Textbook Versus Digital Simulation for Cleft Surgery Education: A Prospective, Randomized, Blinded Trial

Background: Digital and online resources play a major role in surgical education. However, the educational value and effectiveness of these resources have not been critically evaluated in the field of cleft surgery. We present a prospective, randomized, blinded trial comparing the educational efficacy of a textbook versus digital simulation in teaching novice learners the surgical markings for cleft lip repair.

 Methods: Novice learners (N = 35) were asked to draw cleft lip repair markings on a standardized patient photograph of a complete unilateral cleft lip deformity (Pretest). Subjects were then randomized to one of two educational tools for cleft markings: textbook (n=17) or digital simulation (n=18). Participants were given 20 minutes of study, and were then asked to draw cleft lip repair markings a second time on the same standardized photograph (Posttest). They were then exposed to the educational tool provided to the other study group and asked to complete a validated survey comparing the educational value of both resources. Cleft lip markings were graded in a blinded fashion twice, using a 10-point scale created by two senior cleft surgeons. Paired and independent t-tests were used to compare differences between groups. Inter and Intra-rater reliability was evaluated using intra-class correlation coefficients (ICC).

Results: Intra-rater reliability was excellent for both pretest (ICC = 0.94; p<0.001) and posttest (ICC = 0.95; p<0.001) grading. Pretest performances between the textbook and simulator groups were comparable (0.82 ± 1.17 vs. 0.64 ± 0.95; p=0.31). There was significant improvement in posttest performance compared to pretest in both the textbook (3.50 ± 1.62 vs. 0.82 ± 1.17; p<0.001) and simulator (6.44 ± 2.03 vs. 0.64 ± 0.95; p<0.001) groups. However, significantly greater improvement was demonstrated by the simulator group when compared to the textbook group (5.81 ± 2.01 vs. 2.68 ± 1.49; p<0.001). Participants thought the simulator increased interest (3.91 ± 1.01 vs. 2.31 ± 1.21; p<0.001), allowed learning (3.83 ± 0.95 vs. 2.17 ± 1.20; p<0.001), was stimulating (3.74 ± 0.98 vs. 1.69 ± 0.87; p<0.001), clearer (3.66 ± 1.08 vs. 2.17 ± 1.22; p<0.001), effective in teaching (4.14 ± 0.94 vs. 2.31 ± 1.21; p<0.001) and likely to be recommended to others (4.00 ± 1.11 vs. 2.14 ± 1.19; p<0.001) more than the textbook.

Conclusions: A prospective, randomized, blinded trial demonstrates superior cleft lip repair markings education though digital simulation compared to textbook. Participants subjectively found digital simulation to be a superior educational platform. Our findings highlight the need to invest in these digital resources to teach the next generation of cleft surgeons.