Anatomic donor surgeries increase self‐efficacy in physical therapy education: Use of live versus recorded viewing

Anatomy serves as a foundational course in physical therapy education, but, due to its early placement in the curriculum, may have limited clinical application at that point of a student's education. Thus, augmenting a standard dissection course with surgical procedures can enhance the clinical relevance and knowledge of the anatomical structures involved in those surgeries. Doctor of Physical Therapy students viewed a variety of cadaveric orthopedic and cardiothoracic surgeries performed by a surgeon. Students unable to participate live viewed the recorded surgeries. Participants completed a 10‐point Likert scale survey, developed by the researchers, pre‐ and post‐viewing, on self‐efficacy of knowledge, patient intervention and communication. Data analysis revealed improved self‐efficacy of knowledge of the anatomy and the surgical procedures, confidence in treating patients undergoing those surgeries, and confidence communicating with surgeons, regardless of whether students viewed the surgeries live or recorded. Students participating in this experience expressed a clear value enhancement on their education. Programs should feel confident that this type of experience in the curriculum, whether live or recorded, will have a positive effect on student self‐efficacy as related to the relationships and pertinence of anatomical structures involved in the surgeries, the surgical procedures, treating patients having undergone those surgeries, and interprofessional communication.

dissection and digital instruction or hybrid approaches for shortterm academic performance.Estai and Bunt (2016) report that the best way to teach modern anatomy for clinical carryover is a multimodal approach incorporating various pedagogical resources.Good et al. (2013) found that the vast majority of preclinical allied health students employed a multimodal approach to learning and studying content.One option for the multimodal approach discussed in the medical literature is to incorporate surgical procedures into anatomy instruction.Rather than focusing solely on individual structures, by incorporating surgical procedures into the foundational anatomy content, knowledge and appreciation of the anatomical structures and their relationships to each other are enhanced (Jordan et al., 2016), thus optimizing the applicability to clinical practice.
Additionally, by fostering a deeper appreciation of the importance of anatomical knowledge in clinical practice, synergies and integration between the foundational anatomy course taught early in a student's education and pathophysiological principles and patient management offered later in health education programs can be fostered.This integration of contextual anatomy through varied experiences potentially enhances the student's self-efficacy of the information.This in keeping with the recommendations of Carroll et al. (2021) on the importance of stressing clinical relevance in anatomy education.
Curriculum of the Wingate University Physical Therapy program is a scaffolding of didactic and clinical content so that courses appearing later in the curriculum build upon earlier courses.The first-year courses are primarily foundational science-based content (anatomy, neuroscience, research, physiology, pathophysiology) with clinically oriented content offered later in the first year and throughout the second year of the three-year curriculum.Thus, with scant clinical relevance present in the first semester, knowledge, retention and application of the anatomical foundational science course content to the clinical sciences may be limited.This study will describe a multimodal presentation experience for learning didactic content, incorporating material that spans multiple courses (anatomy, orthopedics, cardiovascular content, interprofessional education, and professional communications) to engage the learner and integrate content and application of the material in a clinically oriented manner.Wilson et al. (2018) pondered whether the preference to perform traditional dissection over digital mediums may be related more to students' confidence levels of their ability to demonstrate clinically oriented anatomy knowledge rather than actual academic performance.Self-efficacy has been defined by Bandura "as people's judgments of their capabilities to organize and execute courses of action required to attain designated types of performances" (Artino, 2012).Simply put, those with higher levels of self-efficacy believe that they can more readily perform a task, while those with low self-efficacy believe they cannot successfully complete a task.Development of self-efficacy of any subject matter is reliant on varied experiences specifically related to that topic.Previous studies have demonstrated the relationship between students' self-efficacy and clinical reasoning (Venskus & Craig, 2017), as well as between self-efficacy and academic didactic performance (Burgoon et al., 2012).The highest levels of accuracy in clinical reasoning among clinicians is observed in individuals who demonstrate the highest levels of selfefficacy (Venskus & Craig, 2017).Burgoon et al. (2012) found that higher levels of anatomical self-efficacy led to higher academic performance in a human anatomy course.
Previous research has explored approaches to improving selfefficacy as it relates to anatomy and clinical reasoning.High-fidelity simulation has been shown to improve students' self-efficacy in readying for practice in the acute care setting (Silberman et al., 2015).
A systematic review by Karbasi and Niakan Kalhori (2020) found that virtual technologies are effective for teaching clinical anatomy to medical students and recommended that it be studied in other health disciplines.Cadaveric surgeries, as a simulation of an actual surgical situation, have been a staple of surgical training (Minhao et al., 2018) but have rarely been used in health professions' foundational anatomy courses.Given the results of prior studies on both self-efficacy and multimodal learning, it is reasonable to assume that student participation in witnessing cadaveric surgeries could improve their self-efficacy related to anatomical knowledge and management of post-surgical patients.In consideration of Wilson et al. (2018) findings noting no difference between traditional dissection and digital or hybrid approaches for learning clinical anatomy, the question remains whether viewing live demonstrations of cadaveric surgeries or recorded versions would impact self-efficacy in different ways.Hew and Lo (2018) conducted a meta-analysis to determine if a flipped model classroom as compared to a standard classroom approach for medical professional students improves learning.The flipped classroom approach involves watching a pre-recorded lecture which can be a video or podcast prior to attending class, then completing activities such as a quiz or discussion during class time, as compared to a traditional class format where there is a lecture and then a potential take home assignment.Across all studies in the meta-analysis, the flipped classroom method was preferred, as students could watch the video or listen to the lecture on their own time and at their own pace with unlimited access.Class time could then be used for discussion and application of the learned material.Given the various formats that simulation can take, and the traditional hands-on nature of an anatomy dissection course, it is important to determine whether live or recorded simulation leads to better self-efficacy.
Both Prince (2004) and Cake (2006) noted that direct experiential opportunities are necessary for cultivating deep learning.With this in mind, the primary purpose of this quasi-experimental study was to investigate whether witnessing orthopedic and cardiothoracic cadaveric surgeries would improve Doctor of Physical Therapy (DPT) students' self-efficacy as related to the anatomic knowledge and patient management of these post-surgical patients.Additional aims were to assess the impact of the experience on interprofessional communication, and to collect value statements and ratings from those who participated.Lastly, we wanted to determine if there was a difference in student perceived self-efficacy between those who viewed the surgeries live versus those who viewed a recording of the surgical procedures.The primary hypothesis was that there would be a significant increase in self-perceived understanding of anatomical knowledge and surgical procedures performed on a human donor and improved self-efficacy in treating patients who have undergone those surgeries in both those who view it live and those who watch a recording of the surgeries, with those watching the live demonstration showing greater gains than those who viewed the recording.
The secondary hypothesis was that there would be increased selfefficacy in professional communication in those who viewed the live demonstrations over those who viewed it on a recording.An orthopedic surgeon and a cardiothoracic surgeon from a local hospital system each donated their time conducting surgeries in the educational institution's anatomy lab.These two specialties were chosen since (1) musculoskeletal conditions comprise a significant portion of the content on the licensing exam (FSBPT, 2023), and (2) knowledge of the anatomy of cardiothoracic structures and corresponding cardiopulmonary medical conditions are a common weakness for physical therapy students (FSBPT, 2023), but an important content area to grasp.The surgeons each had over 10 years of experience in their respective specialties, were board-certified, and had experience teaching medical residents and supervising surgical residents.

ME THODS
Equipment vendors donated the supplies needed to perform a total knee arthroplasty (TKA), a hip hemiarthroplasty (HA), a quad tendon graft ACL reconstruction (ACL), and an aortic valve replacement, as well as a full arthroscopic setup, clamps, sutures, and other necessary surgical tools (Figure 1).The surgeons provided detailed descriptions of the surgeries, pertinent anatomical structures associated with each surgical technique, pathology and rehabilitation implications as they were performing the surgical procedures.First (DPT 1) and second year (DPT 2) students were invited to participate in the live sessions.
DPT students who were observing live were able to freely ask questions of the surgeon and assist, as able, in the surgeries performed.
These conversations, as well as the surgeries, were recorded for the recorded versions.Each surgical session lasted approximately 3 h.Surgeries were recorded using a permanently mounted camera system in the anatomy lab, a GoPro™ (Hero 8) and an iPad Air™ (4th generation) to capture multiple viewing angles.Videos were then edited and uploaded to a secured and unlisted YouTube channel with the course instructor controlling access to the links.Viewing statistics were not captured as students watched the videos while in class; those who viewed the recorded procedures did so during their patient management courses related to that content area, specifically the lower limb orthopedics and cardiopulmonary courses.Using IBM SPSS v.24 (Armonk, NY) for all analyses, a nonparametric within groups pre-and post-analysis with a Wilcoxon Signed Rank was utilized for each arm of the study.Differences in pre-and post-measures between viewing live and viewing the recorded surgeries for all dependent variables was analyzed using a nonparametric Mann-Whitney U test.GPA data for between group differences of live versus recorded for both the orthopedic and cardiothoracic surgeries was also analyzed using a Mann-Whitney U test.Significance was set at p ≤ 0.05.Anecdotal comments regarding overall value of the experience were also collected.This was not a true mixed methods analysis as a thematic approach was not utilized.Students were simply asked to comment on the experience.

RE SULTS
There was no significant difference in the professional program cumulative GPAs of students who viewed the orthopedic surgeries (p = 0.204) or the cardiothoracic surgery (p = 0.205) live versus recorded.Differences in GPA between cohort levels was not calculated as the only session that had a significant mix of first-and second-year students was the cardiothoracic live surgical session.

Orthopedic surgeries
Data analysis revealed that there was a statistically significant improvement in efficacy related to anatomic knowledge, knowledge of the surgery, and patient management for all students for ACL reconstruction, TKA and HA surgeries, regardless of whether they viewed it live or on a recording (see Table 1 for median, range and significance data).Viewing the surgeries live versus viewing them from a recording made no difference on improving self-efficacy (Table 2 for mean rank, U-value and significance).Those interacting live with the surgeon showed a statistically significant improvement in comfort related to interacting and communicating with the orthopedic surgeon (Table 3 for median, range and significance).Efficacy for communication was not collected for the group who viewed recorded orthopedic surgeries.

Cardiothoracic surgeries
Data analysis revealed significant improvements in self-efficacy re- those viewing the procedure live (Table 4 for median, range and significance).Similar to the data on orthopedic surgeries, there was a statistically significant difference in comfort level talking with a surgeon pre and post participation in the live experience (p < 0.0001, Table 3).
Data analysis for those viewing the surgeries through the recorded medium revealed significant improvements in efficacy related to knowledge of the valve replacement surgery performed (p < 0.001), knowledge of treatment for patients having that surgery (p = 0.021) and knowledge of the anatomical structures involved in that surgery (p = 0.015; Table 4 for median, range and significance).
However, different from the orthopedic surgeries, although all subjects improved in all surveyed items, there was a significant difference in all survey responses between those who viewed it live and those who viewed the recorded surgery, with those viewing it live scoring significantly higher in all categories (Table 5 for mean rank, U-value and significance).
Participants who viewed the recorded cardiothoracic surgery also showed increased comfort speaking with a surgeon (p < 0.001), although they did not have any live interaction with the surgeon (Table 3).TA B L E 2 Orthopedic surgery analysis between those viewing live versus recorded.

Overall value of experience
Participants rated the overall of this experience high (Table 6).
Students' subjective comments supported the value ratings found quantitatively.Students overwhelmingly stated the experience was valuable to their education and enhanced their understanding of the anatomical structures involved in the surgeries and the surgical procedures themselves (Appendix B).

DISCUSS ION
Our results show clear value in students observing cadaveric surgeries in either a live or recorded format.DPT students demonstrated noted improvement in self-efficacy related to knowledge of the surgery, knowledge of the anatomic relationships of structures, and confidence in treating patients with both orthopedic and cardiovascular dysfunction.There was also greater self-efficacy for professional communication with surgeons regardless of whether they viewed the surgical sessions live or on a recorded medium.
The multimodal approach used in our study to learn the associated anatomy involved in a variety of surgeries led to improved confidence in all areas.We surmise that viewing the surgery and hearing its step-by-step approach, seeing firsthand the importance of considering anatomical relationships, and being able to query the surgeon on: (1) the surgical implications for successful rehabilitation, (2) the involved and injured tissues and (3) the application of this knowledge to clinical practice, clearly enhanced confidence with the content.And although raw knowledge was not assessed, it is reasonable to speculate that confidence with the content could signify knowledge translation.Nicholson et al. (2016) found that a multimodal approach to learning anatomy led to improved examination performance and deeper learning in health science students.Although Nicholson et al. (2016) used clay modeling, body painting, and frequent quizzes, it highlights the ability to tap into different learning styles and enhance engagement in the content.
Learning preferences have primarily been cataloged into visual, auditory, read/write, and kinesthetic with the acronym VARK.Khanal et al. (2014) performed a literature review and found that, worldwide, multimodal learning, using combined elements of VARK, is preferred.However, a study by Husmann and O'Loughlin (2019) found little to no benefit in academic performance in an anatomy class when undergraduate students used their preferred, primary VARK learning style for studying.However, they did note in that study that up to 68% of students self-identified as having a multimodal learning style, incorporating two or more elements of the VARK.This is in keeping with comments by Wilson et al. (2018) who posited that a multifaceted approach to learning anatomy has the greatest chance of fulfilling the needs of diverse learning populations.
Our results are in keeping with previously published studies regarding participation in cadaveric surgery for medical students as well as active and engaged multimodal learning in simulation scenarios for the health professions.(Brown et al., 2008;Jeyakumar et al., 2020).Interestingly, in our study, there was no difference in outcomes between viewing the surgeries live versus viewing them from a recorded video for the orthopedic surgeries.Cardell et al. (2008) found that medical students at Harvard found recorded lectures to be equally or more valuable as live lectures.For the purposes of our study, this implies that students can benefit from viewing surgeries from readily available videos on common social media servers or medical library holdings rather than programs needing to have the facilities and partnerships to participate in live sessions.While both the live and recorded groups in our study showed improvements in efficacy related to knowledge of the associated anatomy for both orthopedic and cardiothoracic surgeries a secondary, but significant value in our live experience was the opportunity for our students to interact professionally and genuinely with the surgeons and ask questions at will, and in real time in a small group setting.This was evident in the cardiothoracic aspect of the study where there was a clear difference in efficacy and knowledge gained between the live TA B L E 5 Cardiovascular surgery analysis between those viewing live versus recorded.session the recorded session.We surmise that because students of physical therapy generally more comfortable with the musculoskeletal system than the cardiovascular system, the ability to interact with the cardiothoracic surgeon in real time and ask questions in the moment may have led to greater self-efficacy in that subgroup as compared to those who viewed the recorded session.This was also the only arm of the study that had a significantly mixed group of DPT 1 and 2 students participating, so greater gains might have been seen in the DPT 1 students' confidence since they had very little exposure to this content previously, thus skewing the overall results in favor of greater efficacy gained in the live-viewing group.

Onsite
Self-efficacy improved as evidenced by the subjects' selfperceived improvements in knowledge and confidence.Forbes et al. (2018) found that students of physical therapy who reported a learning experience as "significant" as compared to those rating an experience as "not significant" regarding patient education, were more likely to demonstrate improved self-efficacy for that task.
The anecdotal comments of students, coupled with the relatively high median score for overall value of the experience demonstrate the noteworthy effect of this experience.The overall median value scores ranged from 7-10 with recorded cardiothoracic surgeries having the lowest value median score at 7/10 and both live surgery sessions scoring 10/10.This may point to the general unease which many students express with cardiovascular content and the perceived benefit of having been able to attend in person and interact with the surgeon.The cardiothoracic in-person experience was valued identical to the onsite orthopedic experience.
There were a few limitations in our study.The most notable was that students from only one DPT program were involved in the study and results may not be applicable to other programs of physical therapy study.Secondly, we employed a relatively small number of participants in each subgroup which limits application of the findings to the broader community and we used mixed groups of students at different levels in their educational journey.And although all participants improved in self-efficacy, it is logical to surmise that students at different levels of their education might experience the surgeries differently.However, the small number of students limited our ability to stratify analysis by cohort year.Because participants viewing the surgeries live volunteered to do so, that may have skewed results in favor of those with a greater interest in those areas of practice and thus, greater interest in learning the topic.Similarly, students were aware that the researchers felt this experience was valuable to their education which may have impacted responses.Lastly, our survey was not externally validated in other populations of students.

CON CLUS IONS
Students who engaged in viewing orthopedic and cardiothoracic ca- Great experience.I am glad I was able to be a part of it I thoroughly LOVED this experience.If I could do it again, I'd doing it in a heartbeat.On the serious side, this was a very insightful and priceless experience and I was very happy that I was able to be a part of this I feel one benefit from this experience would be able to explain the general procedure to my patient to give them a better understanding and show them that I understand what they have been through All DPT 1 and DPT 2 students were invited to view the surgeries live, but attendance was limited to the first 25 to respond to the invitation.This convenience sample of students participated in the live surgical sessions, whereas viewing the recorded videos was a requirement of the corresponding clinical management course (Figures2 and 3).The first arm of the study involved ten DPT 1 and four DPT 2 students who observed live and/or assisted during an arthroscopic ACL reconstruction, a TKA and an HA performed on a cadaveric human donor (Figure4).During the second arm of the study, 23 DPT 2 students watched a video during their lower extremity musculoskeletal course showing the full arthroscopic ACL reconstruction, TKA and the HA which had been performed (Figure5).During the third arm of the study, 12 DPT 1 and 10 DPT 2 students observed aortic valve replacement surgery live (Figure 6), with the fourth arm having 20 DPT 2 students observe the videotaped recording during the Diagnosis and Management of Cardiopulmonary Conditions course.Data was collected for each participant on year in program and professional program GPA, but not gender or age.Students completed a pre-and post-survey assessing selfefficacy of knowledge of the surgical technique and the associated anatomy, and efficacy for treating patients who have undergone those surgeries.They were also queried on their confidence speaking to surgeons and their overall value rating of the experience.

F
I G U R E 1 Live orthopedic surgery setup.Each question was scored on a 10-point Likert survey question (see Appendix A for survey tools).The surveys used were developed from those used in a prior study completed at this institution on efficacy of anatomical knowledge after a community-based anatomy open house experience.An initial draft of the survey used in the current study was reviewed by an anatomist and a physical therapist involved in that prior study.Revisions were suggested to clarify the efficacy outcome desired.

F
I G U R E 3 Orthopedic surgery flowchart.*DPT1 Completed Coursework (December 2020): Anatomy, neuroscience, physiology, pharmacology, pathophysiology, basic assessment and intervention, kinesiology, professionalism, upper limb orthopedics, and amputation.+ DPT2 Completed Coursework (Summer, 2011): All of the DPT1 coursework (above), plus: neurologic conditions, lower limb orthopedics, cardiopulmonary, differential diagnosis, special populations, clinical internship 1 (8 weeks).^DPT2 Completed Coursework (Summer, 2021): All of the DPT1 coursework (above), plus acute care, motor development, neurologic conditions.In process coursework: lower limb orthopedics and advanced neurologic conditions.Based on that revision, the final surveys were generated.Surveys were distributed via Qualtrics™ (Seattle, WA) immediately preceding and following the live or recorded viewing.Included in the postexperience surveys was a final question asking the participant to comment on the experience.That was the extent of the anecdotal, qualitative information received.
lated to knowledge of the valve replacement surgery, confidence treating patients having undergone that surgery and understanding of anatomical relationships at the p < 0.0001 significance level for F I G U R E 4 Live orthopedic surgery.F I G U R E 5 Recorded orthopedic surgery.

TA B L E 4
Efficacy of knowledge, treating patients with the surgeries and anatomical structures of cardiovascular surgeries pre-and post-viewing.Communication with the surgeon pre-and post-viewing.
Student value ratings of live and recorded experiences using a 0-10 Likert survey question.
daveric surgeries, both live and recorded, improved their self-efficacy in anatomy knowledge, confidence in treating patients with TKA, partial THR, ACL reconstruction and cardiothoracic surgeries, as well as comfort communicating with surgeons.While not all educational programs can engage in this activity and only a limited number of students have the opportunity to view a surgery during their clinical education experiences, programs should feel confident in knowing that participating through available recorded platforms showed similar results to viewing the surgeries live.Future studies should investigate whether there is actually a change in student content knowledge and whether there is long-term retention of covered material.ACK N OWLED G M ENTSThe authors wish to thank Tom Theruvath, MD and Tim Ewald, MD for donating their time and sharing their surgical expertise, as well as Novant Health and Greg Bielec, PT, DPT, MBA for partnering with us on this project.Jeremy Overfelt from Arthrex and Michael Kidd from DePuy Synthes provided surgical supplies necessary to perform the surgeries.However, there was no conflict of interest as the vendors were chosen by the surgeons and not the educational program.Portions of this data were previously presented at the 2020 Educational Leadership Conference of the American Council of Academic Physical Therapy as well as the 2021 Combined Sections Meeting of the American Physical Therapy Association.It was a good learning experience!It was helpful to see what muscles were cut through in order to better understand precautions for our patients This was very helpful!It allowed me to see the structures in relation to one another and to begin tying it to my treatment sessions with these patients It was interesting to see the hardware used and the force required to place the hardware.The video helped to reinforce the anatomy and the kinematics of the hip Very beneficial to know how the surgery is performed!Very helpful to visualize what the process looks like I really enjoyed seeing how this procedure is performed, it helps provide a visual to what we have learned in class I think this is a great idea and very valuable for PT's to truly understand what they're working with!Enjoyed watching these videos!It was interesting to gain some insight on the surgery This was helpful to see the structures that end up being involved in this surgery I had this surgery so it's super interesting to see what happened!It was interesting to observe the surgery completed through arthroscopy.Because the ACL repair is arthroscopic, it reinforces the importance of knowing the anatomy and landmarks for a successful surgery.It was a great learning experience to see the technology and tools utilized throughout the procedure, along with the explanations of each step throughout the procedure For how common of a procedure this is and for how often we will see this in outpatient clinics, this was extremely helpful!Very neat to actually see the structures we learn about.Much easier to visualize and follow along with a video So cool to see what is done in the ACL reconstruction Thankful for the videos!It was helpful to learn what anatomical structures are replaced I order to help shape interventions, as well as learning about possible outcomes we will see following surgery This was very helpful in seeing what structures patients no longer have after a TKR, so we can alter our treatment plans accordingly Very valuable to see the trauma that the body undergoes during a TKR.Increased understanding of the anatomy as it relates to the kinematics of the knee Hard to watch but beneficial I feel like I have a much better understanding of this procedure and what is done Amazing what they can do!Very interesting!Enjoyed the videos!This was very cool and beneficial!I think it was very beneficial because now I have a better understanding of what surgery they had and how I could potentially help them Cardiothoracic surgery Very helpful, learned a lot This was a very valuable and amazing opportunity!I would jump at the opportunity to do it again if it comes up/presents itself.It gave insight to what our patients will go through Loved it!Was probably one of the most interesting educational experiences I have ever had.It felt very relaxed and the surgeon explained every very well.Definitely would do it again The majority of students enter the program with an undergraduate degree in exercise science or kinesiology.The average age of entering students is 23 years old and the average undergraduate GPA is approximately 3.45.This study received approval from Wingate University's Research Review Board, protocol #KF120320.There is no separate Anatomical Review Board at Wingate University.