In are advised to practice their suturing and

In a small animal practice, routine
procedures include ovariohysterectomies (spays) and castrations1.

The students at the Royal Veterinary College (RVC) can either receive surgical
training while visiting practices during extra mural studies (EMS) or during
scheduled school rotations2. Unfortunately, it is difficult to
standardize the teaching and amount of surgical cases that each student
receives. The Royal College of Veterinary Surgeons (RCVS) requires at
graduation that students can competently apply principles of aseptic surgery,
but the organization does not have a minimum requirement for surgical
procedures performed3.

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At the RVC, students receive most
of their small animal spay and neuter surgical practice during their shelter
medicine rotation. Students are allotted between 10-20 minutes of feline spay
surgical time, starting from the time of first incision. Each student receives
one-to-one direct surgical supervision by the attending veterinarian. When
students are not performing surgery, they have the option to alternate between
monitoring anaesthesia or taking care of post-operative patients4.

Students also have the opportunity to practice a few days at the Beaumont
Sainsbury Animal Hospital (BSAH) where they also receive one-to-one direct
supervision for surgery. BSAH allows students the opportunity not only to spay
and neuter cats, but also the opportunity to spay and neuter dogs. Students are
allotted more time depending on the type of surgery that is performed; for
example, canine ovariohysterectomy surgeries receive more time compared to a
feline neuter5. Students are advised to practice their suturing and
surgical skills in the live Clinical Skills Centre (CSC) prior to and during the
shelter medicine rotation, as the availability of animals are limited, and the
amount of exposure and practice that students receive throughout their training
can vary4-5.

 

Though Ohio State University is not
a UK school, they have also recently reviewed their surgical teaching
techniques. A study in 2007 was primarily motivated by the lack of resources
available, as increased public concern over the use of live animals further
restricted their use. The revised program included exposing student to surgical
training from year one, which included basic instrument handling and
dissection. Second year students learned gowning and aseptic technique as well
as suturing. In third year models and cadavers were used to practice different
surgical procedures, and in final year students were able to perform multiple
live animal procedures at a local shelter11. This is a new
implementation, and it is currently unknown if the change in the surgical
training course has improved student success.

 

RVC students are required to
complete 26 weeks of EMS placements, which gives the students freedom to pursue
their own personal subjects of interest2. A 2011 study interviewed
final year and recent graduate students on their opinion of transitioning into
veterinary practice and how they viewed EMS opportunities. One individual said “….it
utterly depends on how much they let you do on EMS, which is really hit and
miss6.” Another
individual was quoted saying the following: “some people that had done
absolutely no surgery and some people that had done a fair amount, because
they’d gone back routinely to the same placement and got a relationship with
them and been allowed to do more than they would have otherwise6.

” Although RVC tries
to structure rotations so students receive the same training as much as
possible, it is difficult to control how much or how little students are taught
during EMS placements.

 

A 2012 study investigated 155
fourth year veterinary students about their emotions towards their upcoming
first live animal surgery in a week. 63% of students felt negative emotions and
58% felt positive emotions towards the procedure. Interviews were taken of 26
students after participating in a live animal surgery. All of the students
interviewed reported that negative feelings were primarily associated with a
lack of confidence, whereas positive feelings were primarily associated with
the confidence of being well prepared. The students’ preparation included
literature studies, online preparation, surgical skills and cadaver labs. Twenty
five out of twenty-six students reported that nervousness, anxiety, and other
negative emotions were detrimental to their learning and performing, but that a
positive and psychologically safe environment enhanced their ability to focus
and learn35. These results clearly underscore the significance of
ensuring ample teaching opportunities such that students can feel well-prepared
and confident in their future surgical undertakings.

 

A questionnaire was sent to recent
graduates that attended Murdoch University, which established that 97% of the
respondents performed a feline spay soon after graduation without supervision.

Of those respondents, only 41% had the opportunity to perform feline spay during
rotations, and 49% were able to perform a supervised procedure during EMS7.

Another study surveyed and interviewed recent graduates about the how much
support they received and their perception of their first few years in
practice.  The results revealed that 43%of
graduates felt like surgery posed difficulties because they had a lack of
experience executing routine operations. During an interview, one of the
graduates stated, “If we had been
competent in common surgical procedures when we graduated then the first few
months would not have been as stressful8.” Studies have shown
that stress during surgery can affect a person’s judgement, decision making and
communication, which can cause further surgical complications allowing the
stress to escalate9. With this in mind, it is imperative to
understand what students report are the most difficult aspects of performing a
routine feline spay. This way the time spent teaching students can be used
effectively to target what students find most difficult or stressful.

 

This is a descriptive study that
aims to solicit information about what area of a feline spay students find
particularly challenging. By collecting and analysing this information
modifications can be made to further improve teaching techniques in the future
and to focus on ‘problem areas’ when teaching feline spays.  

 

Methods

 

A questionnaire was designed to
assess student perception of how difficult it is to perform a routine cat
ovariohysterectomy (spay). Questions were created based on similar studies and
common surgical steps that are performed in a feline spay10-13. The
questions were trialled within small focus groups of Royal Veterinary College
(RVC) students in their clinical years, and based off their comments the
questions were edited and improved. The finalized questionnaire was given via
email to penultimate and final year students at the RVC. The survey itself was
hosted on SurveyMonkey, a cloud-based website devoted to providing customizable
surveys at no cost to either the author or respondents22. Using this
service allowed the survey to be disseminated via email to the university’s
year groups (BV4 and BV5) and also among RVC-based Facebook group pages. It was
utilized in the hopes that the ease of completing the survey, as it could be
answered on any computer, tablet, or smartphone with an internet connection,
would maximize the number of responses.

 

The survey was split into five
sections. The first section asked students to identify their year of study and
how many feline spays they had performed. The second section asked students how
difficult they thought a feline spay would be prior to participating in a
procedure. The third section was a step-by-step guide describing the parts of a
feline spay. Repeatable steps in a feline spay were combined together to reduce
the length of the survey10-13. Respondents were asked to rate the difficulty
level of each step based on a 7-point Likert scale (very easy, easy, moderately
easy, neutral, moderately difficult, difficult, or very difficult). At each
step, students were also given the option to mark ‘not-applicable’ as some
students may not have performed that specific portion of a cat spay. Students were
then asked if they believed the age of the patient affected the difficulty of
the spay. The last section asked students how difficult they perceived cat
spays to be with their current experience level.

 

The survey was anonymous and
ethical approval was granted by the RVC’s Ethics and Welfare Committee. When it
was distributed, it was made clear to all participants that their contribution
was voluntary and they may discontinue the survey at any point in time. The
Mann-Whitney test and frequency tables were performed to analyse the data using
a program called Statistical Package for the Social Sciences (SPSS) 14.

For the full questionnaire please see Appendix A. The top four categories that
students qualified as difficult (rated either moderately difficult, difficult, or
very difficult) include the following: locating the first uterine horn (N=59%),
placing intradermal sutures (N=52%), locating and grasping the muscle layers
(N=49%), and closing the muscle layers (N=49%). Students found excising the
ovaries (N=78%) and holding tissues to check for bleeding (N=78%) to be the
easiest aspects of performing this surgery. Considering time constraints, one
possible solution would be to focus teaching and supervision on the student
opening the body cavity as well as locating and ligating the first uterine
horn. The teacher could then take a turn, locating and ligating the second
ovary, as well as ligating and excising the uterus. The teacher and student
could then check for bleeding together, and finally allow the student to close
the incision. It is possible that this ‘tag-team’ method could help students
focus on practicing the tasks they perceive as most difficult.  There was no significant
statistical difference in the perception of how difficult surgical tasks were
between students with less or more surgical experience. This finding disregards
the popular theory that mere repetition of surgical tasks will make them easier
over time. This could indicate that targeted teaching may provide more
beneficial than simply providing more opportunities to practice surgery, or it
could indicate that the number of surgical experiences needed to improve such
skills must be significantly larger than these respondents managed to accrue. It was possible there was a greater
proportion of final year student responses due to them having more experience.

At the time this survey was released fourth year students had only been able to
participate in 10-12 weeks of EMS experience. Third year students also began
the clinical portion of the course, but at the time this survey was released
they had not begun EMS. Unfortunately, the timing of this study was suboptimal
due to the constraints of the scheduled research blocks. It would be
interesting to revisit this study at a later date and see how students’ answers
may differ. It is also possible that some final year students had not yet
completed their shelter rotation and subsequently had not completed a spay. A
further study could investigate how many feline spays final year students have
performed at the end of their course and inquire how prepared they felt for
their future profession, as well as exploring what they would have done
differently if they could. A similar study asked 196 veterinary students one
month before graduation how many canine ovariohysterectomies they were allowed
to scrub into and assist the supervising veterinarian. Of those respondents
only 34% of students had the opportunity to participate in 5 or more such
procedures, and 26% of students felt that an experienced veterinarian should
scrub in with them for at least three canine ovariohysterectomies during their
first job15.  The majority of RVC students
surveyed had only performed on average, three (N=30 students) or four feline
spays (N=23 students). The second largest group of students performed at least
eight or more surgeries (N=31 students). It is unfortunate that there are such
variations in student experience, yet it is challenging to cover all of the
academic content required to complete the BVetMed course. As resources and time
are limited within the course, the onus is on the student to seek out hands-on
opportunities independently during EMS. These experiences are also highly
variable, as they could range from everyday practice in a first opinion small
animal hospital to a focus on large animal medicine. If additional
opportunities are not specifically sought out, the first significant surgical
experience students may encounter is in their daily career as a new graduate6. Lastly, students were asked if patient’s age
contributed to the difficulty level of the spay. 15% of students noted that
pediatric cats were more difficult, 23% noted that adult cats were more
difficult, and 24% said that age does not affect difficulty level.  Unfortunately, 30% of students reported that
they have only operated on one age group and 9% of students did not answer the
question. One study surveyed 85 practicing veterinarians and their opinion was
that that pediatric spays and neuters were safer, easier, and faster than adult
spays21. It is possible that students did not have enough experience in surgery
to answer this question.  Veterinary students who completed
the questionnaire were all members of one veterinary college (RVC) so it can be
assumed they all received similar levels of teaching, yet, as mentioned prior,
it is unknown if students have completed their surgery/ shelter rotation when
they completed this survey. It would be interesting to see if student responses
changed if they were given the questionnaire directly after performing a feline
spay compared to the actual delivery method in which they received the survey
via social media and schoolwide emails. Depending on the students’ rotation
timetable, a significant amount of time may have elapsed since they performed a
spay so their responses might not reflect the actual level of difficulty
accurately. It would also be interesting to see how students of other schools
view the difficulty of practicing a spay. Additionally, it would be interesting
to investigate if their rotations and EMS experiences made them feel their course
provided them with enough practical experience to confidently perform spay
surgeries.  

The key findings of his study were
that students found the above-stated four topics most difficult, and that there
was no difference in what students found difficult compared to their experience
level. RVC students currently have access to the Clinical Skills Centre (CSC)
which allows students to practice clinical skills with models, yet it is
difficult to find a practice model that emulates skin and placing intradermal
sutures. It is possible that students need more time allotted to CSC or model
practice before performing a surgery, as students receive only one day to
practice during their shelter rotation and are advised to practice at the CSC
in their own time. A
study showed that students had anxiety regarding topics that were associated
with learning surgical skills, and the opportunity to practice in a laboratory
prior to live-animal surgery helped to reduce their stress levels16. Another study tested
multiple canine ovariohysterectomy models and reported that students who used
models before performing an ovariohysterectomy on a live animal showed a
significant improvement in overall skills compared to the control group17. There are multiple
papers that compare canine ovariohysterectomy models, yet further research
comparing feline midline or flank spay models needs to be done18.

Surgical models
should not replace live surgical options because they do not provide anatomical
realism or provide learning about postoperative care18.  Of course, each model has pros and cons, but overall models can help
enhance surgical training15-20.

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