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Medical Education

Medical Training

In medical education, animals have traditionally been used to teach human physiology and pharmaceutical principles, study human anatomical form and function, and practice human surgical procedures. Yet numerous developments have contributed to a paradigm shift in this field. They include improvements in human-patient simulation and computer-assisted learning technology that teaches medical education as well as or better than animal dissection and experimentation,12 rising public opposition to the use of animals in laboratories,3 increasing cost burdens associated with building and maintaining facilities that keep animals,45 and a renewed focus by the medical community on improving patient safety and reducing clinical errors through simulation-based training.67

Undergraduate Medical Training

Human simulation-based teaching has become the gold standard in undergraduate medical education. Medical students in Canada, India, and the U.S. learn without using live animals throughout the undergraduate curricula.89 Medical experts have recommended moving away from an animal-based pedagogy and toward “a robust curriculum composed of didactics, task trainers, virtual reality, cadavers, computer software, high-fidelity patient simulators, and supervised clinical work.”10 Unlike approaches that use animals, these non-animal training methods accurately model human anatomy and physiology, allow students to repeat medical procedures until proficiency is achieved, improve provider confidence and transference of learned skills to clinical practice, and allow educators to receive real-time objective performance feedback.1112 Other evidence supports using simulations to improve skills and/or clinical performance in lumbar punctures,13 suturing,14 chest tube placement,15 and many other procedures. There is no scientific or ethical justification for continuing to use animals for undergraduate medical training. Therefore, we recommend ending the use of animals for this purpose.

Graduate Medical Training

In graduate medical education, the benefits of animal-free training methods have been demonstrated across various medical disciplines and techniques. A systematic review found that using immersive virtual reality simulators in surgical training programs improved procedural times, task completion, accuracy, user ratings, and cost-effectiveness.16 Furthermore, a meta-analysis on the efficacy of virtual reality (VR) training in laparoscopic surgery found it to be as effective as or superior to traditional, video, or box trainers in training performance and in the operating room.17 VR can also train surgeons to cope with technical problems encountered during surgeries.18 Another meta-analysis found that time efficiencies and improvements in technical surgical performance on robot-assisted surgery VR simulators were transferable to the operating room and that performance on the simulators was predictive of performance in the operating room.19 Improvement in technical skills was found in a meta-analysis of obstetric VR simulation studies, and the authors note “that consideration ought to be given to integrate simulation training into the clinical curriculum.”20

There is no scientific or ethical justification for continuing to use live animals for graduate medical training. Therefore, we recommend ending the use of live animals for this purpose.

Microsurgery Training

There now exists an array of low- and high-fidelity non-animal methods that researchers have developed to effectively teach a wide variety of basic and advanced microsurgical skills to novice and expert physicians. These tools, which include task trainers, virtual reality simulators, human-tissue models, and ethically sourced perfused human cadavers—all of which teach skills such as nerve repair, nerve transfers, and flap reconstruction as well as vessel dissection, anastomoses, repair, and grafting—have been endorsed as replacements for live-animal use.

A study by a team of researchers in London evaluated the validity of a three-in-one silicone model, Surgitate, to reduce the use of animals in microsurgery training.21 The participants performed end-to-end anastomosis on arteries, veins, and nerves and rated the model favorably for acquiring basic microsurgical skills.22 The authors state that the Surgitate model “could be particularly useful in enhancing suturing skills as a replacement or reduction in the use of chicken models.”23 Given that plastic surgery is a subspecialty that often uses microsurgical techniques, a comprehensive review concluded that “prosthetic simulators are set to play a larger role in the development of a standardized, ethical, accessible, and objectively measurable microsurgery training curriculum for the modern-day plastic and reconstructive surgery resident.”24

A systematic review of microsurgical training methods supported these findings:

It would appear from the best available evidence that simulated microsurgery training on low fidelity models can be as effective as on high fidelity models. … In the UK and elsewhere, the mainstay of microsurgical simulated training has historically been exposure to an in vivo rat microsurgery course, but generally this [is] at a far too early stage in training where the bridge with clinical hands-on exposure to relevant cases cannot be made, and without repetition.25

A three-dimensional, animal-free neurosurgical simulator for aneurysm microsurgery training developed by a team in Bern, Switzerland, was touted as “reliable and potentially useful for training neurosurgical residents and board-certified neurosurgeons,” and a majority of the study participants reported that this simulator was superior to conventional neurosurgical training methods.26 VR technology is another promising training tool that bypasses the use of animals in microsurgical training. In a study in which authors sought to evaluate the impact of VR in microsurgical clipping of the middle cerebral artery, the team reported that training with VR technology improved the participants’ surgical efficiency, speed, and safety, regardless of the complexity of the procedure.27

Researchers at the Division of Plastic Surgery at Baylor College of Medicine reviewed the current training models for plastic surgery residents and fellows. They concluded that the “use of human cadavers in microsurgical skills training is superior to animal cadaveric models because it provides the most ‘like’ tissue available.”28 Training on human cadavers is particularly helpful for learning flap reconstruction. A study led by a team of researchers in Scotland used perfused human cadavers to simulate a flap surgery; ultimately, they found the model was well received by trainees, easily reproducible, and cost- and time-effective.29 This team noted that while the use of anesthetized live animals was previously popular for teaching microvascular flap-raising surgeries, the need for specialized staff to oversee the animals resulted in high costs and that the live-animal models “lack direct comparison with human tissues and anatomy, which limits the transferable skill acquisition of the simulation.”30 Most plastic surgery residency programs send residents to microsurgical and flap skills courses.31 Many non-academic institutions provide microsurgery training courses that do not use live animals; for example, residents can attend the Penn Flap Course, which uses latex-injected cadavers to teach flap-based microsurgical reconstruction.32

Human tissue ex vivo models are currently being used internationally for microsurgery training. The University of Zurich has “developed a standardized and, by now, established and tried-and-true protocol for preparing the perfused placenta models using tools that are readily available in any surgical department, and this model is now regularly used for microsurgical training of staff members and residents as well as during regularly held training courses.33 The Zurich Microsurgery Lab uses these placentas to teach highly realistic microdissection, microvascular repair, and microanastomosis and to replicate blood flow, while also providing many more vessels that the trainees can use.34 Placenta models are well recognized as good simulation models for microsurgery training for neurosurgery trainees, as they allow for simulation and training in different types of anastomosis and intracranial aneurysm surgeries.35 French researchers have taken the versatility of the placenta model further, combining a synthetic 3D-printed skull replica with anatomical landmarks and placental vascular structures to create a more realistic surgical experience for neurosurgical trainees looking to practice aneurysm clipping.36

Other examples of human tissue ex vivo models used for resident microsurgery training include cryopreserved vessels, which medical education researchers are also exploring as a novel way to learn vein grafting,37 and vessel anastomosis with concurrent pulsatile flow.38 Cryopreserved models are not currently widely used and are just one of the variety of alternatives available for microsurgery training that should be explored further.

Around 44% of integrated plastic surgery residency programs in the U.S. do not use live animals to teach anastomosis microsurgical skills;39 instead, these programs use some or a combination of the previously described alternative models. Given the many validated, animal-free training methods already available, we recommend ending the use of live animals for microsurgery training. Medical education researchers should increase funding for developing alternatives to using animal tissues for microsurgery training, as more human-relevant models are necessary to ensure the best training for surgical residents.

Trauma Training

A study published by a U.S. Air Force team compared the self-efficacy reported by military trainees who were taught emergency procedures on human simulators versus those taught using live animals—otherwise known as live tissue training (LTT)—and found equivalent results in both groups, concluding that “the belief in the superiority of animal training may just be a bias” and that “if the goal for trainers is to produce individuals with high self-efficacy, artificial simulation is an adequate modality compared with the historical standard of live animal models.”40 The lead author published a separate letter in the same medical journal, stating, “[w]e have entered into an age where artificial simulator models are at least equivalent to, if not superior to, animal models. … [T]he military should make the move away from all animal simulation when effective equivalent artificial simulators exist for a specific task. For emergency procedures, this day has arrived.”41

Non-animal methods are used exclusively instead of animals for military medical education by more than 70% of NATO member states,42 and the U.S. Coast Guard has become the first branch of the U.S. Armed Forces to end the use of animals for this practice.43 Commandant Adm. Paul F. Zukunft of the Coast Guard stated that he found LTT “quite honestly—abhorrent in terms of meeting our mission requirements.”44 These developments confirm that animal use for trauma training is neither necessary nor justified.

Efforts to replace the use of animals with human simulators in military trauma training have gained many prominent supporters, including The New York Times Editorial Board45 as well as numerous medical and veterans organizations representing more than 255,000 physicians and doctors-in-training, which have former U.S. surgeons general among their leadership.46

A 2018 study found that “[h]igh-fidelity simulation offers many advantages, including broad exposure to procedures, their complications, and the opportunity for repetitious learning in a non-clinical setting” and that “[s]ynthetic models can produce a stress response equivalent to that of live tissue during simulation training” and “produce a sufficient immersive and realistic experience for trainees.”47

One study examined the training of U.S. Navy and U.S. Army surgical teams involving live human role players wearing a surgical simulator known as a “Cut Suit” and using film industry special effects. The authors found that simulation training enhances team performance and “improves surgical procedures and processes,” concluding, “High fidelity surgical simulation equipment such as the … ‘Cut Suit’ combined with highly realistic replicated settings will allow surgical trauma teams to improve their life-saving skills and teamwork communication to maximize successful patient outcomes. High fidelity, highly realistic, immersive and stress-provoking surgical trauma training is now an option to improve the readiness and capabilities of trauma teams.”48

Cadavers and perfused cadaver models have been used in field settings with minimal resources to accurately simulate the critical skills for all combat trauma procedures, including training using extremity tourniquets, right common carotid intra-arterial and distal femur intraosseous (IO) access for perfusion, and oropharynx preparation for airway procedures.49 Additionally, cadaver models can teach tactical combat casualty care procedures, including nasopharyngeal airway, endotracheal intubation, cricothyroidotomy, central-line access, needle decompression, finger and tube thoracostomy, resuscitative endovascular balloon occlusion of the aorta, junctional tourniquets, IO lines, and field amputations.50

A 2019 study in the Journal of Surgical Education states that the purported benefits of LTT to patient outcomes are unsubstantiated: “[N]o published evidence from prospective controlled trials exists suggesting that surgical skills training courses change trauma patient outcome, or improve performance of the skills taught, when performed in the real-world operating room. … Published evidence of course training benefit was not identified for many established courses including: Definitive Surgical Trauma Skills, Emergency Management of Battlefield Injuries, Endovascular Skills for Trauma and Resuscitative Surgery, Emergency War Surgery Course (EWSC), Military Operational Surgical Training, Specialty Skills in Emergency Surgery and Trauma, Surgical Training for Austere Environments, or Surgical Trauma Response Techniques”—all of which, according to the paper, “used live tissue (usually porcine).”51 This remains true as recently as 2023, when a systematic review analyzing current evidence on the use of live tissue training (LTT) for military and civilian physicians, as well as military medical technicians, found that “the literature does not demonstrate translational outcomes or subsequent behavioral and performance changes in learners within a clinical environment that affect actual patient care.”52

Furthermore, an independent, peer-reviewed study published by German scientists has shown that the use of animals in such LTT is ethically unacceptable. The researchers conclude, “[a] close examination of the evidence base for the presumed advantages of LTT showed that it is not superior to simulation-based methods in terms of educational benefit. Since credible alternatives that do not cause harm to animals are available, we conclude that LTT on animal models is ethically unjustified.”53

In the civilian sector, the American College of Surgeons has affirmed that human simulators can replace the use of animals in Advanced Trauma Life Support (ATLS) training,54 and national ATLS programs in numerous countries have made the transition to ending animal use for this purpose.55

Based on the evidence supporting the efficacy of non-animal training methods, we recommend ending the use of animals for military and civilian trauma training.

The Future of Medical Education Research

Educators should assess new simulations’ accuracy and effectiveness to integrate them into surgical and procedural training. Worthwhile studies should evaluate how well these models teach specific skills and translate into real-world clinic, procedure, and operating room proficiency. However, current evaluation methods often lack robust study design and fail to provide sufficient evidence of these models’ effectiveness in improving clinical performance.

Medical education researchers should gather diverse data to comprehensively evaluate simulation models or replicate previous study designs with new technologies to compare findings. It’s crucial that medical education researchers make an argument for the use of a specific simulator for a specific skill in a specific context, rather than arriving at binary conclusions about validity, as validation is an ongoing process.56

Many studies focus on subjective opinions about a simulation’s performance and design to establish face and content validity.57 While these assessments are useful, they are less rigorous than other measures of a simulator’s validity.58 Systematic reviews, similar to those in clinical and, increasingly, preclinical research, are valuable for identifying the limitations of medical education research methodologies.

To develop high-quality simulation curricula, researchers should do the following:

  • Prioritize studies that evaluate a simulator’s predictive validity to determine if it effectively builds transferable clinical skills.
  • Design and evaluate comprehensive training programs, rather than validating only one aspect of a simulator.

Good study design in medical education simulation training is crucial for proper physician training, minimizing patient risk, and avoiding continued animal use based on faulty studies.

References
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