This study explored the subjective and objective results of ophthalmological microsurgical training for medical students. The microsurgical skill modules available on the Eyesi Surgical simulator, specifically those that are more abstract in nature, are useful for all medical students, not just those pursuing ophthalmology training. With the Eyesi Simulator, students are able to practice the precise movements that are required for microsurgery and receive immediate feedback. Our results showed that students achieved better scores on tissue treatment tasks than on instrument handling tasks. Students seemed to struggle in particular with the ‘odometer’ and ‘instrument slipped out of sphere’ criteria. These criteria relate directly to basic skills that must be acquired through extensive practice for successful surgery under a microscope. These results are not surprising as precision skills such as instrument handling take time to develop and all students in this study were complete novices.
Limitations to this study are the short training interval and a relatively high (n= 36) loss to follow-up rate. Loss to follow-up was attributed to curriculum conflicts which resulted in some students not attending their second planned simulator training day. These students were required to complete projects for a previous clerkship during their ophthalmology clerkship, which unfortunately resulted in a lower attendance rate on day two of simulator training.
Over recent years, there has been a decreased interest in pursuing general surgery residencies in many countries worldwide [10,11,12,13], Exposing students to surgical skills by means of a simulator such as Eyesi may be helpful in providing a window into a future surgical career and boost interest in surgical subspecialties. The majority of students in this study reported that the Eyesi Surgical simulator was a useful component of their ophthalmology clerkship.
Students engagement, how to enhance it and how the result might have an effect onto the acceptance of a curriculum, the creation of innovative curricular changes and also the development of impactful extracurricular projects can be followed up in literature more frequently over the last 10 years.
In Germany, students in their 10.th semester of medical school choose which elective specialty they would like to rotate through during their final year. Thus, giving students prior surgical experience with a simulator might help them to decide if they should consider a surgical specialty rotation. As the above results show, a number of students in this study were still undecided about which specialty they hoped to pursue after medical school. Considerations such as talent and enjoyment should not be minimized, and these are two factors that early introduction to basic skills with a simulator can help to clarify. Seo et al. and Yang et al. both reported increased medical student interest in surgical disciplines following a short surgical skills workshop [14, 15]
The importance of self-reported confidence in abilities and skills should not be overlooked when considering choice of specialty. Our results showed that a majority of students were more confident in their microsurgical abilities after completing training on the simulator. Similar results were reported by Antiel et al., who developed an intensive pre-clinical surgical experience for medical students. This one-week course, which included a simulation component, resulted in increased confidence in a variety of surgical skills as evidenced by self-reported abilities on pre and post experience surveys ,
Kahu and Nelson  have summarized the understanding of mechanisms of student success and the meaning of student retention for higher education institutions. First, an educational interface adequate for the interaction between students and institutions is required. Second, psychological constructs including self-efficacy, emotions, belonging and well-being are essential for mediating the interaction between both students and institutions. Third, a concept to understand why some students with lower completion rates are retained and do go on to successfully complete their studies and others do not. This could help to explain the lower second session attendance rates in this study, which was mentioned as a limitation, and resulted from a conflict between several clerkships during the medical school curriculum. The design and implementation of curricula and co-curricular initiatives with different subspecialties considerations for each other are essential for a global success of education in medicine.
A meticulous debriefing with defined communication content (eg advocacy, inquiry, illustration, and confirmation) between debriefers and participants is mentioned by Berger-Estilita et al.  to be positively related to learning outcomes. Others, like Peters et al. , give suggestions for enhancing student engagement by maximizing dialogue between students and faculty. Zdravkovic et al.  stresses out that peer teaching, school governance and extracurricular activities lead to a high level of student engagement which can also affect innovative curricular changes and enable students to deliver highly impactful extracurricular projects.
The number of studies about students engagement potentially facing a shift in the teaching paradigms using simulation has increased over the last 15 years:
Okuda et al.  summarized in 2009 that simulation had become increasingly prevalent in medical school and resident education and that simulation is proven to be effective in the teaching of basic science and clinical knowledge, procedural skills, teamwork and communication as well as in assessment at the undergraduate and graduate medical education levels.
In educational scenarios let by a physical instructor, objective judgment and subjective feelings are united. The virtual trainer is completely free from subjective opinions, and provides clear objective feedback about student performance. As simulator software and technology continues to develop, this will become increasingly more optimized and fine-tuned to fit specific learning objectives. From our personal point of view, the stand-alone function has significant advantages, however the best training procedure includes an additional in-person instructor, who can provide hands-on assistance to the trainee at certain times during the training interval. This leads to the best results in satisfaction of the trainee as well as learning curve during the training process.
McGue  highlights the modern educational concept of simulation-based medical education. Essential experimental learning opportunities can be offered without risk to patients and simulation devices are differentiated into various categories: low-technology models, standardized “patients”, screen-based computer simulations, complex task trainers, high-fidelity patient simulators, and virtual reality systems .
Lu, Cuff and Mansour  To summarize that because simulation is becoming an important tool in surgical education, faculty is being forced to modify their teaching of technical skill concepts. The authors recommend to concentrate teaching surgical skills ideally in a simulation center. Our personal experiences are that in such simulation centers which bring different medical subspecialties together in one place there are lots of advantages in regard to the infrastructure but we also found an imbalance between subspecialty representation: eg ophthalmology is considered to be a “small” subject with less need to be represented in these educational centres.