1 Bristol Medical School, University of Bristol, Bristol, UK

2 Children's Services Directorate, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK

1 Bristol Medical School, University of Bristol, Bristol, UK

3 Bristol Heart Institute, University Hospitals Bristol and Weston NHS Trust, Bristol, UK

3 Bristol Heart Institute, University Hospitals Bristol and Weston NHS Trust, Bristol, UK

4 National Heart and Lung Institute, Imperial College London, London, UK

1 Bristol Medical School, University of Bristol, Bristol, UK

3 Bristol Heart Institute, University Hospitals Bristol and Weston NHS Trust, Bristol, UK

Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information. All eligible papers selected in the review are referenced in the final manuscript. Full PDF texts are available upon request.

In the UK, undergraduate paediatric training is brief, resulting in trainees with a lower paediatric knowledge base compared with other aspects of medicine. With congenital conditions being successfully treated at childhood, adult clinicians encounter and will need to understand these complex pathologies. Patient-specific 3D printed (3DP) models have been used in clinical training, especially for rarer, complex conditions. We perform a systematic review to evaluate the evidence base in using 3DP models to train paediatricians, surgeons, medical students and nurses.

Online databases PubMed, Web of Science and Embase were searched between January 2010 and April 2020 using search terms relevant to “paediatrics”, “education”, “training” and “3D printing”. Participants were medical students, postgraduate trainees or clinical staff. Comparative studies (patient-specific 3DP models vs traditional teaching methods) and non-comparative studies were included. Outcomes gauged objective and subjective measures: test scores, time taken to complete tasks, self-reported confidence and personal preferences on 3DP models. If reported, the cost of and time taken to produce the models were noted.

From 587 results, 15 studies fit the criteria of the review protocol, with 5/15 being randomised controlled studies and 10/15 focussing on cardiovascular conditions. Participants using 3DP models demonstrated improved test scores and faster times to complete procedures and identify anatomical landmarks compared with traditional teaching methods (2D diagrams, lectures, videos and supervised clinical events). User feedback was positive, reporting greater user self-confidence in understanding concepts with users wishing for integrated use of 3DP in regular teaching. Four studies reported the costs and times of production, which varied depending on model complexity and printer. 3DP models were cheaper than ‘off-the-shelf’ models available on the market and had the benefit of using real-world pathologies. These mostly non-randomised and single-centred studies did not address bias or report long-term or clinically translatable outcomes.

3DP models were associated with greater user satisfaction and good short-term educational outcomes, with low-quality evidence. Multicentred, randomised studies with long-term follow-up and clinically assessed outcomes are needed to fully assess their benefits in this setting.

CRD42020179656.

In 2017, the Royal College of Paediatrics and Child Health published a response to the ‘Shape of Training Review’ of postgraduate training within the UK. They observed that ‘doctors coming into paediatric specialty training do so from a lower knowledge base than adult medicine’.1 This could partly be explained by the brevity of undergraduate exposure to paediatrics, typically 4–8 weeks during the entirety of medical school.2 Furthermore, some paediatric trainees report a lack of educational opportunities within their postgraduate training programme,3 potentially driven by the varied facilities offered by different regions and centres.4 5

It is increasingly important for non-paediatric clinicians to fully appreciate paediatric pathologies. Novel therapies have allowed many children, who would have had poor outcomes from previously life-limiting diseases, to now live with such pathologies resulting in complex patients with chronic conditions.5 Clinical care and observation over the adult lifetime of these patients is often overseen by a myriad of clinicians, frequently requiring specialised oversight such as in the case of pregnant women with congenital heart disease (CHD).6

In recent years, 3D printing has played a role in a variety of medical and surgical training and educational settings.7–9 3D printed (3DP) models can replicate in vivo clinical pathologies based on radiological images, allowing trainees to be exposed to pathologies and potential procedures they would not ordinarily experience through their routine clinical exposure.10 With this review, we aimed to evaluate the current evidence base regarding the utility of 3DP models compared with traditional teaching methods (ie, 2D images/diagrams, lectures, videos and ward-based teaching) in educating and training of medical students and clinical trainees in paediatrics.

The study protocol is registered on International Prospective Register of Systematic Reviews and can be found with the following ID: CRD42020179656. Throughout the review, the authors referred and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.11

The databases PubMed, Web of Science and Embase were searched. The search included all published material since January 2010 (last accessed in April 2020) in the English language. This time frame was selected to ensure the studies reviewed used the most recent available technology. The following terms were used across all databases: ((3d-prin*) OR (3d prin*) OR (three-dimensional print*) OR (three dimensional print*) OR (3-d print*)) AND ((paediat*) OR (pediat*)) AND ((education) OR (teaching) OR (training) OR (session) OR (simulation)). Synonyms and spelling variations were also searched to allow for international spellings and alternative terms (eg, paediatrics vs paediatrics). Searches on PubMed included Medical Subject Headings.

The inclusion criteria for final review were studies using 3DP models derived from paediatric patient imaging data (eg, CT, MRI, ultrasound or echocardiography) and that occurred in an educational or training setting. This was defined as a preplanned session or programme as part of an educational syllabus, training programme or professional course separate from a clinical setting and not aimed to directly contribute towards patient outcomes. This excluded studies which used 3DP models to facilitate communication with patients, carers or clinical staff. Studies that produced a 3DP model for preoperative planning for a specific case were also excluded. Included studies evaluated the use of patient-specific models with physicians, surgeons, nurses and allied health professionals undergoing teaching, training or simulation. Comparative studies would compare the use of 3DP models against traditional educational methods such as lectures, tutorials, practical sessions or textbooks. Case reports and case series were also included if they used the models in an educational setting and reported educational outcome measures. Published conference abstracts were included as per PRISMA guidance to minimise publication bias.12 Primary outcome measures were either objective measures such as preintervention/postintervention testing scores or procedure performance, or subjective measures such as participant-reported opinions from questionnaires. Additional outcome measures that were recorded included the time taken to produce models and the cost of model production.

The titles and abstracts of all papers obtained during the searches were screened for relevance by two authors independently (AA and EL). Relevant papers were then independently assessed for eligibility in full against the study protocol (AA and EL). Any disagreements were resolved by consensus, with the senior author (AS) acting as the final adjudicator for any unresolved discrepancies. The final included papers were then reviewed and appraised by AA and EL. Data were extracted manually onto a Microsoft Excel (V2110, Microsoft, Redmond, WA, USA) spreadsheet.

No patients were involved, nor were any patient data used, in the development or analysis of this review.

Our search resulted in a total of 587 articles. The screening for eligibility is illustrated in figure 1. A final total of 15 articles were included, with no additional articles identified from cross-referencing.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowchart of identifying eligible studies.

The studies included in this review focused on five main specialties relating to paediatric or congenital disorders: cardiovascular surgery, general surgery (one study shared with urology), neurosurgery, respiratory medicine and gynaecology. Figure 2 breaks down the included studies by subspecialty.

Breakdown of specialties for included studies.

The majority of eligible studies (n=10) assessed the use of 3DP models in CHD. Out of the 15 included studies, 3 assessed the utility of 3DP models among undergraduates.13–15 One study was a multicentre study,10 and only two studies followed up participants after a period of time.13 16 The majority of studies were non-randomised, single-centred cross-sectional studies with no sample size calculations to determine the optimal number of study participants. Tables 1–3 summarise the study design, participants and findings of the included studies.

Study characteristics of cross-sectional studies

Study characteristics of randomised control trials

The authors acknowledge the generous support of the British Heart Foundation (CH/17/1/32804) and The Grand Appeal (Bristol Children’s Hospital Charity).

Twitter: @asharasif2

Contributors: AA conceived the study and drafted the study protocol, registered the review to PROSPERO, conducted the review searches, was first reviewer of the eligible studies and led the writing of the manuscript. EL reviewed eligible papers and contributed to the writing of the manuscript. MC assisted in editing the final manuscript. GB assisted in editing the final manuscript. AS conceived and supervised the study, was adjudicator for any conflicts in study selection for the review, assisted in editing the final manuscript, and acts as guarantor of the study. All authors read and approved the final manuscript.

Funding: The authors received no specific grant from any funding agency in the public, commercial or not-for-profit sectors for conducting this review.

Competing interests: None declared.

Provenance and peer review: Not commissioned; externally peer reviewed.

Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information. All eligible papers selected in the review are referenced in the final manuscript. Full PDF texts are available upon request.

Not required.