Introduction
Ear, Nose and Throat is a surgical specialty with an array of acute and chronic presentations, some of which are life-threatening. In the UK, a patient presenting with an ENT condition is usually first assessed and managed by a junior doctor,Reference Aryasomayajula, Raithatha, Haywood, Jobanputra, Roplekar and Acharya1 typically a foundation or a core surgical trainee doctor. Although these trainees are expected to act independently before senior support becomes available, many are unfamiliar with the necessary ENT practical skills prior to starting their rotation, having last experienced ENT at medical school. Furthermore, current literature suggests that ENT teaching in medical school is lacking.Reference Ferguson, Bacila and Swamy2,Reference Patel, Saeed and Smith3 Common practical skills of ENT are not adequately taught and/or assessed, leading to trainees feeling unprepared for the demands of an ENT senior house officer post.Reference Ferguson, Bacila and Swamy2
A potential way of addressing this knowledge gap is through simulation-based learning, defined as the emulation of real-life scenarios in artificial settings for education and training. Simulation-based medical training provides several advantages over experiential or ‘on the job’ learning. Firstly, it creates a safe environment for trainees to practise essential clinical skills without risking harm to real patients. Secondly, simulations allow facilitators to deliver practical, as opposed to didactic, teaching, and trainees can be observed and receive instant feedback. Finally, the sessions can be recorded, allowing replay and reflection. Many further benefits exist, allowing simulation-based training to be particularly suited for a skill-heavy specialty like ENT.
Simulation-based learning in ENT is already establishedReference Pankhania, Pelly, Bowyer, Shanmugathas and Wali4,Reference Evans and Owens5,Reference Sheehan, Green and Grimshaw6 ; however, most of these courses are only delivered to senior trainees,Reference Kelly, Cao, Ahmedli and Nassar7,Reference Hogg, Kinshuck, Littley, Lau, Tandon and Lancaster8,Reference Favier, Kimmoun, Gatin and Gallet9 with only a few documented to be aimed at junior doctorsReference Bhalla, Beegun, Awad and Tolley10 or medical students.Reference Frithioff, Frendø, von Buchwald, Trier Mikkelsen, Sølvsten Sørensen and Arild Wuyts Andersen11 Moreover, with the ENT simulation models described in the literature, there is little validation or demonstrated educational impact assessed.Reference Pankhania, Pelly, Bowyer, Shanmugathas and Wali4 Thus, this study aimed to provide ENT simulation-based training to foundation doctors and examine its efficacy and suitability as a preparation method for an ENT senior house officer post.
Materials and methods
Ethical approval was deemed to not be required by the National Health Service (NHS) research ethics committee tool, provided by the Medical Research Council.
Foundation doctors from the Health Education England East of England deanery, which incorporates the East Anglia and Essex, Bedfordshire and Hertfordshire foundation schools, were invited to an online sign-up for the ENT simulation course delivered as a hub day.
The course consisted of two portions. Firstly, there was an online component. Prior to in-person course attendance, participants watched a careers talk and didactic videos on the skills that would be practised during the simulation. Secondly, there was an in-person simulation course.
The ENT simulation course consisted of 5 stations, each lasting 30 minutes, as detailed in Table 1. They were staffed by core surgical trainees who have completed, or are currently doing, an ENT rotation.
Table 1. Simulation skills practised on the course and a synopsis on how they were run
Furthermore, online pre-course and post-course surveys were developed and sent to participants. The surveys established basic demographic data about participants and consisted of a 12-item questionnaire that included dichotomous, multiple choice and Likert scale questions with allowance for additional free text responses per question. Participants were asked to self-assess on a five-point Likert scale of agreeableness against specific questions relating to their confidence in performing key skills required of an ENT senior house officer, prior to and after attending the course. The surveys were delivered through Google® forms, which required participants to sign in to a Google account and prevented duplicate entries. Study participation was voluntary, and no identifying information, including e-mail addresses, was collected to maintain anonymity.
The Dundee Ready Educational Environment Measure,Reference Roff, Harden, Al-Qahtani, Ahmed and Deza12 a validated tool used in assessing the education environment of healthcare education programmes, was also provided to participants. Specifically, the perceptions of learning subscale of the questionnaire was provided to assess the overall effectiveness of the simulation format as a teaching modality. The scoring matrix for this tool is described in Tables 2 and 3.
Table 2. DREEM students’ perception of learning scores
DREEM = Dundee Ready Educational Environment Measure
Table 3. DREEM students’ perception of learning score interpretation
DREEM = Dundee Ready Educational Environment Measure
Statistics were performed using SPSS® statistical analysis software (version 28). The Wilcoxon signed rank test was used to compare median scores of participants before and after the course because of the non-parametric nature of our data.
Results
Demographic data
A total of 41 foundation doctors across the East of England foundation deaneries participated in our ENT hub day. Of these 41 doctors, 23 were foundation year 1, and 18 were foundation year 2 doctors. More than 50 per cent of participants (n = 21) were from Norfolk and Norwich University Hospitals NHS Foundation Trust, with the remainder from hospitals within the East of England region (Figure 1). A total of 87.8 per cent of participants (n = 36) graduated from medical schools within the UK, and 12.2 per cent (n = 5) graduated from international medical schools. Only one participant had undergone a four-month ENT job prior to the hub day. A total of 24.4 per cent of participants (n = 10) reported having an upcoming ENT foundation job. A total of 39.0 per cent of participants (n = 16) were in agreement that the ENT teaching they received at medical school prepared them for common ENT conditions they may encounter as a foundation doctor. A total of 14.6 per cent of participants (n = 6) reported coronavirus disease 2019 (Covid-19) affecting their experience of ENT, either during medical school or during their foundation programme, with less clinical time or shortened placements being given as the reason for this.
Fig. 1. Hospitals of participants’ current employment. Answers given in response to the question ‘What hospital do you currently work at?’
Previous exposure to simulation training
A total of 95.1 per cent of participants (n = 39) had been exposed to simulation methods in their medical training, and 14.6 per cent of participants (n = 6) reported having been exposed to ENT-specific simulation training. Furthermore, 95.1 per cent of participants (n = 39) agreed or strongly agreed that simulation within medical education was an effective teaching tool.
Effect of ENT simulation on participants’ self-ratings
Participants were asked to rate themselves on different core skills that would be taught in the ENT simulation course prior to and after attendance, using a Likert scale ranging from 1 (equivalent to strongly disagree) to 5 (equivalent to strongly agree). As seen in Table 4, statistically significant median scores increased for confidence in managing epistaxis (p < 0.001), confidence in utilising nasal packing (p < 0.001), confidence in draining peritonsillar abscesses (p < 0.001), confidence in removing foreign bodies from the ear (p < 0.001), confidence in managing the acutely unwell patient with a tracheostomy in situ (p < 0.001), confidence in managing the acutely unwell patient with a laryngectomy stoma in situ (p < 0.001) and confidence in performing fibre-optic nasendoscopy (p < 0.001). Median scores for confidence in managing the general acutely unwell patient remained the same; however, there was an improvement in range for these scores (p = 0.0025). Median scores of participants’ confidence (p < 0.001) and preparedness (p < 0.001) for work on day 1 as an ENT senior house officer also increased post simulation.
Table 4. Comparison of participants’ pre-course and post-course self-rating scores
Participants’ views on the ENT simulation format
A total of 100 per cent of participants (n = 41) agreed or strongly agreed that they enjoyed the format of the ENT simulation day, and 100 per cent of participants (n = 41) agreed or strongly agreed that they would recommend this course to their fellow colleagues. Furthermore, 100 per cent of participants preferred the simulation format over didactic-based teaching in this course (n = 41).
A total of 56.1 per cent of participants agreed or strongly agreed that attendance at the ENT simulation event had positively influenced their decision to pursue ENT as a career (n = 23). As seen in Figure 2, a Likert scale ranging from 1 (definitely will not pursue a career in ENT) to 10 (definitely will pursue a career in ENT) was provided to participants before and after the course to assess likelihood of pursuing ENT as a career. A non-significant increase in median scores for this was noted post-simulation (p = 0.54).
Fig. 2. Pre- and post-course likelihood of choosing ENT as a career. Answers given in response to the question ‘How likely are you to pursue ENT as a career?’
Validation scores
The median total score achieved for this course, using the Dundee Ready Educational Environment Measure (perceptions of learning) questionnaire, was 48. Maximum median scores of 4 were reported for all questions. A breakdown of scores for individual questions within the Dundee Ready Educational Environment Measure (perceptions of learning) questionnaire is shown in Table 5.
Table 5. Modified DREEM score (perception of learning) questions and ENT simulation course participants' ratings, with the DREEM scoring system interpretation
DREEM = Dundee Ready Educational Environment Measure
Discussion
ENT teaching for undergraduates and postgraduates
Undergraduate teaching of ENT in UK medical schools is scant. On average, medical students only experience 3.4 days of preclinical or didactic teaching and 5 days of clinical exposure in their ENT curriculum.Reference Powell, Cooles, Carrie and Paleri13 Shockingly, 51 per cent of students reported in one survey that they have examined less than 10 pairs of ears during medical school. Not much improvement is seen at the postgraduate level either, with only 21 per cent of general practitioners reportedly having formal ENT postgraduate training, and nationally, 91 per cent stating the need for increased ENT teaching at the postgraduate level.Reference Lennon, O'Donovan, O'Donoghue and Fenton14 These numbers underpin why junior doctors feel ill-equipped when starting an ENT post, which is observed within our cohort where only 39 per cent of foundation doctors reported that their medical school's ENT teaching prepared them adequately for the common ENT conditions encountered during their foundation programme.
This issue may have been exacerbated by the Covid-19 pandemic, when many institutions moved from in-person to virtual curricula learning.Reference Longhurst, Stone, Dulohery, Scully, Campbell and Smith15 A small proportion of our cohort, 14.6 per cent, reported their ENT teaching to be directly impacted by the pandemic. Moreover, the majority of UK medical students had their final examinations cancelled or altered because of the pandemic, especially their objective structured clinical examinations.Reference Ferrel and Ryan16 Thus, not only have students lost out on time to learn ENT practical skills, many also lost the opportunity for their skills to be assessed under standardised examinations.
Benefits of an ENT simulation course for trainees
Although remote learning has increased, 76 per cent of students nationally have reported that online learning cannot replace clinical teaching involving patient contact.Reference Dost, Hossain, Shehab, Abdelwahed and Al-Nusair17 In order to ensure trainees achieve competency in the necessary clinical skills, simulation-based training can be an effective teaching supplement,Reference Mohd Slim, Hurley, Lechner, Milner and Okhovat18 as evidenced by data from our study. Simulation-based ‘bootcamp’ courses for ENT are already being trialled in the UK, USA and Canada for inducting senior ENT trainees.Reference Malekzadeh, Malloy, Chu, Tompkins, Battista and Deutsch19 However, within current literature, our ENT simulation course appears to have hosted the largest cohort and is also the first one documented as being addressed towards foundation doctors in the UK.
A smaller pilot bootcamp course, covering advanced life support type scenarios for patients presenting with ENT life-threatening emergencies, was run for 18 junior doctors within the East of England deanery in the UK in 2016.Reference Smith, Trinidade and Tysome20 Their course design was different to ours, consisting of a mixture of in-person focused lectures, emergency scenario simulations and practical skills training. However, despite this difference, our findings similarly replicate those obtained from their course, with 100 per cent of participants from both courses feeling strongly confident after the course in performing all ENT examinations and dealing with emergencies.Reference Smith, Trinidade and Tysome20 The Dundee Ready Educational Environment Measure median score of 4 for an increase in confidence also corresponds well with this.
Beyond the skills themselves, our cohort experienced an increase in self-reported scores for confidence and preparedness for starting on day 1 as an ENT senior house officer after course attendance. Reassuringly, it has been demonstrated that trainees are likely to retain the knowledge they have learned from simulation for as long as six months.Reference Bhalla, Beegun, Awad and Tolley10,Reference Swords, Smith, Wasson, Qayyum and Tysome21 Simulation can help trainees remain confident and fulfilled in their work and maintain a high standard of care that ensures patient safety. Moreover, in the UK, specialist senior support is unlikely to be immediately available on site out of hours; thus, it is crucial that these doctors can initiate independent assessment and management of patients throughout their ENT rotation.
Along with its effectiveness, simulation-based training can be a fun teaching modality that attracts trainee engagement. Our participants enjoyed the practical aspect of simulation, with 100 per cent of participants preferring this portion of the course over the pre-course didactic method, and they are likely to recommend it to colleagues. These responses provide further evidence that simulation-based teaching is a suitable method of providing foundation doctors with the ENT teaching that they are keen to undertake.
Benefits of an ENT simulation course for the department
Foundation doctors in the UK typically rotate through job positions every four months, which can cause a lack of care continuity and disruption to the service provision of the department.Reference Dave, Mobarak, Spiers, Tarazi and Jamdar22 The literature suggests that changeover of junior doctors, especially at the year-end, can result in increased mortality and decreased efficiency of service provision, although a definite degree of risk is difficult to ascertain because of the heterogeneity present within existing data.Reference Young, Ranji, Wachter, Lee, Niehaus and Auerbach23 The ENT bootcamps could be a time- and cost-effective way to improve knowledge adherence and confidence, thus mitigating disruptions from the frequent changeovers. Our simulation course, although labour intensive to set up, could be run routinely, with small changes dependent on feedback from previous cohorts.
• ENT is poorly taught in medical undergraduate and postgraduate curricula
• Simulation training in ENT has become popular but is currently only provided for doctors at a more senior level
• This study is the largest and the first documented simulation centred towards foundation doctors in ENT
• Results demonstrate that simulation is effective and suitable in improving the skills, confidence and immediate preparedness of foundation doctors
• In order to provide a more tailored learning experience, overseeing bodies should provide standardised guidance on ENT learning outcomes for this cohort
Although non-significant, a slight increase in median scores in likelihood of pursuing ENT as a career was noted from our participants after attendance. Evidence suggests that exposure to the specialty,Reference Bhutta, Mandavia, Syed, Qureshi, Hettige and Wong24 as well as having role models within the field,Reference Lock and Carrieri25 is key to retaining and inspiring foundation doctors to be the next generation of ENT surgeons. Considering the junior doctor staff retention crisis that the NHS has been experiencing in recent years,Reference Lock and Carrieri25 simulation could be one pertinent solution.
Improving ENT simulation courses for future cohorts
Currently, foundation doctors do not have established learning outcomes to achieve during their ENT rotation. The Intercollegiate Surgical Curriculum for Core Surgical Training, released by the Joint Committee on Surgical Training, has specific ENT competencies that are expected of core surgical trainees,26 a training grade under the scope of a senior house officer but a grade senior than a foundation doctor. Given that both foundation year 2 and core surgical trainees are likely to be on the same ENT on-call rota, we modelled our stations on the Joint Committee on Surgical Training ENT competencies that core surgical trainees should achieve.
In the literature, the ENT simulation courses addressed to junior doctors have a varied curriculum, possibly because of a lack of specific recommendations from larger training boards. Having more specific guidance in the UK Foundation Programme Curriculum or from specialty related societies, such as the Student and Foundation Doctors in Otolaryngology (a branch of ENT UK), can provide standardisation in the skills taught to foundation doctors.
Furthermore, although our teaching during the simulation was highly regarded (Dundee Ready Educational Environment Measure total median score of 48), there was a slightly wider discrepancy over whether long-term learning was emphasised over short-term learning on this course. Jiang et al. found that maximum learning from simulation was saturated after four sessionsReference Jiang, Chen, Wang, Zhou, Li and Chen27; thus, to improve our participants’ long-term retention, further repeat courses of up to four sessions, or adjusting the simulations to provide a greater emphasis on real-world application of skills, can be considered.
Limitations
The authors acknowledge that the study's sample size may result in findings that are not generalisable to views of all UK foundation doctors. Furthermore, although evidence in literature suggests that medical simulation training is generally beneficial, the authors acknowledge that the usefulness of assessing the long-term knowledge and skill retention of participants attending such a course is not fully established. Similarly, the association between exposure to a specialty during foundation years and the likelihood of pursuing that specialty in the future is also not fully clear.
Acknowledgements
The authors wish to thank the 41 foundation doctors in the East of England foundation schools who participated in our simulation course.
Competing interests
None declared
