Will nonrecovery surgery courses survive?
Many veterinary educators persist in their belief that there is no comparable substitute for live animal experience in teaching surgery to veterinary medical students. But are traditional, nonsurvival surgery exercises the only — or even the best — hands-on approach?
At some schools, live animal experience is designed to not only revive but also benefit the animal, as with neuter surgery. In recent years, collaboration has become commonplace between veterinary college surgery departments and shelters housing adoptable animals in need of sterilization. Students benefit from the opportunity to perform the surgery.
Not so many decades ago, veterinary students practiced surgical techniques on animals that were put through multiple, major surgeries before being euthanatized. Today, the Animal Welfare Act dictates that an animal cannot be used for a second major survival surgery, except in cases of scientific necessity or veterinary care.
Attitudinal changes on the part of students, society, and occasionally faculty have nudged and, in some cases, compelled schools to develop alternative teaching methods.
Nonsurvival surgical exercises remain, however, a component of many schools' curricula, sometimes even their core. A 1999 survey conducted by the Association of Veterinarians for Animal Rights (and approved by the Association of American Veterinary Medical Colleges) found that, of the 21 US and Canadian veterinary colleges that responded, 16 perform nonsurvival surgeries or procedures in their core curriculum (15 of them offer an alternative). Thirteen colleges perform nonsurvival surgeries or procedures in their elective courses (eight provide an alternative).
A more complete picture may emerge when the AAVMC conducts a planned survey on use of animals in veterinary medical education.
The American College of Veterinary Surgeons' standard for use of animals in teaching is its humane care and use of animals statement. The statement includes a provision that animal use should be reserved for times when acceptable alternatives are not available. It also states that use of animals in teaching must be scrutinized to ensure that meaningful results are obtained for the benefit of animal or human health.
Dr. Alan Lipowitz, ACVS executive secretary, views the specialty's statement as a broad approach to animal usage, one that encompasses use of unowned pound animals for teaching as well as synthetic animals and cadavers.
"I happen to be old enough to think that the use of live animals in surgery teaching, if it's done right and judiciously, is a better method of teaching surgery. That doesn't necessarily mean it has to be terminal," Dr. Lipowitz said. "The more aftercare experience students get, the better."
Although Dr. Lipowitz holds strongly to some form of live animal surgical training of students, he is aware of studies that have found no difference when comparing the surgical techniques of students who practiced on cadavers with those of students who used live animals.
In an Oct 1, 1993 JAVMA Special Report, Dr. Michael S. Bauer acknowledged that, although many educators believe using live animals in surgery laboratories is essential in training veterinary students, things were rapidly changing as a result of social attitudes, university budgetary constraints, and student and faculty attitudes.
Dr. Bauer documented "considerable change over the past decade" in methods used to teach veterinary surgery at US and Canadian veterinary schools (27 of 31 schools responded to his survey). He reported a decrease in live animal laboratories and an increase in laboratories using cadavers and inanimate models. Twenty-four schools used cadavers, models, or both in at least one laboratory session. Most models were used to teach basic surgical skills such as suturing, knot tying, and hemostasis. Sixteen schools had already developed some type of program with local humane societies.
The AVMA position on use of animals in research, testing, and education encourages proper stewardship of animals but defends and promotes use of animals in meaningful programs. The Association position also endorses the Russell and Burch (1959) principles of refinement (of experimentation methods to eliminate or reduce animal pain and distress), reduction (of the number of animals, consistent with sound experimental design), and replacement (of animals with nonanimal methods, wherever feasible).
In 1991 the AVMA Council on Research created a Panel on Animal Surgery in Research and Teaching to develop guidelines to assist individuals charged with stewardship of such animals. The report was referred to the American Society of Laboratory Animal Practitioners and published in the AJVR in Sept 1993.
In some cases, student sentiment about nonsurvival surgery has culminated in lawsuits. In the mid-'80s, two third-year veterinary students sued the University of Pennsylvania over such a course requirement. "In the end," said Dr. Chuck Newton, associate dean for student and curricular affairs, "a negotiated settlement was reached that didn't alter the surgery class. The students agreed to do the required surgery in a dog with spontaneous disease that would result in death." After a difficult search, the college found a dog dying with cancer, and the students completed the laboratory and graduated.
Independently from the lawsuit, the college later changed the course to a spay exercise. The elective surgery class still includes nonsurvival exercises.
In the early '90s a veterinary student at The Ohio State University withdrew from nonsurvival surgical exercises. According to Dr. John A. E. Hubbell, current associate dean for academic affairs, no alternatives were offered to the student, and she would have failed the course. The student sued. A faculty committee decided to offer her alternatives. She reentered the curriculum and graduated in 1992.
"We've maintained an alternative," Dr. Hubbell said. "The [traditional] course itself has changed since '92 and continues to evolve." He said the incident "moved things along more rapidly than they would have otherwise."
The University of Illinois College of Veterinary Medicine has been a leader in pioneering its surgery instruction program. Those innovations were faculty driven. In 1989 Drs. Ann Johnson and Cathy Greenfield of the Department of Veterinary Clinical Medicine were among the U of I faculty who started looking at other ways of teaching surgery. Dr. Johnson said, "As surgeons, we were tired of teaching a lab where dogs were euthanatized. We started looking at bone models and cadavers for teaching orthopedic surgery. Our conclusion was that it was maybe even better that students were first learning on this equipment.
"We also looked at how to do the same thing with soft tissue surgery. Our students learn the basics on chicken from the grocery store, learn the instruments, use cadaver parts, and then do survival surgery. The last step was to organize a spay/neuter program for the students with the local humane society."
A 1997 JAVMA article of which Dr. Greenfield was senior author and Dr. Johnson a co-author reported that employers who had hired recent U of I graduates assessed them to be most proficient at the surgical procedures performed commonly in private practice, and the procedures for which high proficiency is needed.
In the U of I large animal surgery program, Dr. David Freeman, associate professor of equine medicine and surgery, is working with students to find alternatives to third-year surgery laboratories using live animals. The third-year program includes a goat gastrointestinal laboratory that is survival, as are a castration laboratory and an exploratory celiotomy on ponies. The second gastrointestinal laboratory on goats is nonsurvival.
Dr. Freeman said, "Students who don't want to participate in the live animal surgery can take the cadaver lab, which is an equine orthopedic laboratory, and it counts as their surgery. Or we can arrange to get them a stillborn calf or foal for abdominal surgeries. These can be frozen beforehand. In the fall semester, we have an all-cadaver gastrointestinal laboratory, which is designed to prepare students for the second-semester live animal procedures."
At the University of California-Davis School of Veterinary Medicine, Dr. John Pascoe, executive associate dean of academic programs, said that student suggestions for "academically sound and comparable experiences" are embraced by faculty, who want students to be in partnership in this area.
For the past eight years, UC-Davis has had three nonsurvival surgical exercises in its core curriculum, although students can opt for a cadaver alternative for these exercises. The other six laboratory sessions in the core involve spaying and neutering animals from five area shelters. The faculty, in consultation with students, has decided to replace the nonsurvival surgical exercises with cadaver exercises beginning this next academic year.
Dr. Daniel Smeak, professor in the Department of Veterinary Clinical Sciences at The Ohio State University, said that after the 1990s lawsuit at OSU, the veterinary college reevaluated its surgery emphasis. As a result, Ohio State has progressed from a procedure-oriented approach to a skill-oriented approach, something other veterinary colleges have shifted to as well.
"In the past, we set the student up for opening a bladder or preparing a shoulder joint, to gain skills as they learn the procedure. It turns out by the time, as a junior, they get exposure to one surgery, they have no recollection how to do it a year later.
"So now we teach them how to drape, handle instruments, place sutures, and retract tissues. We concentrate on giving students the nuts-and-bolts practice surgery skills, so they're prepared to go into cadavers and live animal surgery, whether in the regular or alternative curriculum."
Dr. Smeak has created models with "tissue" tactilely similar to normal tissue and similar suturing characteristics. Students can take the model home during their second year and practice, so their hands grow familiar with basic techniques. This better prepares them for third-year cadaver laboratories and eventually spaying and neutering live animals from a humane society, shelters, and a seeing-eye organization.
"Students do the procedures time and again, and learn the procedures and skills this way. They may not have opened a stomach, but now they know how to get there."