Early exposure to hands-on surgical training encourages urological interest in undergraduate medical students

Early exposure to hands-on surgical training encourages urological interest in undergraduate medical students | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research article Early exposure to hands-on surgical training encourages urological interest in undergraduate medical students Tomokazu Kimura, Kosuke Kojo, Atsushi Ikeda, Shuya Kandori, Takahiro Kojima, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-19513/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Urological education is as important as surgical training for undergraduates. However, those in undergraduate medical schools have less exposure to surgery and urology as their curriculum focuses more on clinical skills, particularly community-based healthcare for a super-aging society. This study aimed to evaluate whether urologic hands-on training could encourage surgical and urological interest in medical undergraduate students. Methods: A one-day elective program in urologic surgery at the University of Tsukuba, particularly in robotic, laparoscopic, and endoscopic surgeries, was offered to 58 fourth-year medical students in 2018 and 2019, prior to their clinical clerkship. The average age of participants was 22 (range: 21–25) years. We assessed scores (1–5 Likert-type items) in training activity, interest in surgery, and interest in urology before and after the course. Results: Before attending the program, average scores in interest in urology were 3.53 in 2018 and 3.15 in 2019. After training, the total likely scores of this program in 2018 and 2019 were 4.59 and 4.76, respectively. The likely scores in surgery increased after the program; however, this was not significantly different to that prior to the program. However, the average interest scores in urology were significantly increased to 3.91±0.63 (p<0.05) and 3.88 ± 0.58 (p<0.01) in 2018 and 2019, respectively, indicating a motivation to pursue surgery and urology following clinical clerkship, 1 year after training. Conclusions: Urological hands-on training facilitated interest in urology in medical students prior to their clinical clerkship. Early experience in actual urological procedures could encourage medical students to consider specializing in urology and pursue a career as a urological specialist. Urology & Nephrology Educational Philosophy and Theory early exposure urology surgical skills career choice Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Background Medical school provides an opportunity to not only acquire the knowledge and skills but also experience in various specialties. Medical students in lower years of study, study and learn with the help of classroom lectures and other recently adopted clinically-oriented teaching methods 1 . After gaining basic medical knowledge, they learn skills through a rotating clinical clerkship over a period of 6 years after graduating from high school in Japan 2 . In addition to subject knowledge, medical students must learn the required attitude and skills that make them qualified to meet the needs of citizens 3 . In Japan, upcoming medical doctors should have clinical skills, especially in community-based health care for the super-aging society 4 . Thus, medical schools are modifying their curriculum to consider these societal needs. Thus, medical students obtain less experience in surgical subjects than in other essential medical specialties such as internal medicine, psychology, and primary healthcare 5 . To bridge this increasing gap in knowledge, several surgical departments have been trying to teach surgery more efficiently in an educational program (such as simulation-based learning) during clerkship. Simulation-based learning is broadly used in medical schools globally. Simulation is very useful for beginners to learn invasive procedures, including the physical examination, puncture procedures, and emergency treatment 6 . To achieve better outcomes with simulation-based education, the following factors need to be considered: range of difficulty, repetitive practice, distributed practice, cognitive interactivity, multiple learning strategies, individualized learning, mastery learning, feedback, length of training, and clinical variation 7 . For expert training, more novel challenges are recommended. However, this adds to the financial cost and burden of faculties as simulation equipment is expensive and requires that instructors put in extra work. Nevertheless, simulation-based education is effective in imparting basic science and clinical knowledge and improving procedural skills, teamwork, and communication skills in undergraduate and graduate medical students 8 . Choosing a specialty is one of the most important decisions for medical students 9 . In Japan, postgraduates rotate through several specialties within two years as junior residents before starting their training in their selected specialty 2 . Medical students and junior residents choose their specialty based on a variety of factors, including medical lifestyle, societal orientation, hospital orientation, scope of practice, and the impact of role models 10 . Compared to any other specialty, urology is less popular among medical students due to the misconception that urologists are generally male organ specialists 11 . A urologist deals with the entire genitourinary system of men and women. Moreover, the need for female urologists has increased over the past 10 years 12 . Medical students’ misunderstanding of urology will remain uncorrected unless they are exposed to the correct clinical circumstances. Students are more likely to be influenced to pursue surgical careers if they are offered early exposure to positive role models and career and academic opportunities 13 . Thus, early involvement of medical students may provide ideal opportunities or mentored externships for recruitment, not only in urology but also in other departments. The school of medicine at the University of Tsukuba has given an “advanced course” to fourth-year medical students prior to starting their clinical clerkship. This short course consists of intensive lectures based on the concept of exposing pre-clinical clerkship students to recent, focused, and advanced medical issues. Several professors offer lectures on various disciplines such as basic science, medical statistics, internal medicine, psychology, surgery, anaesthesia, social medicine, and space medicine. Each student can select several courses in their fields of interest over one week. Our urology department has given hands-on seminars on endoscopic, laparoscopic, and robotic surgeries since 2012. Students who had attended this course were motivated to learn about surgery and were more interested in urology. We hypothesized that specific factors could contribute to urological and surgical experience and that a positive experience would be associated with students’ interest in a career in not only surgery but also in urology. This study evaluated whether this urology course, designed to provide the required exposure to medical students, could cultivate an interest in surgery and urology among pre-clinical clerkship medical students. Methods Course design A one-day elective course focused on hands-on training in urologic surgery, particularly robotic, laparoscopic, and endoscopic surgeries, was offered to fourth-year medical students of the University of Tsukuba in 2018 and 2019. Participants were separated into three groups. Subsequently, each group rotated through endoscopic procedures, laparoscopic suturing, and robotic surgery, respectively, over 2 hours (Fig. 1 ). The grouped students were further separated into four subgroups rotating through endoscopic workshops lasting for 30 minutes each, including cystoscopy, transurethral resection, laser prostatectomy, and transurethral lithotripsy (Fig. 2 ). In the robotic surgery course, students used the DaVinci skills simulator of preinstalled tasks including “Endo Wrist Manipulation”, “Energy and Dissection”, and “Needle Control and Driving”. In the laparoscopic course, the students were trained in suturing skills using string with a needle in a dry box. Meanwhile, the students in the endoscopic course were divided into 4 groups: transurethral resection (TUR), photo-selective vaporization of the prostate (PVP), cystoscopy, and transurethral lithotripsy (TUL). During the TUR session, the students cut into a konjac plate (a jelly-like food made from the starch of the konjac potato) under a saline pool using the TUR system. During the PVP session, the laser vaporization procedure was demonstrated to students using a PVP simulator. During the cystoscopy session, students performed the cystoscopy procedure using a flexible cystoscope on a flask, which resembled the urinary bladder. During the TUL session, students used a flexible ureteroscope and basket forceps to remove simulated renal stones out of a urinary tract model. Evaluation Before the start of training, the participating students were asked to provide their demographic information in a pre-course survey. Moreover, they provided a self-assessment (1–5 Likert-type items) on their interests. They checked the “5” score when they were very interested, while a “1” was scored when they were not interested at all. After the training, the participating students and faculty members were made to answer a post-course survey in which they were able to provide a free description to the questions. To evaluate the long-term effect of the course, we used a web questionnaire on participating students. Evaluation of the participating students was performed 3 months after having taken the course in 2018. Conversely, the evaluation done in 2019 was performed after 1 year. The questionnaire was the same as the provided self-assessment (1–5 Likert-type items) and free description surveys. Assessment Data for these evaluations were collected from all students enrolled in the course who completed the pre- and post-course surveys. We analysed the mean difference in the interest score in surgery and urology before and after the program using paired t-tests in 2018 and 2019. All data analyses were performed using JMP14 and Microsoft Excel®. Descriptive statistics, chi-square test, or Fisher's exact test were used, as appropriate. We also analysed the answers obtained from the free description section of the questionnaire. Results Two-hundred and twenty-two medical students have selected to enrol in our course since 2012. Of these, 32 and 26 students took part in this course in 2018 and 2019, respectively (Table 1 ). The average age of participants was 22.2 (range: 21–24) years and 22 (range: 21–25) years in 2018 and 2019, respectively, among approximately 140 medical school fourth-year students. Overall, 34.4% and 38.5% of participants were female, respectively. Eleven urology faculty members including two female urologists and several staff members from the medical equipment company helped teach the workshops. Table 1 Background characteristics of participants Fiscal year 2018 2019 P-value No. of students 32 26 Age Median 22 22 n.s. Range 21–24 21–25 Sex Male 21 65.6 16 61.5 n.s. Female 11 34.4 10 38.5 Curiosity Internal medicine 20 62.5 15 57.7 n.s. Surgery 22 68.8 15 57.7 n.s. Urology 14 43.8 5 19.2 0.044 Pre-course likely score Surgery Average 4.12 4.00 n.s. SD 0.148 0.111 Urology Average 3.53 3.15 0.06 SD 0.149 0.613 n.s: not significant, SD, standard deviation Before attending the course in 2018, the average interest scores in surgery and urology were 4.12 and 3.53, respectively. Those in 2019 were 4.00 and 3.15, respectively. Attending students were already interested in surgery but not in urology. After training, robotic surgery was the most interesting to participants in both periods. Regarding laparoscopic suturing, single port surgery tended to have more of a “less likely” score than the 3-dimensional and 2-dimensional classical laparoscopic procedures. Endoscopic procedures such as TUR, PVP simulation, cystoscopy, and TUL were also attractive to medical students. The comprehensive evaluation scores of this course in 2018 and 2019 were 4.59 and 4.76, respectively (Fig. 3 ) Table 2 shows the difference in likely scores before and after the course. After attending the course, the likely scores in surgery were higher, but this difference was not significantly different to that obtained prior to the course in both years. Interestingly, those of urology were significantly increased compared to those of the pre-course. Particularly, the number of students who selected a score of 5 increased, and the number of students who selected a score of 2 decreased (Fig. 4 ). Free description questionnaire results showed that medical students became more interested in urology and surgery and felt motivated for their clinical clerkship. Faculty members found the teaching workload and burden of costs too high; thus, they placed their clinical practice ahead of teaching the course. However, they felt that the course was very important for medical students in addition to clinical practice. Table 2 Likely scores of interest for surgery and urology before and after the course Surgery Urology 2018 2019 2018 2019 Average Before 4.13 4.00 3.53 3.15 After 4.34 4.27 3.91 3.88 Effect size 0.18 0.35 0.35 0.72 Mean difference 0.22 0.27 0.38 0.73 Standard deviation 0.21 0.14 0.18 0.14 Upper 95% 0.65 0.56 0.74 1.02 Lower 95% -0.21 -0.02 0.01 0.44 P-value 0.30 0.07 0.04 0.00 To evaluate the long-term effect of this course, we performed a post-course web questionnaire, with 13 (40.6%) students in 2018 and 17 (65.4%) in 2019 completing the questionnaire. Table 3 shows the results of the long-term evaluation. Regarding memory, “Remember the course” maintained very high scores of 4.53 ± 0.50 3 months after the course and 4.62 ± 0.49 1 year after the course. Regarding the effect on learning during clerkship, this course played a significant role on the effect of learning both surgery and urology. However, the scores obtained for interest in surgery and urology gradually decreased over time (Fig. 5 .). The average likely scores dropped to below 4 in surgery and below 3 in urology. Table 3 Long-term effect of this course 2018 2019 Ave SD Ave SD Remembering Whole course 4.62 0.49 4.53 0.50 Robotic surgery 4.31 0.82 4.12 0.68 Single port surgery 3.54 1.08 3.47 0.98 3-dimensional laparoscopy 3.62 0.92 4.06 0.64 Laparoscopic surgery 4.54 0.63 4.12 0.90 TUR 3.85 0.86 2.65 0.84 PVP 3.85 0.95 3.24 1.06 Cystoscopy 3.69 0.99 2.82 0.98 TUL 3.77 0.89 3.00 0.97 Interested in Surgery 4.54 0.63 4.24 1.00 Urology 3.54 1.01 3.24 0.55 Affect the learning at clerkship Surgery 4.15 0.77 4.35 0.76 Urology 4.23 0.70 3.88 0.68 Career selection Surgery 3.92 0.92 3.76 1.00 Urology 2.85 1.03 2.47 0.61 SD: standard deviation, ave: average, PVP: photo-selective vaporization of the prostate, TUL: transurethral lithotripsy, TUR: transurethral resection Discussion According to this study, early exposure to urological hands-on training in pre-clinical clerkship students resulted in an increasing interest, especially in urology. Surgical training courses were generally conducted during clinical clerkship or postgraduate periods 14 . The most novel aspect of this study was conducting a hands-on course that focused on urological training in medical students prior to clinical clerkship. Early exposure is an effective method for educating medical students in not only basic science but also clinical clerkship 15,16 . This study showed that hands-on training in urologic procedures impacted on pre-clinical clerkship medical students as it increased their interest in urology. However, this course did not increase the interest in surgery among students who already had an interest in surgery prior to the course. Thus, it was of limited value to those who showed an interest prior to the course. In contrast, this course made a good impression on students with regards to urology. Generally, there were more students interested in surgery than in urology at the beginning of the course. Moreover, what urologists do is relatively unknown to the public compared to what is done in surgery, internal medicine, paediatrics, and other specialties. The lesser-known specialities may be able to promote their specialty and the roles they play to medical students in their earlier years of training as well as the public. As medical students are rarely provided with experience in performing not only surgical procedures but also independent simulated surgeries prior to undergoing their clinical clerkship, this course could have a great impact on medical students prior to their clinical clerkship. As a systematic review and meta-analysis showed that technology-enhanced simulation was more effective than instructional methods, actual experience could be beneficial for learners 17 . In this course, students could perform surgical procedures and use simulators for a certain amount of time under the supervision of several faculty members. Regarding endourologic skills, early feedback can be beneficial when learning through novel simulation training 18 . Thus, these experiences may encourage students to learn surgery and urology further following their clinical clerkship. However, numerous experiences may influence their choices because medical students must rotate through several subjects for a long period of time during their clerkship. Recently, motivation was found to be one of the most important factors for continuing learning in the field of medical education 19 . To maintain and improve the effect of the course, surgeons and urologists should continue offering students the opportunity to obtain surgical experience and the opportunities provided to them during their surgery and urology rotations should be performed using technical and educational approaches such as the motivational dynamic model 19 . Early clinical experience as a degree on influence on the selection of a particular career by undergraduate students 7 . In Japan, medical students usually undergo a 2-year primary resident course followed by a 4-year specialized medical course to pursue their career path 20 . The career chosen by medical students depends on their experiences since birth and their own prerogatives. Particularly, parental career expectations may also have an impact on their career choice 21 . However, for medical undergraduates, exposure to specialties and the timing of this exposure are crucial to career choice; this is true for any specialty 22 . Medical students should rotate through several departments during their clinical clerkship, although not through all departments. Most medical school curriculums tend to focus on good clinical practitioners who are trained to care for a super-aging society; thus, the time spent rotating through surgical departments is likely to decrease. This limits the exposure of students, particularly those with an interest in surgery, to non-essential subjects. Several medical experts have been trying to recruit young doctors and medical students in Japan as junior residents are able to select their specialty of choice freely. As there are several reports showing that short courses and surgical simulations could influence their choice in career specialty, early exposure to surgical subspecialties could influence students to pursue a career in these fields 23–26 . In contrast, several surgical departments showed that early surgical exposure increased their understanding and interests; although, it did not affect their career choice 27 . Regarding urology, only a limited number of medical schools require a formal educational rotation in urological surgery; thus, medical students perceive their knowledge of urology as poor even when medical students are aware of urology as a specialty 28 . In contrast, clinical performance during a rotation at their school is the most important factor taken into account when choosing future urology residents 29 . Regarding timing, a report showed that third-year medical students were more likely to consider urology than final-year students due to multifactorial reasons 30 . Extrinsic and intrinsic motivation was correlated with several factors such as being female, personal choice, and positive attribute of determination 31 . Accordingly, this early exposure course, provided during fourth year, could be an effective initiation to a urological career for medical students prior to clinical clerkship. This study has several limitations. First, the number of students was small because this course was conducted by a single urology department at a medical school. Second, although an increase in scores for surgery and urology were found, we only evaluated the change in likely scores before and after the course. However, we did not compare this to a control group. Third, as students had not yet graduated and selected their specialty, the true outcome could not be evaluated, Further long-term studies are required to determine whether the course results in graduates selecting surgical or urological specialties. However, this study found that early exposure to hands-on training in urology increased students interest in urology. This course may be used by other departments to encourage students to learn or take up their specific specializations. Conclusions Urological hands-on training encouraged interest in urology among medical students prior to their clinical clerkship. Early experience in actual surgical techniques could motivate students to learn about surgical specialities during their clinical clerkship as well as encouraging them to pursue a career in a surgical specialty. Abbreviations PVP, photo-selective vaporization of the prostate TUL, transurethral lithotripsy TUR, transurethral resection Declarations Ethics approval and consent to participate This study was approved by the Ethics Committee at Medical school, University of Tsukuba (approval number 19-1394). The study participants provided written informed consent. Consent for publication Not applicable. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding No funding was received for this study. Authors' contributions TKi analyzed and interpreted this study data and write most of the manuscript. TKi, KK, AI, SK, TKo, and HN contributed this course as faculty members. JH was contributed important and unique insight to the article. All authors read and approved the final manuscript. 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10:22:02","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-19513/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-19513/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":810427,"identity":"c6e544b1-46da-4674-9d86-c92a0f13021c","added_by":"auto","created_at":"2020-03-31 19:06:11","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":77256,"visible":true,"origin":"","legend":"Rotation schedule of medical students \nStudents are divided into small groups of 2 or 3 students each, and they rotated through each procedure.","description":"","filename":"1.PNG","url":"https://assets-eu.researchsquare.com/files/rs-19513/v1/1.PNG"},{"id":810428,"identity":"6f006107-e39b-4754-bd2a-cffa96ca0ed5","added_by":"auto","created_at":"2020-03-31 19:06:11","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1051717,"visible":true,"origin":"","legend":"The schema of the arrangement of the training room and pictures of each procedure \nSmall groups move around the room in a circle, spending 30 minutes at each station.","description":"","filename":"2.PNG","url":"https://assets-eu.researchsquare.com/files/rs-19513/v1/2.PNG"},{"id":810429,"identity":"9b25a322-8fdc-426c-85de-9537f09a741a","added_by":"auto","created_at":"2020-03-31 19:06:11","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":35661,"visible":true,"origin":"","legend":"Likely scores of interest for surgery and urology before and after the course","description":"","filename":"3.PNG","url":"https://assets-eu.researchsquare.com/files/rs-19513/v1/3.PNG"},{"id":810430,"identity":"aaa30725-383e-4f78-b480-b69d09df7d4f","added_by":"auto","created_at":"2020-03-31 19:06:11","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":32065,"visible":true,"origin":"","legend":"Likely scores in each course after the training","description":"","filename":"4.PNG","url":"https://assets-eu.researchsquare.com/files/rs-19513/v1/4.PNG"},{"id":810431,"identity":"da260f0c-87dc-4f0d-ac57-cae511d8235b","added_by":"auto","created_at":"2020-03-31 19:06:11","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":42049,"visible":true,"origin":"","legend":"Time course of likely scores of interests for surgery and urology","description":"","filename":"5.PNG","url":"https://assets-eu.researchsquare.com/files/rs-19513/v1/5.PNG"},{"id":13496131,"identity":"21d53079-85db-4767-bbc6-6af7066057c1","added_by":"auto","created_at":"2021-09-16 22:48:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":627269,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-19513/v1/6b24c338-8b48-4825-a7b1-a402ba378ada.pdf"}],"financialInterests":"","formattedTitle":"Early exposure to hands-on surgical training encourages urological interest in undergraduate medical students","fulltext":[{"header":"Background","content":" \u003cp\u003eMedical school provides an opportunity to not only acquire the knowledge and skills but also experience in various specialties. Medical students in lower years of study, study and learn with the help of classroom lectures and other recently adopted clinically-oriented teaching methods\u003csup\u003e1\u003c/sup\u003e. After gaining basic medical knowledge, they learn skills through a rotating clinical clerkship over a period of 6\u0026nbsp;years after graduating from high school in Japan\u003csup\u003e2\u003c/sup\u003e. In addition to subject knowledge, medical students must learn the required attitude and skills that make them qualified to meet the needs of citizens\u003csup\u003e3\u003c/sup\u003e. In Japan, upcoming medical doctors should have clinical skills, especially in community-based health care for the super-aging society\u003csup\u003e4\u003c/sup\u003e. Thus, medical schools are modifying their curriculum to consider these societal needs. Thus, medical students obtain less experience in surgical subjects than in other essential medical specialties such as internal medicine, psychology, and primary healthcare\u003csup\u003e5\u003c/sup\u003e. To bridge this increasing gap in knowledge, several surgical departments have been trying to teach surgery more efficiently in an educational program (such as simulation-based learning) during clerkship.\u003c/p\u003e \u003cp\u003eSimulation-based learning is broadly used in medical schools globally. Simulation is very useful for beginners to learn invasive procedures, including the physical examination, puncture procedures, and emergency treatment\u003csup\u003e6\u003c/sup\u003e. To achieve better outcomes with simulation-based education, the following factors need to be considered: range of difficulty, repetitive practice, distributed practice, cognitive interactivity, multiple learning strategies, individualized learning, mastery learning, feedback, length of training, and clinical variation\u003csup\u003e7\u003c/sup\u003e. For expert training, more novel challenges are recommended. However, this adds to the financial cost and burden of faculties as simulation equipment is expensive and requires that instructors put in extra work. Nevertheless, simulation-based education is effective in imparting basic science and clinical knowledge and improving procedural skills, teamwork, and communication skills in undergraduate and graduate medical students\u003csup\u003e8\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eChoosing a specialty is one of the most important decisions for medical students\u003csup\u003e9\u003c/sup\u003e. In Japan, postgraduates rotate through several specialties within two years as junior residents before starting their training in their selected specialty\u003csup\u003e2\u003c/sup\u003e. Medical students and junior residents choose their specialty based on a variety of factors, including medical lifestyle, societal orientation, hospital orientation, scope of practice, and the impact of role models\u003csup\u003e10\u003c/sup\u003e. Compared to any other specialty, urology is less popular among medical students due to the misconception that urologists are generally male organ specialists\u003csup\u003e11\u003c/sup\u003e. A urologist deals with the entire genitourinary system of men and women. Moreover, the need for female urologists has increased over the past 10 years\u003csup\u003e12\u003c/sup\u003e. Medical students\u0026rsquo; misunderstanding of urology will remain uncorrected unless they are exposed to the correct clinical circumstances. Students are more likely to be influenced to pursue surgical careers if they are offered early exposure to positive role models and career and academic opportunities\u003csup\u003e13\u003c/sup\u003e. Thus, early involvement of medical students may provide ideal opportunities or mentored externships for recruitment, not only in urology but also in other departments.\u003c/p\u003e \u003cp\u003eThe school of medicine at the University of Tsukuba has given an \u0026ldquo;advanced course\u0026rdquo; to fourth-year medical students prior to starting their clinical clerkship. This short course consists of intensive lectures based on the concept of exposing pre-clinical clerkship students to recent, focused, and advanced medical issues. Several professors offer lectures on various disciplines such as basic science, medical statistics, internal medicine, psychology, surgery, anaesthesia, social medicine, and space medicine. Each student can select several courses in their fields of interest over one week. Our urology department has given hands-on seminars on endoscopic, laparoscopic, and robotic surgeries since 2012. Students who had attended this course were motivated to learn about surgery and were more interested in urology.\u003c/p\u003e \u003cp\u003eWe hypothesized that specific factors could contribute to urological and surgical experience and that a positive experience would be associated with students\u0026rsquo; interest in a career in not only surgery but also in urology. This study evaluated whether this urology course, designed to provide the required exposure to medical students, could cultivate an interest in surgery and urology among pre-clinical clerkship medical students.\u003c/p\u003e "},{"header":"Methods","content":" \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eCourse design\u003c/h2\u003e \u003cp\u003eA one-day elective course focused on hands-on training in urologic surgery, particularly robotic, laparoscopic, and endoscopic surgeries, was offered to fourth-year medical students of the University of Tsukuba in 2018 and 2019. Participants were separated into three groups. Subsequently, each group rotated through endoscopic procedures, laparoscopic suturing, and robotic surgery, respectively, over 2 hours (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The grouped students were further separated into four subgroups rotating through endoscopic workshops lasting for 30 minutes each, including cystoscopy, transurethral resection, laser prostatectomy, and transurethral lithotripsy (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn the robotic surgery course, students used the DaVinci skills simulator of preinstalled tasks including \u0026ldquo;Endo Wrist Manipulation\u0026rdquo;, \u0026ldquo;Energy and Dissection\u0026rdquo;, and \u0026ldquo;Needle Control and Driving\u0026rdquo;. In the laparoscopic course, the students were trained in suturing skills using string with a needle in a dry box. Meanwhile, the students in the endoscopic course were divided into 4 groups: transurethral resection (TUR), photo-selective vaporization of the prostate (PVP), cystoscopy, and transurethral lithotripsy (TUL). During the TUR session, the students cut into a konjac plate (a jelly-like food made from the starch of the konjac potato) under a saline pool using the TUR system. During the PVP session, the laser vaporization procedure was demonstrated to students using a PVP simulator. During the cystoscopy session, students performed the cystoscopy procedure using a flexible cystoscope on a flask, which resembled the urinary bladder. During the TUL session, students used a flexible ureteroscope and basket forceps to remove simulated renal stones out of a urinary tract model.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eEvaluation\u003c/h2\u003e \u003cp\u003eBefore the start of training, the participating students were asked to provide their demographic information in a pre-course survey. Moreover, they provided a self-assessment (1\u0026ndash;5 Likert-type items) on their interests. They checked the \u0026ldquo;5\u0026rdquo; score when they were very interested, while a \u0026ldquo;1\u0026rdquo; was scored when they were not interested at all. After the training, the participating students and faculty members were made to answer a post-course survey in which they were able to provide a free description to the questions. To evaluate the long-term effect of the course, we used a web questionnaire on participating students. Evaluation of the participating students was performed 3\u0026nbsp;months after having taken the course in 2018. Conversely, the evaluation done in 2019 was performed after 1\u0026nbsp;year. The questionnaire was the same as the provided self-assessment (1\u0026ndash;5 Likert-type items) and free description surveys.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eAssessment\u003c/h2\u003e \u003cp\u003eData for these evaluations were collected from all students enrolled in the course who completed the pre- and post-course surveys. We analysed the mean difference in the interest score in surgery and urology before and after the program using paired t-tests in 2018 and 2019. All data analyses were performed using JMP14 and Microsoft Excel\u0026reg;. Descriptive statistics, chi-square test, or Fisher's exact test were used, as appropriate. We also analysed the answers obtained from the free description section of the questionnaire.\u003c/p\u003e \u003c/div\u003e "},{"header":"Results","content":" \u003cp\u003eTwo-hundred and twenty-two medical students have selected to enrol in our course since 2012. Of these, 32 and 26 students took part in this course in 2018 and 2019, respectively (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The average age of participants was 22.2 (range: 21\u0026ndash;24) years and 22 (range: 21\u0026ndash;25) years in 2018 and 2019, respectively, among approximately 140 medical school fourth-year students. Overall, 34.4% and 38.5% of participants were female, respectively. Eleven urology faculty members including two female urologists and several staff members from the medical equipment company helped teach the workshops.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cdiv class=\"SimplePara\"\u003eBackground characteristics of participants\u003c/div\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eFiscal year\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e2018\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e2019\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cdiv class=\"SimplePara\"\u003eP-value\u003c/div\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eNo. of students\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e32\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e26\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eAge\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eMedian\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e22\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e22\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cdiv class=\"SimplePara\"\u003en.s.\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eRange\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e21\u0026ndash;24\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e21\u0026ndash;25\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eSex\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eMale\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e21\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003e65.6\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e16\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003e61.5\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd 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colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eCuriosity\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eInternal medicine\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e20\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003e62.5\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e15\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003e57.7\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cdiv class=\"SimplePara\"\u003en.s.\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eSurgery\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e22\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003e68.8\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e15\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003e57.7\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cdiv class=\"SimplePara\"\u003en.s.\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eUrology\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e14\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003e43.8\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e5\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003e19.2\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.044\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ePre-course likely score\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eSurgery\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eAverage\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.12\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.00\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cdiv class=\"SimplePara\"\u003en.s.\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eSD\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003e0.148\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003e0.111\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eUrology\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eAverage\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e3.53\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e3.15\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.06\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eSD\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003e0.149\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003e0.613\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003en.s: not significant, SD, standard deviation\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eBefore attending the course in 2018, the average interest scores in surgery and urology were 4.12 and 3.53, respectively. Those in 2019 were 4.00 and 3.15, respectively. Attending students were already interested in surgery but not in urology.\u003c/p\u003e \u003cp\u003eAfter training, robotic surgery was the most interesting to participants in both periods. Regarding laparoscopic suturing, single port surgery tended to have more of a \u0026ldquo;less likely\u0026rdquo; score than the 3-dimensional and 2-dimensional classical laparoscopic procedures. Endoscopic procedures such as TUR, PVP simulation, cystoscopy, and TUL were also attractive to medical students. The comprehensive evaluation scores of this course in 2018 and 2019 were 4.59 and 4.76, respectively (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the difference in likely scores before and after the course. After attending the course, the likely scores in surgery were higher, but this difference was not significantly different to that obtained prior to the course in both years. Interestingly, those of urology were significantly increased compared to those of the pre-course. Particularly, the number of students who selected a score of 5 increased, and the number of students who selected a score of 2 decreased (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Free description questionnaire results showed that medical students became more interested in urology and surgery and felt motivated for their clinical clerkship. Faculty members found the teaching workload and burden of costs too high; thus, they placed their clinical practice ahead of teaching the course. However, they felt that the course was very important for medical students in addition to clinical practice.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cdiv class=\"SimplePara\"\u003eLikely scores of interest for surgery and urology before and after the course\u003c/div\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003eSurgery\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003eUrology\u003c/div\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e2018\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e2019\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e2018\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e2019\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eAverage\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eBefore\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.13\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.00\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e3.53\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e3.15\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eAfter\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.34\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.27\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e3.91\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e3.88\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eEffect size\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.18\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.35\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.35\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.72\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eMean difference\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.22\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.27\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.38\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.73\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eStandard deviation\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.21\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.14\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.18\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.14\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eUpper 95%\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.65\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.56\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.74\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e1.02\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eLower 95%\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e-0.21\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e-0.02\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.01\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.44\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eP-value\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.30\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.07\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.04\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.00\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eTo evaluate the long-term effect of this course, we performed a post-course web questionnaire, with 13 (40.6%) students in 2018 and 17 (65.4%) in 2019 completing the questionnaire. Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows the results of the long-term evaluation. Regarding memory, \u0026ldquo;Remember the course\u0026rdquo; maintained very high scores of 4.53\u0026thinsp;\u0026plusmn;\u0026thinsp;0.50 3\u0026nbsp;months after the course and 4.62\u0026thinsp;\u0026plusmn;\u0026thinsp;0.49 1\u0026nbsp;year after the course. Regarding the effect on learning during clerkship, this course played a significant role on the effect of learning both surgery and urology. However, the scores obtained for interest in surgery and urology gradually decreased over time (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e.). The average likely scores dropped to below 4 in surgery and below 3 in urology.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cdiv class=\"SimplePara\"\u003eLong-term effect of this course\u003c/div\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e2018\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e2019\u003c/div\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003eAve\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eSD\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003eAve\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eSD\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eRemembering\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eWhole course\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.62\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003e0.49\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.53\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003e0.50\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eRobotic surgery\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.31\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003e0.82\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.12\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003e0.68\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eSingle port surgery\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e3.54\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003e1.08\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e3.47\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003e0.98\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e3-dimensional laparoscopy\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e3.62\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003e0.92\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.06\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003e0.64\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eLaparoscopic surgery\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.54\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003e0.63\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.12\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003e0.90\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eTUR\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e3.85\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003e0.86\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e2.65\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003e0.84\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003ePVP\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e3.85\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003e0.95\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e3.24\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003e1.06\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eCystoscopy\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e3.69\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003e0.99\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e2.82\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003e0.98\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eTUL\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e3.77\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003e0.89\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e3.00\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003e0.97\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eInterested in\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eSurgery\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.54\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003e0.63\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.24\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003e1.00\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eUrology\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e3.54\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003e1.01\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e3.24\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003e0.55\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eAffect the learning at clerkship\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eSurgery\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.15\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003e0.77\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.35\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003e0.76\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eUrology\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.23\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003e0.70\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e3.88\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003e0.68\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eCareer selection\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eSurgery\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e3.92\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003e0.92\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e3.76\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003e1.00\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eUrology\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e2.85\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003e1.03\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e2.47\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003e0.61\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eSD: standard deviation, ave: average, PVP: photo-selective vaporization of the prostate, TUL: transurethral lithotripsy, TUR: transurethral resection\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e "},{"header":"Discussion","content":" \u003cp\u003eAccording to this study, early exposure to urological hands-on training in pre-clinical clerkship students resulted in an increasing interest, especially in urology. Surgical training courses were generally conducted during clinical clerkship or postgraduate periods\u003csup\u003e14\u003c/sup\u003e. The most novel aspect of this study was conducting a hands-on course that focused on urological training in medical students prior to clinical clerkship.\u003c/p\u003e \u003cp\u003eEarly exposure is an effective method for educating medical students in not only basic science but also clinical clerkship\u003csup\u003e15,16\u003c/sup\u003e. This study showed that hands-on training in urologic procedures impacted on pre-clinical clerkship medical students as it increased their interest in urology. However, this course did not increase the interest in surgery among students who already had an interest in surgery prior to the course. Thus, it was of limited value to those who showed an interest prior to the course. In contrast, this course made a good impression on students with regards to urology. Generally, there were more students interested in surgery than in urology at the beginning of the course. Moreover, what urologists do is relatively unknown to the public compared to what is done in surgery, internal medicine, paediatrics, and other specialties. The lesser-known specialities may be able to promote their specialty and the roles they play to medical students in their earlier years of training as well as the public. As medical students are rarely provided with experience in performing not only surgical procedures but also independent simulated surgeries prior to undergoing their clinical clerkship, this course could have a great impact on medical students prior to their clinical clerkship.\u003c/p\u003e \u003cp\u003eAs a systematic review and meta-analysis showed that technology-enhanced simulation was more effective than instructional methods, actual experience could be beneficial for learners\u003csup\u003e17\u003c/sup\u003e. In this course, students could perform surgical procedures and use simulators for a certain amount of time under the supervision of several faculty members. Regarding endourologic skills, early feedback can be beneficial when learning through novel simulation training\u003csup\u003e18\u003c/sup\u003e. Thus, these experiences may encourage students to learn surgery and urology further following their clinical clerkship. However, numerous experiences may influence their choices because medical students must rotate through several subjects for a long period of time during their clerkship. Recently, motivation was found to be one of the most important factors for continuing learning in the field of medical education\u003csup\u003e19\u003c/sup\u003e. To maintain and improve the effect of the course, surgeons and urologists should continue offering students the opportunity to obtain surgical experience and the opportunities provided to them during their surgery and urology rotations should be performed using technical and educational approaches such as the motivational dynamic model \u003csup\u003e19\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eEarly clinical experience as a degree on influence on the selection of a particular career by undergraduate students\u003csup\u003e7\u003c/sup\u003e. In Japan, medical students usually undergo a 2-year primary resident course followed by a 4-year specialized medical course to pursue their career path\u003csup\u003e20\u003c/sup\u003e. The career chosen by medical students depends on their experiences since birth and their own prerogatives. Particularly, parental career expectations may also have an impact on their career choice\u003csup\u003e21\u003c/sup\u003e. However, for medical undergraduates, exposure to specialties and the timing of this exposure are crucial to career choice; this is true for any specialty\u003csup\u003e22\u003c/sup\u003e. Medical students should rotate through several departments during their clinical clerkship, although not through all departments. Most medical school curriculums tend to focus on good clinical practitioners who are trained to care for a super-aging society; thus, the time spent rotating through surgical departments is likely to decrease. This limits the exposure of students, particularly those with an interest in surgery, to non-essential subjects. Several medical experts have been trying to recruit young doctors and medical students in Japan as junior residents are able to select their specialty of choice freely. As there are several reports showing that short courses and surgical simulations could influence their choice in career specialty, early exposure to surgical subspecialties could influence students to pursue a career in these fields\u003csup\u003e23\u0026ndash;26\u003c/sup\u003e. In contrast, several surgical departments showed that early surgical exposure increased their understanding and interests; although, it did not affect their career choice\u003csup\u003e27\u003c/sup\u003e. Regarding urology, only a limited number of medical schools require a formal educational rotation in urological surgery; thus, medical students perceive their knowledge of urology as poor even when medical students are aware of urology as a specialty\u003csup\u003e28\u003c/sup\u003e. In contrast, clinical performance during a rotation at their school is the most important factor taken into account when choosing future urology residents\u003csup\u003e29\u003c/sup\u003e. Regarding timing, a report showed that third-year medical students were more likely to consider urology than final-year students due to multifactorial reasons\u003csup\u003e30\u003c/sup\u003e. Extrinsic and intrinsic motivation was correlated with several factors such as being female, personal choice, and positive attribute of determination\u003csup\u003e31\u003c/sup\u003e. Accordingly, this early exposure course, provided during fourth year, could be an effective initiation to a urological career for medical students prior to clinical clerkship.\u003c/p\u003e \u003cp\u003eThis study has several limitations. First, the number of students was small because this course was conducted by a single urology department at a medical school. Second, although an increase in scores for surgery and urology were found, we only evaluated the change in likely scores before and after the course. However, we did not compare this to a control group. Third, as students had not yet graduated and selected their specialty, the true outcome could not be evaluated, Further long-term studies are required to determine whether the course results in graduates selecting surgical or urological specialties. However, this study found that early exposure to hands-on training in urology increased students interest in urology. This course may be used by other departments to encourage students to learn or take up their specific specializations.\u003c/p\u003e "},{"header":"Conclusions","content":" \u003cp\u003eUrological hands-on training encouraged interest in urology among medical students prior to their clinical clerkship. Early experience in actual surgical techniques could motivate students to learn about surgical specialities during their clinical clerkship as well as encouraging them to pursue a career in a surgical specialty.\u003c/p\u003e"},{"header":"Abbreviations ","content":"\u003cp\u003ePVP, photo-selective vaporization of the prostate\u003c/p\u003e\n\u003cp\u003eTUL, transurethral lithotripsy\u003c/p\u003e\n\u003cp\u003eTUR, transurethral resection\u003c/p\u003e"},{"header":"Declarations ","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethics Committee at Medical school, University of Tsukuba (approval number 19-1394). The study participants provided written informed consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTKi analyzed and interpreted this study data and write most of the manuscript. TKi, KK, AI, SK, TKo, and HN contributed this course as faculty members. JH was contributed important and unique insight to the article. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank Editage (\u003ca href=\"http://www.editage.com\"\u003ewww.editage.com\u003c/a\u003e) for editing and reviewing this manuscript for English language.\u003c/p\u003e"},{"header":"References ","content":"\u003col\u003e\n\u003cli\u003eZinski A, Blackwell KTCPW, Belue FM, Brooks WS. Is lecture dead? A preliminary study of medical students\u0026rsquo; evaluation of teaching methods in the preclinical curriculum. Int J Med Educ. 2017;8:326-33.\u003c/li\u003e\n\u003cli\u003eOnishi H. History of Japanese medical education. Korean J Med Educ. 2018;30:283-94.\u003c/li\u003e\n\u003cli\u003eDensen P. Challenges and opportunities facing medical education. 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Minerva Urol Nefrol. 2016;68:409-16.\u003c/li\u003e\n\u003cli\u003eKunanitthaworn N, Wongpakaran T, Wongpakaran N, Paiboonsithiwong S, Songtrijuck N, et al. Factors associated with motivation in medical education: a path analysis. BMC Med Educ. 2018;18:140.\u003c/li\u003e\n\u003c/ol\u003e\n"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"early exposure, urology, surgical skills, career choice","lastPublishedDoi":"10.21203/rs.3.rs-19513/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-19513/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: Urological education is as important as surgical training for undergraduates. However, those in undergraduate medical schools have less exposure to surgery and urology as their curriculum focuses more on clinical skills, particularly community-based healthcare for a super-aging society. This study aimed to evaluate whether urologic hands-on training could encourage surgical and urological interest in medical undergraduate students.\u003c/p\u003e\u003cp\u003e Methods: A one-day elective program in urologic surgery at the University of Tsukuba, particularly in robotic, laparoscopic, and endoscopic surgeries, was offered to 58 fourth-year medical students in 2018 and 2019, prior to their clinical clerkship. The average age of participants was 22 (range: 21–25) years. We assessed scores (1–5 Likert-type items) in training activity, interest in surgery, and interest in urology before and after the course. \u003c/p\u003e\u003cp\u003eResults: Before attending the program, average scores in interest in urology were 3.53 in 2018 and 3.15 in 2019. After training, the total likely scores of this program in 2018 and 2019 were 4.59 and 4.76, respectively. The likely scores in surgery increased after the program; however, this was not significantly different to that prior to the program. However, the average interest scores in urology were significantly increased to 3.91±0.63 (p\u0026lt;0.05) and 3.88 ± 0.58 (p\u0026lt;0.01) in 2018 and 2019, respectively, indicating a motivation to pursue surgery and urology following clinical clerkship, 1 year after training.\u003c/p\u003e\u003cp\u003e Conclusions: Urological hands-on training facilitated interest in urology in medical students prior to their clinical clerkship. Early experience in actual urological procedures could encourage medical students to consider specializing in urology and pursue a career as a urological specialist.\u003c/p\u003e","manuscriptTitle":"Early exposure to hands-on surgical training encourages urological interest in undergraduate medical students","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2020-03-31 19:06:09","doi":"10.21203/rs.3.rs-19513/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cd1d769a-eaa3-4d11-8cf0-cb4b7b4ec746","owner":[],"postedDate":"March 31st, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":77193,"name":"Urology \u0026 Nephrology"},{"id":77194,"name":"Educational Philosophy and Theory"}],"tags":[],"updatedAt":"2020-05-29T03:02:05+00:00","versionOfRecord":[],"versionCreatedAt":"2020-03-31 19:06:09","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-19513","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-19513","identity":"rs-19513","version":["v1"]},"buildId":"rHA-KDH7Qsr4HCuvH75dn","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}