardly addressed (less than 3/15 min). Strikingly, there was a significant predominance of questions with a low-level taxonomy. Conclusions: The data indicate a misalignment of competence-oriented frameworks and the "real world" licensing practical-oral medical exam, which needs improvement in both evaluation and education processes.

First successful transcatheter double valve replacement from a transapical access and nine-month follow-up.

AIMS: While TAVI is the treatment of choice in patients with aortic stenosis considered inoperable or at high risk, interventional replacement of the mitral valve is still in the preclinical or early clinical phase. Our aim was to report on the first transcatheter double valve replacement into native valves from a transapical access. METHODS AND RESULTS: A 67-year-old, highly symptomatic female patient considered inoperable due to severe calcification of the mitral annulus and comorbidities was scheduled for transcatheter double valve replacement by the local Heart Team. Preoperative planning was carried out by multiplanar reconstruction from cardiac CT. Through a transapical access, the mitral valve was replaced first by an inverted 29 mm Edwards SAPIEN 3 prosthesis, then the aortic valve by a 23 mm SAPIEN 3, both during rapid pacing. Both prostheses revealed excellent function in angiography and echocardiography. The patient was extubated early after surgery and transferred to the normal ward the following day. After five months, she exhibited signs of cardiac failure again. Migration of the mitral prosthesis was detected, and the mitral valve was replaced surgically. CONCLUSIONS: Transcatheter double valve replacement can be performed through a transapical access. The key to success is thorough preoperative planning based on CT, not only for sizing, but also for estimating the anatomical relationship of the prostheses. However, late migration can be expected and may lead to LVOT obstruction.

The impact of a dedicated training program for oral examiners at a medical school in Germany: a survey among participants from operative and non-operative disciplines.

BACKGROUND: Oral examinations have been a crucial format in ancient and modern assessment to evaluate and guarantee quality of medical education and thereby to secure patient safety. To achieve a high level of quality in the oral part of the final examination of medical students, a training program for oral examiners at the Medical Faculty of Ulm (Germany) has been established since 2007.However, little is known about the attitude of the examiners in regard to the impact of this training program and of oral examinations as instruments to ensure patient safety. METHODS: All 367 academic clinicians from operative and non-operative disciplines, attending the one-day examiner training program at the University of Ulm between 2007 and 2012 have been asked to answer an online survey (EvaSys 5.0). Focus of the survey was to find out in which respect the examiners profited from the trainings, if the training effects were discipline-dependent, and to which degree the oral examinations could contribute to patient safety. Statistical analysis was performed using the t-test for independent samples. Results were considered statistically significant when p < 0.05. RESULTS: A total of 63 participants answered the survey, but in 4 cases the questionnaire was not fully completed (with single items missing). More than half of the study participants (n = 34/59; 58%) have experienced (at least sometimes or rarely) candidates that they deemed incompetent and perhaps even dangerous to the patients' health who nevertheless passed the oral exam successfully. The majority of participants were convinced that oral examinations using concrete clinical cases could significantly contribute to patient safety, if grading is based on clear criteria and if examinations as well as grading are performed more critically. The impact of the training program was rated significantly stronger by surgeons than by non-surgeons in several categories. These categories included "strengths and weaknesses of oral examinations", "reliability", "validity", "competence in grading", "critical grading", and "departmental improvements" concerning oral examinations. CONCLUSIONS: In respect to patient safety, it seems crucial to prevent incompetent candidates from passing the oral examination. The present study indicates the importance to continue and to develop our examiner trainings, with main emphasis on concrete clinical problems and a criteria-based critical grading system for oral examinations. Since the impact of the training was particularly high for colleagues from the operative disciplines, the training program should be offered especially in surgical departments.

Comparative evaluation of multimedia driven, interactive, and case-based teaching in heart surgery.

BACKGROUND: Multimedia-augmented instruction with various approaches is used in heart surgery. There is little evidence which instructional techniques and media are of advantage to impart knowledge more effectively and lead to better application of knowledge in the operation room. METHODS: Sixty-nine students learned with an interactive, case-based teaching (ICBT) course about aortic valve replacement. They were compared with historic controls exposed to identical information provided by a multimedia module presenting content systematically (SMM; n = 69) and a print medium (PM; n = 57). Motivation, computer knowledge, and didactic quality were evaluated with psychometric tests. All groups performed multiple choice pretests and posttests and participated in live surgery during which their performance was assessed. RESULTS: All groups had equal computer knowledge, but the ICBT group felt significantly less-motivated and more challenged. Multiple choice posttest results were comparable (ICBT 80.2% +/- 10.9%, SMM 76.7% +/- 13.3%, PM 76.9% +/- 11.1). During surgery, the ICBT (79.2% +/- 16%) and SMM groups (82.9% +/- 10%) performed significantly better than the PM group (64.7% +/- 12%; both p < 0.0001). Overall didactic assessment was significantly worse in the ICBT group when compared with the SMM and PM groups. CONCLUSIONS: For novices in heart surgery, ICBT was less motivating than traditionally structured content (SMM and PM). The ICBT did not improve performance in the operation room. However, both multimedia groups could better apply their knowledge during live surgery. The PM is as effective as multimedia when factual knowledge has to be retained.