Endoscopy simulation for pre-clerkship students

Implication Statement Here we report a simulation session carried out with pre-clerkship medical students during their gastroenterology block. We used endoscopy simulator to cement the clinical and anatomic implications of endoscopy and to build interest in gastroenterology. Students thought the session was helpful for their interest and understanding. Endoscopy simulation provided for pre-clinical students is an enjoyable adjunct to gastroenterology learning.


Implication Statement
Here we report a simulation session carried out with pre-clerkship medical students during their gastroenterology block. We used endoscopy simulator to cement the clinical and anatomic implications of endoscopy and to build interest in gastroenterology. Students thought the session was helpful for their interest and understanding. Endoscopy simulation provided for pre-clinical students is an enjoyable adjunct to gastroenterology learning.

Background
Medical simulations help trainees develop practical knowledge and skills. 1,2 A previous study demonstrated that endoscopic simulation is useful for third year clerks during their gastroenterology rotation. 2 Endoscopy simulation can also be used for testing 3 and training visuospatial tasks. We found no studies assessing virtual reality simulators with preclinical students. We ran an endoscopy simulation session with pre-clinical students in order to assess student satisfaction. e142

Methods
We conducted a prospective observational study using qualitative methodology to evaluate an endoscopy simulation session for pre-clinical medical students. We sent invitations to the Oncology Club at the University of Alberta, consisting of 142 preclerkship medical students.
We used the CAE Healthcare EndoVR simulator. It consists of a computer module with openings simulating the oral and anal orifices, a screen displaying the VR environment, and a console. We used cases of peptic ulcer disease and chemotherapyrelated esophagitis.
We held a one-hour session facilitated by a pediatric gastroenterologist and gastrointestinal (GI) fellow. After a 15-minute orientation, students performed a supervised simulation with the goal of assessing endoscopic anatomy, reaching the duodenum, and providing a diagnosis. Post-simulation, the authors discussed the case and potential complications with the participants. Students completed a 5-point Likert scale (1-strongly disagree, 2-disagree, 3-neutral, 4agree, 5-strongly agree) evaluation and provided comments. Data are reported as medians with interquartile ranges.

Results
We invited 142 pre-clinical medical students, 86 in second-year and 56 in first-year. Twenty-five students initially responded (17.6%), twenty-two in secondyear and three in first-year. We confirmed attendance one week before the session. Nine second-year students (40.9% of respondents) and one first-year student (33% of respondents) confirmed attendance (n=10).
Evaluations are summarized in Table 1. Cronbach's alpha was calculated using SPSS (a=0.969), and indicated high internal validity. Written comments indicated that students found the session enjoyable and useful. Students requested GI bleed and diarrhea simulations in the future.

Discussion
Medical education employs various simulation-based techniques including virtual patient softwares 4,5 and high-fidelity simulations. 1-3 Endoscopy simulation is typically reserved for residents and fellows. 3 Previous work documents experience with medical students in their clerkship years. 2 While medical students will not have the opportunity to translate endoscopic skills until a later stage of training, hands-on learning and understanding of the process of endoscopy proved to be a valuable experience. Teaching anatomy in an applied manner helps trainees contextualize basic science knowledge 6 At the University of Alberta, gastroenterology is a preclinical block with endoscopy shadowing available. Students shadow endoscopy to visually understand gastroenterology. Students at this session commented that it was a good adjunct to shadowing.
Future sessions may integrate interactive patient simulation into the session as suggested previously 4 . Advances in simulation of clinical experience using natural language interaction may enhance this. 5 We were limited by the small sample size, qualitative data, and sampling bias as the session was voluntary.

Conclusion
Our small pre-clinical student cohort found endoscopy simulation to be an enjoyable and useful adjunct to their gastroenterology block.
Ethics Approval: Ethics approval was sought from the local human research ethics board (HREB) through the University of Alberta Research Ethics Office (REO). Need for ethics approval was waived. Email consent to participate was acquired from all participants.
Contribution: ARP assisted with design of the study and educational session, collected and analyzed data and wrote the manuscript. LKV assisted with design of the session and acted as a preceptor to the session. RP finalized design of the study and the session, and critically reviewed the manuscript and data. All authors read and approved the final manuscript.
Conflicts of interest: The authors declare that we have no competing interests.