The PASS Course: Practical Anatomy and Surgical Skills Course as a Pragmatic Primer for Senior Medical Students Pursuing Surgical Residency

Background

For medical students pursuing surgical residency, the fourth year of medical school is focused on a handful of goals: excelling in specialty-specific sub-internship rotations, preparing applications for residency, passing the United States Medical Licensing Exam (USMLE) Step 2, interviewing for residency, and, ultimately, graduating and matriculating into a residency program in their chosen specialty. The educational value of the fourth year of medical school has been neglected and tends to receive much less emphasis than other years of undergraduate medical education. ¹ Surgical residency program directors have described feeling that interns’ level of practical medical knowledge, patient care skills, and professionalism are often deficient at the outset of residency training. ² At the same time, interns often feel unsure of their practical surgical skills, operative knowledge, and understanding of surgical anatomy.^3,4 Given these challenges, the need to innovate educational opportunities for senior medical students pursuing surgical residencies is clear.

Surgical skill and gross anatomy refresher electives have been found to improve senior medical student confidence prior to beginning residency training as an intern^5-10 but do little to prepare surgical interns for clinical management of patients, which is an important aspect of intern surgical years. In an effort to improve the confidence of senior medical students as they enter surgical residency while also providing them with the pragmatic knowledge, skills, and experiences needed to excel in clinical patient management and behave professionally as resident physicians, we developed a month-long senior medical student elective at our institution. The Practical Anatomy and Surgical Skills (PASS) course consists of 4 components: practical didactics, simulation and skills training, embalmed cadaveric dissections and operations, and fresh perfused cadaver dissections and operations. This course is also the first reported formal educational experience that involves training of medical students on fresh perfused cadavers. Additional detailed descriptions can be found in the online supplemental curriculum document.

Practical Didactics

In addition to improving senior medical students’ surgical skills and knowledge of surgical anatomy, an important aspect of the course was the delivery of practical didactic content that students had not otherwise formally experienced in their preclinical or clinical didactic education. The aim of these didactics was to better prepare students for experiences that they would likely first encounter during their intern year as surgical residents, when assuming the responsibility of taking care of patients. For example, in 1 session, students learned how to communicate adverse events of clinical care to patients and their families and simulated the effective delivery of such information. Students also learned common reasons that surgical interns are paged by other services and nursing staff and how to react and respond in an appropriate, effective, and professional manner. These are critical experiences that every surgical intern will face early in their residency, and preparing students before they are “thrown into the fire” is thought to improve their ability to function well on their surgical teams from the start of residency. Other important and highly practical didactic sessions included crash courses on key topics such as surgical radiology for commonly encountered pathologies and a workshop on critical care and management of critically ill patients in surgical intensive care units. Many of these didactic sessions were adapted from Resident Prep Curriculum developed by the American College of Surgeons, Association of Program Directors in Surgery, and Association for Surgical Education.

Simulation and Skills Training

Simulation experiences also played a key role in this course. In addition to common training experiences including sessions on knot tying, suturing, and laparoscopy early in the curriculum, students were able to simulate performance of common bedside and surgical procedures, receive individual dedicated console time on the robotic surgery simulator system, and practice ultrasound on live standardized patients, while also practicing arterial line insertion, central line insertion, and performance of the Focused Assessment with Sonography in Trauma (FAST) exam. Students also participated in mock morbidity and mortality presentations, which were conducted in front of classmates and surgical faculty to simulate the inevitable and potentially stressful and anxiety-provoking presentations required of residents.

Embalmed Cadaveric Dissections and Operations

The primary emphasis in the early weeks of the PASS curriculum is largely on dissection and performance of procedures and operations on embalmed cadavers. While the tissue quality of embalmed cadavers is far from ideal for simulating clinical surgery, in this intensive 2-week session students become reacquainted with important surgical anatomy, perform steps of multiple procedures and operations, and directly apply surgical skills such as knot tying for vessel ligation, anatomic dissection using the right angle and dissecting scissors, and tissue manipulation and mobilization. In addition to lab time with specialty-specific attendings during dissections, this session included related pre-dissection chalk talks prepared by faculty. These talks covered operative approaches, indications for different procedures, review of key anatomy, and post-operative management of patients who undergo each type of procedure. The specific lab sessions, operations, and curricula are listed in Table 1 and the online supplemental curriculum document and cover the spectrum from orthopedic and neurologic surgery to surgical oncology and vascular surgery. We believe the juxtaposition of each lab session and a handful of relevant operations with chalk talks on the subject helped students solidify not only their anatomy and surgical skills but also their understanding of clinical management of patients and indications for different surgical procedures.

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Table 1.

PASS Course Outline and Summary of Student Experiences. See Supplemental Information for Descriptions of Student Experiences.

Practical didactics	Simulation and skills training	Embalmed cadaver dissections	Fresh perfused cadaver dissections and operations
-Effective communication and organization during residency	-Suture and knot tying	-Foregut and stomach	Day 1
-Surgical instruments, lines, tubes, and drains	-Laparoscopy training	-Pancreas and spleen	-Skin/soft tissue
-Critical care	-Robotic surgery training	-Small bowel anastomosis, staplers, stomas	-Orthopedics
-Social media and professionalism	-Ultrasound for surgeons	-Cardiothoracic	-Plastic surgery
-Weekly morbidity and mortality conference	-Common bedside procedures	-Breast and plastic surgery	-Urology
-Adverse events and delivery of information	-Surgical bedside procedures	-Vascular	-Vascular
-Surgical radiology	-Bronchoscopy and Esophagogastroduodenoscopy	-Two anatomy review sessions with PhD anatomist	Day 2
-Mock pages	-Morbidity and mortality student presentations	-Hepatobiliary	-Cardiac
-Informed consent and discharge planning		-Obstetrics and gynecology	-ENT
		-Urology	-Thoracic
		-Orthopedics	-Vascular
		-Colorectal	Day 3
		-Hand	-Abdominal
		-Surgical biopsy	-General surgery
		-Thyroid and parathyroid	-Gynecology
		-Neurosurgery	-Oncology
		-Hernia	-Urology

Fresh Perfused Cadaver Dissections and Operations

After performing multiple dissections and operations on embalmed cadavers, students had the opportunity to spend three full days in the West Virginia University Critical Care and Trauma Institute’s Fresh Tissue Training Program (FTTP) perfused cadaver lab. There, they were able to demonstrate and apply their refreshed knowledge of surgical anatomy and gain experience performing operations in a low-stakes environment on tissue that is markedly similar to that of patients in the operating room. In these high-fidelity cadaveric specimens, the tissue quality is largely preserved and vessels are perfused with air or simulated blood to preserve normal anatomy (see tissue comparisons in Figure 1). This unique training opportunity has been described in the literature as being highly accurate in terms of replicating tissue quality, vascular anatomy, and dissection for performance of surgical procedures and operations.^11,12 Moreover, the incorporation of perfused fresh human cadavers into surgical training has been shown to improve general surgery residents’ confidence in performing critical trauma operations. ¹³

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Figure 1.

Comparing and contrasting tissue quality in students’ embalmed vs fresh tissue cadaver labs. In panel 1, a right lower lobectomy specimen is depicted in the fresh tissue lab (1A) and embalmed lab (1B). Panel 2 demonstrates differences in cardiac tissue. (2A) shows an emergent suture repair with felt pledgets for a simulated right ventricular injury, compared with the right ventricle in the embalmed lab (2B). Panel 3 shows carotid arterial anatomy in the fresh tissue (3A) and embalmed lab (3B) as students were performing carotid endarterectomy. Panel 4 compares right hepatectomy specimens in the fresh tissue (4A) and embalmed (4B) labs.

With the guidance of course faculty, students ran through the range of bread-and-butter general surgery operations, such as inguinal hernia repair, appendectomy, and soft tissue lesion excision, and performed complex operations including below-knee amputation, right lower lobe lobectomy, femoral-popliteal bypass, splenectomy, and nephrectomy. Additionally, students performed essential surgical maneuvers and procedures for trauma and emergency surgery care including chest tube insertion, resuscitative thoracotomy, cricothyrotomy, aortic cross clamping, and supra-celiac control. They also learned how to mobilize and gain entry into multiple surgical planes by performing Kocher maneuvers, dissection into the lesser sac, and right colon mobilization along the white line of Toldt. Students also were able to perform essential aspects of operations such as fascial closure of exploratory laparotomy incisions and end colostomy and ileostomy creation and takedown. These operations and dissections were performed using a comprehensive set of real surgical instruments and equipment that would be encountered in any operating room, ranging from electrocautery and bed-mounted self-retaining retractors to Gigli saws and tissue fusion devices.

To conclude the experience in the FTTP perfused cadaver lab, students were assembled into teams and presented with a simulated patient scenario similar to those developed when our resident trainees work in the same lab. Faculty created a large injury to the inferior vena cava (IVC) in the perfused fresh cadaver and students were then challenged to work as a team to gain control of the IVC, identify the injury, and repair it.^14,15 While the use of perfused, fresh cadavers has been well described in surgical trauma training at the resident and fellow level, as well as for military surgical teams, this was a unique experience for senior medical students and permitted our trainees to experience audible bleeding for the first time and assess and repair the injury in a lower-stake environment.

Course Logistics

In this new iteration of the course, 7 fourth-year medical students were enrolled in the month-long rotation. Of these students, 4 were pursuing general surgery, 2 were applying for obstetrics and gynecology residency, and 1 was applying for urologic surgery residency. In the future, the intent is to enroll a maximum of 16 students in the course and use 4 embalmed cadavers and 4 fresh cadavers for dissections and operations.

The rotation was intentionally placed toward the end of the academic year, following residency interview season and long after students traditionally complete specialty-specific sub-internship rotations. Although all students in the course were pursuing surgery and associated subspecialties, the course is open to all students at our institution. Most students applying into general surgery this cycle enrolled in the course, while a minority of students applying to other surgical specialties enrolled. This underscores the need to recruit and promote the course more broadly to a wider array of students, which will be a goal for next year’s course.

Regardless of clinical interest, each student completed all described dissections, operations, simulations, and lectures. However, as mentioned, the course content was tailored at the outset to the general clinical interests of the group, and all surgical subspecialties were involved. For example, although no students were pursuing neurological or orthopedic surgery, faculty from both departments were involved in the course to ensure that all students received a well-rounded experience.

A total of 30 faculty and staff members were directly involved with the course, through either lecturing, simulation, or cadaver dissections. These dedicated educators spanned 11 departments and divisions at our institution. Time commitments varied based on the activity each faculty member participated in but each member was present for the duration of each activity. For example, during thoracic surgery dissections, 2 thoracic surgery attending physicians were present for the entire 3-hour experience. A large number of faculty members were involved in the course to avoid placing too substantial a time burden on any given clinician aside from the 2 course directors, who are the senior authors of this paper.

In addition to the challenging logistics of running the course, the curriculum requires a substantial amount of financial backing. Aside from the substantial time investments from course directors, expenses included embalmed and un-embalmed cadaver fees of $1370 and $2000 each, respectively. The perfusion lab fee was $4000 in total for space utilization during the fresh cadaver training. At our institution, time in the embalmed cadaver lab and in our simulation center for medical student education is free of cost. In addition to substantial support from departmental leadership, relationships with the medical school, industry partnerships, and our Human Gift Registry (HGR) are paramount to the success of this course. For example, in this year’s version of the course, the HGR generously paid for the embalmed cadavers on behalf of the department of surgery.

PASS Course Implementation and Value Proposition

The PASS course was established at our institution in 2013 and has gone through multiple iterations. Initially, the course consisted solely of embalmed cadaver dissections, after which some limited simulation-based surgical skills were embedded. New to the current version are the practical didactics, more robust simulation, and fresh perfused cadaver experience. The success in the evolution and development of this course starts at the top with direct funding from our department chair and relies heavily on dedicated faculty throughout the department who are committed to undergraduate medical education and preparing students for success as surgical interns and residents.

Also key to the success of this course are relationships across centers and departments at our institution, including the pathology and anatomy department, our institution’s simulation center, the radiology department, and emergency medicine colleagues, as well as other surgical specialty faculty including neurosurgery, orthopedics, urology, and obstetrics and gynecology. The evolution of this course has been guided by continued thoughtful feedback from students who have participated and perspectives of surgical faculty on how best to prepare senior medical students for success as surgical interns from all standpoints, including knowledge, confidence, surgical skill, and communication skills. Our institution is also uniquely positioned as the state’s flagship land grant university and serves, in many ways, as a cultural epicenter for our state. We are fortunate to have many individuals in our state who elect to donate their bodies to our university’s HGR. Without this close relationship between our university and the people of West Virginia, as well as our successful partnership with our HGR, the embalmed cadaver experience and fresh perfused cadaver experiences provided in this course would not be possible.

We believe that this uniquely organized course will help prepare senior medical students to become excellent surgical interns and residents. The practical hands-on experiences across multiple modalities, from simulation on mannequins to operating on fresh perfused cadavers, will enhance students’ skills in performing procedures at the bedside and in the operating room. The adjoining didactics, chalk talks, and communication-based simulations will provide students with not only the technical skills but also the interpersonal skills and solid foundational knowledge needed to become exemplary residents.

We recognize that different institutions have differing levels of access to a variety of resources. However, we would encourage colleagues around the country to harness the best that their departments have to offer to meaningfully and thoughtfully provide unique educational experiences for senior medical students who plan to pursue careers in surgery. It is also important to note that the key aspect of this course is the combination of anatomy and surgical skills experiences on high-fidelity tissue, as in the case of fresh perfused cadavers, with practical didactics and simulations. This combination sets our educational experience apart from previously described elective courses.

In the future, we intend to longitudinally assess the effectiveness of our PASS course curriculum from the standpoint of our enrolled medical students to better understand their perceived experience. We plan to do this both immediately following the course and once students have had time to apply their knowledge as surgical interns. Additionally, we hope to assess perspectives of program directors at institutions where our students matriculate regarding the quality of this educational experience and its impact on our former students’ effectiveness as surgical interns.

Supplemental Material