Urology boot camp for medical students: Using virtual technology to enhance undergraduate education

Abstract Objectives The study aims to describe the methodology of converting the urology boot camp for medical students into a virtual course with key take home points for a successful conversion and to present quantitative and qualitative data demonstrating the impact of the boot camp on improving delegates' knowledge and clinical acumen. Materials and methods The face‐to‐face boot camp was converted to a virtual format employing a variety of techniques including; utilizing an online platform to deliver live screened lectures, using online polling software to foster an interactive learning environment and displaying pre‐recorded videos to teach practical skills. Validated Multiple Choice Questionnaires (MCQs) were used prior to and after the course. This enabled the assessment of delegates' knowledge of urology according to the national undergraduate curriculum, and paired t tests were used to quantify the level of improvement. Thematic analysis was carried out on post‐course delegate feedback to identify highlights of the course and ways of improving future iterations. Results In total, 131 delegates took part in the pilot virtual course. Of these, 105 delegates completed the pre‐ and post‐course MCQs. There was a statistically significant improvement in the assessment following the course (p = <0.001) with mean score increasing from 47.5% pre‐course to 65.8% post‐course. All delegates who attended the most recent implementation of the virtual course (n = 31) felt it improved their knowledge and confidence in urology. Twenty delegates (64.5%) felt that it prepared them for both final year medical school examinations and working as a foundation year doctor. Positive themes in feedback were identified, which included the interactive nature of the course, the quality of teaching, the level and content of information provided and the high yield, concise organization of the teaching schedule. Conclusion Using virtual technology and innovative educational frameworks, we have demonstrated the successful conversion of the urology boot camp for medical students to a virtual format. At a national level, with support from the British Association of Urological Surgeons, the face‐to‐face component of the course will continue to run in parallel with the virtual course with the aim of standardizing and improving UK undergraduate urological education. The virtual course has been implemented on an international scale, and this has already shown promising results.

UK undergraduate urological education. The virtual course has been implemented on an international scale, and this has already shown promising results.

K E Y W O R D S
online learning, simulation, surgical training, undergraduate medical education, urology boot camp, virtual technology

| INTRODUCTION
The coverage of and exposure to urology in medical school curricula across the UK is often variable and sometimes lacking. 1 This is despite urological conditions accounting for over 25% of acute surgical referrals and 10%-25% of all general practitioner appointments. 2 The urology boot camp for medical students is a registrar-led 1-day course of compact, high-intensity learning that covers the entire undergraduate urology curriculum. 2,3 The core components of the course are displayed in Figure 1. It combines theory-based learning with practical skills with the aim of equipping delegates with the knowledge and clinical acumen to pass their medical school final examinations and be competent in managing urological conditions as foundation year doctors. The urology boot camp for medical students has been running for over 5 years now and has become an integral course for medical students at the University Hospitals of Derby and Burton, UK. Its effectiveness and high yield for educational value has been previously published, with excellent results in improving knowledge, skills and confidence. 3 Part of what has made this course successful and popular amongst medical students has been its focus on interactive teaching, hands-on practical skills and group learning.
Unfortunately, the COVID-19 pandemic led to numerous teaching courses, like the boot camp, being cancelled in order to reduce the risk of viral transmission between groups of students and clinicians.
The boot camp could not be delivered in 2020 due to social distancing requirements. The cancellation of teaching activities had a significant impact on training, and in the face of adversity, many novel forms of education have come to the fore. [4][5][6] One of the major changes to education has been the conversion of in-person courses to virtual courses.
There are numerous positive aspects of virtual training that can be taken forward such as increasing technical and non-technical skill acquisition through simulation. 7,8 It can also reduce the need for facilities and travel costs as well as improve the ease of attendance. 9 Furthermore, virtual technology, such as the Proximie™ platform, can be used to enhance surgical education and can lead to a reduction in geographical barriers to medical education. 10 The UK has come through the rapid wave of the Omicron variant of COVID-19. 11 Worldwide, millions of people remain in lockdown as outbreaks rise and fall across countries in a staggered fashion. 12 In order to reduce the risk of transmission, social distancing, and therefore virtual courses, appear to be the safest strategies for the foreseeable future. In this prospective observational study, the methodology and experience of converting the urology boot camp for medical students into a virtual course is presented with key take-home messages on how to convert an in-person course to a virtual format.
Results showing both quantitative and qualitative improvement in the knowledge and clinical acumen of course delegates are also presented.

| METHODS
The course structure and core components, as used for the in-person course, were maintained in the virtual course. The course was delivered annually in the autumn term, and this currently remains the case for the face-to-face course as well. The reason for this is that the timing is best suited for preparing students for medical school examinations in spring. All faculty had a background in medical education and had previously attended varying levels of formal teaching courses.
The content of the teaching was based on the accompanying course textbook. 13 Although no formal training on online teaching was given, it was on account of the ingenuity and adaptiveness of faculty that face-to-face teaching skills could be translated into online education.
Microsoft (MS) Teams™ was used as the virtual platform for the course. Baseline poll questions, using online polling software, were first asked of the delegates relating to how much of the urology cur- Clarkes' six-phase framework. 18 Microsoft Excel was used to tabularize data and colour-code themes. These coded themes were then identified, reviewed and defined in order to apply to and optimize future iterations of the course.
At the end of the course, faculty debriefed to go through areas of the programme that went well and areas which could be improved.
This was also a time to reflect on how each member of the faculty could develop their skills in training. In this way, faculty were able to continually improve their teaching skills with each implementation of the course.
F I G U R E 1 Schematic representation of the theory-based and clinically oriented topics covered through both interactive workshops and practical skills stations. Practical skills stations incorporate simulation models and case-based discussions.

| RESULTS
As shown in Figure 3A,B, prior to undertaking the course, over half of delegates felt both that their knowledge of urology was 'poor' and that they were 'not confident' in performing urological clinical examinations. Less than 10% felt that most of the urology curriculum had been covered by their teaching sessions thus far ( Figure 3C), and less than 5% felt that their urology teaching had fully prepared them for their medical school examinations ( Figure 3D  Feedback on ways to improve the course included the provision of handouts. There were also requests for more case-based discussions, and these seemed to be of particular interest to the students. In future, reference will be made before commencement of the course to the free textbook that accompanies the course and provides a framework especially for the lecture-based teaching. Case-based discussion will also be included as a formal part of the programme.

| DISCUSSION
The urology boot camp for medical students was originally designed as a formative course, and this remains the case. The poll questions and MCQ assessment are diagnostic, allowing delegates to identify their weak areas and focus on areas for learning. The boot camp provides the opportunity for delegates to work in groups and engage in collective learning. Through this, they can build upon concepts learned previously and apply the theory-based knowledge to clinical cases. The course employs Bruner's theory of spiral learning, allowing delegates to constructively learn, revisit topics and solidify key concepts. 19 The formative polling questions throughout the course keep delegates engaged while providing a further medium for testing knowledge. The course also utilizes the 'flipped classroom' approach by encouraging learners to do their own research on topics and then apply it to problem solving, thereby being more applicable to clinical practice. 20 At the end of the boot camp, reference is made to the course textbook. 13 It is an invaluable resource that was written by the course organizers and can be used to consolidate learning in one's own time. In this way, the course provides a comprehensive educational experience providing assessment for learning and assessment of learning, using evidence-based teaching methods.
The course is not just beneficial for delegates but also provides  Boot camps are defined as compact, high-intensity courses, which provide students with a foundation of curricular practical training for a new clinical role. 23 With reducing opportunities for clinical students to gain practical experience and increasingly complex health needs, medical education boot camps are gaining popularity rapidly. 24 The gap between final year of medical school and working as a doctor has always been a challenging transition. Virtual as well as face-to-face boot camps can be a solution to ease difficulties in this phase of training. 25 The boot camp teaching style has been used in a number of different medical specialties including orthopaedic surgery, neurosurgery, emergency medicine and general internal medicine. [26][27][28][29][30] These have all produced excellent results, not only in increasing the confidence of medical students to undertake their final examinations and future rotations in the specialty but also in inspiring them to join the various specialties. Boot camps offer the opportunity to network with clinicians, find mentors and learn more about a specialty career pathway.
In the UK, newly appointed urology registrars take part in the, now mandatory, registrar boot camp where delegates receive training in the core skills and knowledge required for starting work as a urology registrar. 31 The strengths of the medical student boot camp are similar to the registrar boot camp such as its intensive, high-yield teaching style and use of simulation. 32 The registrar course has been well-received by trainees with overwhelmingly positive feedback and a statistically demonstrable improvement in competence. 33 It is likely that the medical student boot camp will continue to run in parallel with the registrar boot camp, following on from its successes in innovation and ingenuity.
Urology is at the forefront of integrating simulation with surgical training, with the first international randomized control trial assessing the transferability of urological simulation teaching currently underway. 34 The use of virtual reality, fully immersive and cadaveric simulators as well as webinars and traditional dry lab models have all been reported in urological training with promising results. 35,36 As the urology boot camp for medical students continues to incorporate these new technologies, it is hoped that students will be further enabled to progress rapidly in their knowledge and skill acquisition.
UK undergraduate assessment and standards vary substantially between medical schools, and this is especially true for urological education. 1,37 Standardization brings equity, validity and fairness to medical education, which also reassures the public on the competency of graduates. 38 The use of virtual training breaks down geographical barriers to education and enables access to high-quality teaching. Incorporating virtual training into medical school curricula has the potential to bring standardization to undergraduate education. 39  'Practical tips and clear and simple and concise explanation of why certain management and investigations are done. Very well organised! Giving information at the right level.'

| FUTURE DIRECTIONS
Following the success of the pilot virtual boot camp for medical students, the virtual format of the boot camp was successfully upscaled and expanded to reach more students. In October 2021, the course was delivered to an international audience of medical students and junior doctors. Delegates from more than 16 UK medical schools and 4 continents were able to attend the virtual boot camp without any financial cost. The course was rated as 'excellent' by 73% and a further 23% of delegates rated it as 'very good'. Our plan is to continue to deliver this international course on an annual basis to improve access to teaching in urology and also reduce geographical and financial barriers to learning.
While the virtual course has transformed and advanced the delivery of the boot camp, the in-person course will continue so as not to lose the vitally important hands-on aspects of surgical training. Indeed, when students were asked whether they preferred in-person or virtual courses, the split was roughly equal ( Figure 3F), highlighting the need for both. The face-to-face course will run in parallel with the virtual course to ensure that the benefits of virtual learning are not lost while also maintaining practical skills training using simulation models. Transitions through the levels of seniority in a medical career often come with new and unique challenges; the step from medical student to year one doctor is no exception. 41 These transitions can be re-framed as 'critically intensive learning periods' (CILPs). 42 CILPs are times when trainees are particularly engaged and focused on obtaining the knowledge and skills to work in a particular environment. Providing structured, hands-on, practical teaching during these times can overcome the challenges of working in new environments. 43 In this way, boot camps can ease the challenges associated with working as a newly qualified doctor.

| STRENGTHS AND LIMITATIONS
An inevitable limitation of the boot camp being delivered in a virtual format is that it is difficult to assess delegates competency in clinical skills and subjective measures of confidence do not always equate to clinical competence. Hands-on, in-person training is vital to surgical education, and this is why the face-to-face course will continue to run in parallel with the virtual course.
It will also be of value to study the long-term learning assessment outcomes of the delegates by comparing cohorts who have not taken part in the boot camp to cohorts who have attended, with regard to how they perform in final medical school examinations and in clinical practice. Records have been kept of the students in each year group who did and who did not attend the boot camp, be it in its virtual or face-to-face format. It is planned to carry out a cohort comparative study to assess for difference in the level of urological skills and knowledge of ward doctors with those who attended the boot camp compared with those who did not. This will further elucidate the impact of the urology boot camp on clinical acumen.
One of the benefits of virtual platforms is that courses can be delivered nationally or internationally with relative ease. It may well be that boot camps of the future use a hybrid of both virtual and face-to-face interaction. This will likely develop as new technology in virtual reality and simulation are adopted. This could retain the elements of the course that are served best through physical meeting whilst maintaining the benefits of remote learning.

| CONCLUSIONS
The urology boot camp for medical students has now received support from BAUS. As it continues to expand, it is hoped that it will not only bring standardization to undergraduate urology education but also inspire the next generation of doctors to embark on a career in urology. As virtual technology continues to be used to enhance medical education, the boot camp will remain at the forefront of these advancements.