Experiences with basic microsurgical training programs and skill assessment methods at the University of Debrecen , Hungary

During the past decades microsurgical training programs together with skill assessment methods had been developing intensively worldwide. Concerning the teaching of basic techniques at various levels, we aimed to summarize the education program types and experiences at our department, in order to define the way of continuity. All in the hope that this summary might contain useful information for other educators as well. About 50 years ago, in the late 1960s, microsurgical basic education had been established in Debrecen. Since the 1990s multilevel education programs have been developed, starting in undergraduate years up to the postgraduate training, residency and continuous medical education programs. In the last three decades about 2,300 participants completed courses, including over 470 residents. The ones who already succeeded microsurgical course as medical students, during residency program could reach better results and skill development. Concluding thoughts, the traditional methods and special experiences are highly important in microsurgical education. The necessary duration and individual training approach are emphasized. Standardization (self and international), comparability, accessibility, providing milestones of microsurgical skills are key factors. Proper feedback and skill assessment (experiences, internationally recognized scores, or combinations) are indispensable, but have to be fitted to the characteristic elements

In Debrecen, Hungary, the microsurgical basic education had been established in the late 1960s 3,4,6,9,10 .Organized courses have been held since 1986 at graduate and postgraduate levels in Hungarian and English programs.The most intensive and main custom-tailored course is the 80-hour postgraduate one 6,9,10,16 .The principles of this microsurgical basic educational program are: activity (the student must be active in practice as well), synchronism (working together with the teacher and/or with under continuous guidance), video-assistance (the teacher's actions, movements and tricks are show on a monitor), self-controlling (by real time monitoring on screen and video/DVD recordings, and the student can fix their work on video and can observe and realize their failures), individualization (custom tailored and based on the individual's skill level and development), and analysis (with the offering constructive criticism of the teacher everyday -pitfall analysis) 3,4,6,9,10,15 .
During the past decades the course programs together with skill assessment aspects and methods had been developing worldwide.Concerning the teaching and

Special courses
Microsurgical postgraduate courses for urologists/andrologists: testicle biopsy and suture, anastomosis of the ductus deferens.
In cooperation with the Department of Ophtalmology, microsurgical course for ophthalmologists on biopreparates of animal origin: techniques for corneal sutures, plastic surgical basic techniques around the eye.

Evaluation of work and skill assessment during basic microsurgical trainings
How do we evaluate?What are the milestones of competence and for stepforwards in the microsurgical training program?
1.The beginnings: The proper usage of the magnification on the microscope and the microsurgical instruments (forceps and scissors) during warm-up exercises (scratching of ink from a newspaper, pulling and taking fibers on a gauze pad).3. Creating end-to-end vascular anastomosis on non-living biomodels (chicken thigh, femoral artery): Tissue handling is atraumatic.During passing needle through tissue: the needle does not wobble in the needle holder, needle enters tissue perpendicularly, forceps handles vessel adventitia to provide counter traction, needle is pulled through tissue following its curve, suture is pulled out parallel to the tissue, suture tails are left at the correct length, appropriate depth tissue bite on each side and the sutures are placed appropriately.The score of the modified GRS for non-living biomodels reaches 75% of the maximum.The time to create an end-to-end anastomosis with 7-0 or 8-0 monofilament suture material on a femoral artery in a chicken thigh is below 30 minutes.

Methods of assessment
Methods of assessment: continuous guidance, qualitative control by the tutor, measurement of time, detailed analysis of the sutures possible (GRS, OSATS, etc).Methods of assessment: continuous guidance, qualitative control by the tutor, measurement of time, detailed analysis of the sutures possible (GRS, OSATS, etc).Skill assessment and feed-backs  As part of the "Surgical skill training" course, the microsurgical module provided special practice of the residents.From all the related disciplines of operative medicine the residents found the microsurgical module very useful, and most of them were enthusiastic learning more atraumatic work together with the fundamentals of microsurgical procedures.Important observation was that the residents who already completed microsurgical course before as medical students, in this residency training program they could have significantly better results in their microsurgical skill level and in further individual skill development.This result enforce the importance of the multilevel microsurgical training programs starting during the medical school years.

■ Discussion
On microsurgical education and training numerous papers have been published in the last two decades, which articles mostly focus on the methods helping the effectiveness of the training, providing models and definitive educational programs [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16] .Since for the obtainment and practicing safe stitching and suturing techniques, atraumatic tissue preparation, fine and precise movements well-established and well-controlled practical programs are needed.However, the methodological palette, as for educational programs, is very colorful.On the websites, containing the course announcements, the teaching method cannot be necessarily identified because the programs are often linked to definitive persons, traditions and schools.On the other hand there is a need for the skill assessment, and so the supply and the demand must meet.
Concerning the microsurgical courses it is important to emphasize the 3Rs (replacement, reduction and refinement).For the surgical safety and successful microsurgical work in the clinical practice, it is necessary to practice on living tissue, but after a well-established microsurgical skill level acquired during trainings on various models and biopreparates.If the participant does not reach a certain level of skill, he/she is not allowed to work on living tissue (anesthetized rat).
In a previous study we analyzed a sample out of the courses found on the web (91 courses' data from 21 countries) it became obvious that: (1) The demand for microsurgical training opportunities is high worldwide, although the accessibility is altering.(2) Accessibility is influenced by numerous entrance barriers, such as maximal number of applicants, number of microscopeworkstations and tutors, and the amount of registration/tuition fee, among others.(3) The offered hours vary in a wide range.(4) There are only a few courses that provide trainings over 40 hours at a decent price, offering a relatively low class-hour/price ratio 24 .
By our opinion, for learning basics of microsurgery 8-16 hour courses cannot be effective.The aim is to develop the skill for the participant.The short course is too long for an introduction but not enough for the effectiveness.For the one who already trained that is another question.
The skill assessment is inevitable during any kind of microsurgical course.However there is no uniformly accepted method or guideline.In Debrecen the skill assessment of the microsurgical courses firstly focused on the direct quality evaluation.Later, keeping the strong quality control the system developed with a stepwise inclusion of objective parameters.
Standardization of education methods and skill assessment is an old and important desire of several societies over the past decades, rising again and again since the 1970s 1,2,17,20,[25][26][27] .The most important issue is to acquire the necessary microsurgical skill.Thus, determination of the skill level and clear definition of milestones are important.The methods reaching those 'key competencies' are naturally different.Comparability is important, so a kind of standardization is needed, but the importance of the individuals, the tutors themselves, the style, the art and traditions should not be neglected.Therefore quality assurance is considered much more important.The 'long-term' effectiveness is a key question and the importance of feed-backs, including the real feed-back: the patients' benefit, the art of the surgeon that hopefully had been improved also by the successfully completed microsurgical course (Figure 4).Perhaps most of the standardization protocols, publications, comparative analyses mainly focus on the clinical microsurgical skills.Regarding various organ and tissue transplantation models in rodents and considering the quality and the time factor, in the field of experimental microsurgery, certain milestones fall within different assessment and quite different dimension [28][29][30] .
Overviewing the tematics and the existing quality assurance can be tools to evaluate the courses and supported accordingly by professional international societies (e.g., International Society for Experimental Microsurgery, European Society for Surgical Research, International Microsurgical Simulation Society, etc).
Concluding the thoughts and aspects: (1) The traditional methods, special experiences (leader mentors, tutors) are highly important in microsurgical education.

Figure 1 -
Figure 1 -Main steps and practical elements of the basic microsurgical training program I. A,B: scraping printed letters from a newspaper with needle (with left and right hand, in different directions, at various magnifications); C,D: practicing on textile fibers, preparation and pulling and taking back of textile fibers with microsurgical forceps bimanually (on dry and wet gauze, at various magnifications); E,F: cutting off a flap from the gauze with microsurgical forceps and scissors (on dry and wet gauze, at various magnifications); G,H: stitching and making knots on rubber pad (in different directions).

Figure 3
Figure 3 shows an example of skill assessment chart completed during a basic course for medical students.It could be stated that the proper feedback and assessment

Figure 3 -
Figure 3 -An example chart for general skill assessment taken during basic microsurgical course for medical students.A: Duration of taking stitches and knotting (10 sutures after learning the method; means±S.D., *p<0.05 vs. the first suture, one-way/repeated measure ANOVA test); B: quality scoring of the individual sutures; C: percents of the general mistakes and pitfalls.

Figure 4 -
Figure 4 -The importance of the variety of microsurgical education programs leading the participant to certain level of skill (milestones of skills and competencies), and the necessity of short-term and long-term feed-back.
(2) The necessary duration (above 40 hours) and individual training are emphasized.(3) Standardization (self-and international), comparability, accessibility, reaching milestones of microsurgical skills, all are key factors in the success of microsurgical courses.Proper feedback and assessment of the technique during the training is a constructive method to help the participant to continue their skill training and emphasize the point out where the correction should be made.

Table 1 -
Microsurgical course types and participants since the beginnings till June 2018 at the Microsurgical Education and Training Center, Department of Operative Techniques and Surgical Research, Faculty of Medicine, University of Debrecen.