Dr. Natnael Shimelash

OBJECTIVE: We report on the development and implementation of a surgical simulation curriculum for undergraduate medical students in rural Rwanda. DESIGN: This is a narrative report on the development of scenario and procedure-based content for a junior surgical clerkship simulation curriculum by an interdisciplinary team of simulation specialists, surgeons, anesthesiologists, medical educators, and medical students. SETTING: University of Global Health Equity, a new medical school located in Butaro, Rwanda. PARTICIPANTS: Participants in this study consist of simulation and surgical educators, surgeons, anesthesiologists, research fellows and University of Global Health Equity medical students enrolled in the junior surgery clerkship. RESULTS: The simulation training schedule was designed to begin with a 17-session simulation-intensive week, followed by 8 sessions spread over the 11-week clerkship. These sessions combined the use of high-fidelity mannequins with improvised, bench-top surgical simulators like the GlobalSurgBox, and low-cost gelatin-based models to effectively replace resource intensive options. CONCLUSIONS: Emphasis on contextualized content generation, low-cost application, and interdisciplinary design of simulation curricula for low-income settings is essential. The impact of this curriculum on students’ knowledge and skill acquisition is being assessed in an ongoing fashion as a substrate for iterative improvement. ABBREVIATIONS: LMIC, Low- and Middle-Income Country HIC, High-Income Country ADW, Activity Development Worksheet FSG, Faculty Scenario Guide WHO, World Health Organization LA, Local Anesthesia FAST Focused Assessment with Sonography in Trauma KEY WORDS: Surgical Simulation, Surgical Education, Global Surgery, Global Health COMPETENCIES: Medical Knowledge, Practice-Based Learning and Improvement

Simulation-based training often fails to meet the needs of low- and middleincome countries with limited access to high-cost models. We built on an existing surgical simulation curriculum for medical students in Rwanda and assessed students’ experience. Methods: Based on a contextual simulation-based education curriculum that was piloted in 2022, our team designed and delivered an intensive week-long surgical simulation course for medical students. We increased interactive clinical scenarios using high-fidelity mannequins, improved and added benchtop models for training, and incorporated a new postcourse assessment of students’ experiences using a survey on the first Kirkpatrick level to determine sessions with the highest utility. Modules included informed consent, preoperative patient preparation, trauma simulations, and procedural skills. The final day focused on integrating and applying skills learned throughout the week in an interactive circuit. Results: Thirty-six students participated in the 5-d simulation course and 24 completed an end of course survey. When asked about their exposure to simulation prior to the course, 20/24 (83%) students reported “a lot” and 4/24 (17%) reported “a little”, 24/24 (100%) strongly agreed that simulation is a valuable educational tool and 23/24 (96%) felt that the week enhanced their knowledge and skills to “a great extent”. The modules with the highest self-rated level of engagement were the interactive trauma simulations, knot-tying and suturing practice and competition, and a model-based session on cutaneous lesions. The lowest ranked session was the interactive circuit on integrated skills. Conclusions: Implementing a locally-informed and locally-sourced surgical simulation curriculum is feasible and effectively engages medical students in low-income settings

Background Simulation-based training (SBT) enhances medical education but is often limited in low-resource settings. This study aimed to describe the development, use, and cost implication of three low-cost models of soft tissue lesions for SBT of medical students in Rwanda as part of their general surgery clerkship. We also aimed to evaluate perceptions and knowledge gained from the course. Methods Surgical educators and healthcare providers from Rwanda and the United States partnered to design and implement SBT for soft tissue procedures. We prioritized three common procedures based on operative log reviews and a Delphi process: abscess drainage with/without ultrasound guidance; excision of a subcutaneous nodule; and wound debridement. Materials for the SBT models were locally sourced. Data was collected as a prospective cohort study assessing the participants pre- and post-course knowledge using the Kirkpatrick level one and two questions. Students’ self-reported confidence and course feedback was also collected. Results Cost was <$1.20 per model and each took≤5 min of active time to construct. Sixty-two students participated over 3 iterations of the soft tissue SBT. Few students had previously observed nodule excision (8.3%), abscess drainage (10.0%), or wound debridement (27.1%). On a five-point Likert scale, student perception of confidence in performing soft tissue procedures improved by +1.7 (p<0.001) for nodule excision, +1.4 (p<0.001) for abscess drainage, and +1.7 (p<0.001) for wound debridement. Confidence scores were greater than or equal to 3.9 out of 5 for all procedures post-session. Conclusions SBT for management of soft-tissue lesions using low-cost, locally-sourced models was well-received, and increased students’ perceived confidence in three common procedures. These models may be adaptable to other procedural settings and learning levels.