Discussion

Students from the USA and Ghana both demonstrated significant knowledge gains after the TEAM course; however, only Ghana students retained this knowledge at 6 months, counter to our hypothesis. The immediate effect of the TEAM course on trauma knowledge has been shown in multiple prior studies, with the course benefitting students from locations as diverse as the USA,12 Canada,8 Australia,13 Mexico,14 Jamaica, Trinidad, Costa Rica and the United Arab Emirates.9 Knowledge retention, however, has been poorly studied to date—we could not find any prior studies comparing pre-course to longer-term knowledge in medical students. Li et al15 do evaluate comparative knowledge retention in senior medical students who took the course as juniors (11–23 months earlier); however, they compare the standard 2-hour TEAM lecture to a unique expanded (eTEAM) course of their own design rather than to pre-course knowledge. Their findings that students exposed to the eTEAM course perform better on specific aspects of the follow-up structured clinical examination is relevant however, as we theorize that the difference in USA and Ghana students at 6 months is partially explained by ongoing exposure to patients with trauma and the opportunity to use learned resuscitation skills.

Like many other cognitive and procedural skills, trauma knowledge and the ability to run a well-organized resuscitation may be affected by ongoing skill use. Ali et al have shown progressive attrition of trauma knowledge in physicians with less ongoing trauma exposure,16 whereas Fisher et al demonstrated degradation of unused complex clinical skills among medical students over time.17 A recent study by Mackenzie et al18 compared long-term retention of trauma procedural competency after the Advanced Surgical Skills for Exposure in Trauma course, finding that practicing surgeons with infrequent interval opportunities to use the learnt skills made more errors on follow-up testing than either in-training residents or subject matter experts. They concluded that skill degradation was more strongly associated with lack of interval practice than time since training. There is even some data that trauma volume correlates with patient outcomes, leading to requirements that trauma centers meet a minimum number of admissions per year in order to qualify for ACS verification.19 We theorize that the higher level of knowledge retention in students from Ghana is directly correlated to both their increased exposure to trauma care and their anticipated future practice. Ghanaian students were taught during their final year of medical school, which consists of 6 months each of surgery and medicine. The surgical service covers all aspects of surgical care, including trauma, leading to frequent immersion in trauma education and skills practice. This is in contrast to US students, most of whom were taught during their MS3 year where only 8 weeks are spent on surgery and the rest on other specialties which often contain no exposure to patients with trauma.

Education is also more effective when knowledge is personally relevant—Ghanaian students all go on to a required period of general medical practice after graduation before being allowed to subspecialty train, whereas US students move straight into specialties and may never care for patients with trauma in their career, as was highlighted in several free-text comments. Given findings by Mock et al that a large volume of trauma care in Ghana is provided in smaller district hospitals by non-surgeon general practitioners, this education is highly relevant to all medical students in Ghana.20

Assessment of the students’ perceived barriers to implementing their new knowledge raises several interesting questions in addition to corroborating some of the above theories. Students’ free-text responses were characterized into themes, with significant differences in the frequency that each was cited between countries. Ghana students tended to focus on external limitations, such as a lack of physical equipment (oxygen or endotracheal tubes), lack of a trauma system (triage, prehospital services and communication) or lack of teammate education (nurses and medics). Only four comments out of the 38 provided cited other barriers—two remarking on the need for further practice and two who saw no barriers to utilizing their new skills. This is in stark contrast to US students who reported a lack of resources or lack of teamwork only once each out of 46 total comments. US students tended to report more internal limitations, with the most frequent potential barriers being either the need for further personal practice or no opportunity to use their skills, obstacles that directly relate to our proposed theory of ongoing skill usage above.

Overall the course was well received, though Ghana students rated the course more positively than US students in all categories. The only question receiving a less than 90% approval rating was regarding new knowledge about mass casualty situations, which is a very limited section of the standard TEAM course. Greater than 95% of students in both groups, and 100% of Ghana students, indicated that they were satisfied with what they had learnt and would recommend the course to colleagues. Our findings regarding perceptions of the course are in line with previous studies, which also indicate a high level of student appreciation for further trauma education, particularly in LMICs.8–11 21

Our study does have limitations. Our participant attrition was higher than expected, with fewer students taking the post-course and 6-month exams than the pre-course test. Approval of this project by the University of California San Diego School of Medicine required that all testing be optional for students, and their results completely de-identified; we applied the same criteria to Ghanaian students to reduce bias that may have arisen if some students were required to take the exam and others were not. This requirement did limit student participation particularly at the 6-month mark, as well as made it impossible to track individual knowledge retention or correlate scores with USA student career interests. There is still a potential for bias in that students more interested in trauma may have been more likely to take the follow-up exams; however, this was likely mitigated by the similar level of attrition between the two groups. We also used the same 18 questions for the pre-test, post-test and 6-month follow-up exams as this is what was provided by the ACS COT; using different sets of questions of a similar difficulty may have been a better test of true knowledge gain, however. Our project only tested cognitive knowledge on a multiple-choice exam rather than assessing clinical applicability or results—we did not assess any improvements in patient outcomes. Studies such as those by Petroze et al22 provide some data that focused trauma education can improve outcomes, but further research will be required to demonstrate this definitively. Finally, a large proportion of trauma care in LMICs is often administered by non-physician providers in rural clinics;20 while medical students are an appropriate target for TEAM the course may require significant expansion to non-physicians to truly improve patient care.

In conclusion, the TEAM course improves cognitive trauma knowledge among medical students in both the USA and Ghana, but this knowledge is retained at 6 months only in Ghana students. The TEAM course is a useful tool to provide the basic principles of trauma care to students in LMICs, and should be expanded. Further study is needed to determine the impact of TEAM education on patient outcomes.