Development, implementation, and results of a simulation-based hands-on brachytherapy workshop for medical students

The further development of medical studies within the framework of the new Medical Licensing Regulations 2025 includes an orientation from fact-based to competence-based learning and focuses on practical, longitudinal, and interdisciplinary training [1]. The specialty of radiation oncology and radiation therapy, as an integral part of therapeutic oncology, represents an interdisciplinary interface and should be adequately addressed in medical education because of its public health importance [2, 3]. Consequently, there is a great need for high-quality teaching and training in radiation oncology to continue during medical school as well as during residency training [4‐8].

In this regard, structured training in brachytherapy techniques is particularly suited to teach practical radiation oncology skills. To date, such courses are rarely offered, although they provide graduates with more confidence and experience in the use of the method [9].

For example, training workshops using a phantom-based simulator have been established for brachytherapy of prostate cancer [10]. In addition to teaching ultrasound-guided treatment planning and implantation techniques, the CT simulation images allow subsequent calculation of the resulting spatial dose distribution, thus providing participants with direct feedback on the quality of catheter positioning [11, 12].

For multicatheter brachytherapy in breast cancer, there are no published results of simulation-based workshops in medical education. Therefore, the aim of the present work was to develop a feasible model for teaching and training practical skills in multicatheter brachytherapy of the breast.

Accelerated partial breast irradiation (APBI) using multicatheter interstitial brachytherapy is a highly effective treatment option for early breast cancer [13‐15]. The treatment is characterized by precise delivery of a high dose to the target volume while minimizing the dose to organs at risk [16]. However, despite the advantages of this technique, many authors report a decline in brachytherapy due in part to lack of time and inadequate education and training [17].

We have (1) developed a new breast model that enables the acquisition of practical skills in multicatheter brachytherapy of the breast and (2) evaluated its feasibility in an education workshop teaching and training students in brachytherapy techniques.

This workshop is the first simulation-based hands-on workshop on interstitial multicatheter brachytherapy for breast cancer described in the literature. The simulation of catheter placement on the breast model enabled participants to achieve the predefined learning objectives. According to the self-assessment, participants benefited significantly from an increase in their competency-based knowledge measurable using the six-point Likert scale. Furthermore, the students appreciated the practical hands-on elements, their close integration with the theoretical content, and the insight into real clinical facilities.

The workshop follows a competency-based and interdisciplinary teaching approach. Thus, it is significantly oriented towards the current reform efforts of medical teaching in Germany, which are expressed in the Masterplan Medizinstudium 2020 and in the revision of the National Competence-Based Catalogue of Learning Objectives in Medicine (NKLM). Here, the demand for a consistent practice and competence orientation of teaching with a special focus on an understanding of effective interdisciplinary collaboration between different professions in health care is found. By synthesizing individual learning objectives, more practice-related competencies are to be taught. The acquisition of competencies not only includes pure knowledge aspects, but also requires additional manual and communicative skills in the application of the acquired knowledge. Lectures such as the brachytherapy workshop are particularly suitable for linking cognitive, psychomotor, and affective learning objectives [18‐20]. These proclaimed educational principles afford a high potential for developing innovative teaching formats especially in radiation oncology, due to its multiprofessional and interdisciplinary nature [1, 7, 21].

The multiprofessional design of the workshop will provide participants with a profound understanding about brachytherapeutic work and treatment processes as well as interdisciplinary collaboration in radiation oncology. A profound understanding of multiprofessional cooperation in radiation oncology care is instrumental for improved patient outcome and should therefore be further promoted through multiprofessionally designed teaching opportunities [22].

Simulation-based training, based on active learning theories in cognitive and learning sciences, is increasingly demanded for modern medical teaching across disciplines [23]. According to Dale’s Cone of Experiences, active learning processes are significantly more effective than passive ones and allow learners to remember up to 90% of what they learn [24]. Complex cognitive processes result from the interaction between declarative and procedural knowledge. The acquisition of high-quality professional competencies therefore requires the essential integration of practical components into teaching. Especially for medical education, it has been shown that simulation-based teaching concepts are superior to purely theoretical lessons [25, 26]. The positive effects were not only shown with regard to the acquisition of technical knowledge and practical skills, but were even associated with an improvement in patient care, which should be seen as a groundbreaking advantage in view of the intention of medical teaching [27‐31]. Furthermore, it has already been demonstrated that simulation-based training achieves particularly sustainable and long-term learning effects [23, 32].

Our results are congruent with observations from other simulation-based workshops on brachytherapy for prostate and gynecologic cancer. Here, it was consistently shown that simulation-based brachytherapy training led to increased confidence in using the method [9, 11, 12]. Despite its advantages, the clinical use of brachytherapy has been declining for years [17]. Conducting such hands-on teaching sessions for residents could be an approach to strengthen the awareness and entrenchment of brachytherapy in radiation oncology.

Recently, it has been reported that there is a great demand for more practical lessons in the training of radiation oncology professionals [33]. While it has been demonstrated that simulation-based education has a high benefit in radiation oncology, it mainly addresses the teaching of contouring. Hence, there is a big gap to fill regarding other specific competencies such like communication or technical skills [34]. Educational training methods like the workshop are a promising approach to meet these needs.

Despite the didactic advantages, only few simulation-based teaching concepts have been established in radiation oncology so far, which is possibly also related to the required personnel, time, and financial burdens. In addition, techniques such as multicatheter brachytherapy of breast carcinoma are not even available at all university centers.

The participants of our workshop particularly appreciated the integration of our workshop into the real clinical setting with participation of the professional groups involved in everyday treatment. They reported being able to better estimate the complexity of the radiotherapeutic treatment chain, with the consequences to be derived from the various treatment steps. From the perspective of cognitive science, the situational learning theory is applied here, according to which learning is understood as a context-dependent process. The content and meaning of what is learned is largely dependent on the environment in which it is taught. Therefore, it is advisable to integrate technical courses into the real-life professional environment [23, 35, 36].

Learning about the various radiotherapeutic procedures, especially interventional techniques such as brachytherapy, could stimulate interest in the entire field of radiation oncology [6, 8]. Although not explicitly recorded in the evaluation form, the majority of students indicated that the workshop increased their interest in the topic.

In addition to the positive results of the workshop described here, some limitations also become apparent. The monocentric nature of this study limits its validity. This is especially true for the questionnaire, which was developed specifically for the study and thus does not represent an established, standardized measurement instrument. Similarly, the number of study participants forms only a small sample size. Furthermore, not all participants completed the questionnaire in full. The voluntary workshop participation of the medical students results in a selection bias, as it is possible that primarily students interested in radiation oncology attended the workshop, which limits a transfer of the results to the general public of medical students. To assess the achievement of the predefined learning objectives, an exam (e.g., as a lightning round or elevator pitch) could be conducted at the end of the event. Likewise, no statement can be made about the long-term learning effect achieved. Further follow-up studies would be necessary for this.

The comparability of the breast model, including the Styrofoam ball as a tumor bed, with a real breast is limited. The consistency of the material was found to be stiffer compared to real breast tissue. A clinical examination of the breast can only be reproduced to a limited extent with the aid of the model, but this was also not the leading intention of this course.

The demand for practice-oriented teaching formats to impart manual skills is countered by the development of an increasing number of digital teaching formats, partly driven by the coronavirus pandemic [37]. While certain elements of the workshop can only be conducted in classroom teaching under supervision (e.g., catheter implantation), some parts are also feasible in digital format. A further development of the course could be the integration of digital technologies as a hybrid format [2]. It would be conceivable to establish a flipped classroom format as preparation for the workshop with the aid of digital teaching materials [38].

The multiprofessional, competence- and practice-based approach of the hands-on workshop is significantly oriented towards the reform movements in the German medical curriculum and could be exemplary for future teaching concepts in radiation oncology.

The simulation-based medical education course for multicatheter brachytherapy can improve self-assessed technical competence and increase enthusiasm for brachytherapy. Residency programs should provide resources for this essential component of radiation oncology. This course is exemplary for the development of innovative practical and competence-based teaching formats to meet the current reforms of medical education in Germany.