The observation that synchronous remote and face-to-face theoretical instruction produced comparable knowledge acquisition is consistent with a substantial body of literature from medical and health professions education. The so-called no significant difference phenomenon, first documented decades ago in distance education research, has repeatedly shown that when content, pacing, instructor quality, and learner engagement are held constant, the delivery medium itself rarely determines learning outcomes for declarative knowledge. What this study adds is a veterinary-specific and surgically contextualized confirmation of that pattern, using a standardized one-hour lesson on bovine tenotomy of the deep digital flexor tendon delivered to novice learners with no prior surgical experience. The randomization, the use of identical slides, images, and instructional guidance across groups, and the controlled classroom environment all strengthen the internal validity of this comparison and address common confounders in modality research, such as instructor variability and content drift between formats.

Equally important is what the study reveals about the limits of theoretical preparation alone. In both groups, initial practical performance was strikingly limited, with few students able to complete the procedure correctly on a first attempt. This result should not be read as a failure of the students or of the instruction, but rather as evidence about the nature of surgical skill itself. Procedural competence depends on the integration of conceptual understanding with visuospatial perception, instrument handling, tissue interaction, and real-time corrective feedback, capacities that cannot be fully encoded through verbal and visual description alone. Cognitive load theory offers a useful framework here: novices confronted with a complex novel motor task experience intrinsic load that overwhelms working memory, and textual or pictorial prelearning, while necessary, is insufficient to scaffold execution without live modeling and guided practice. The significant improvement observed on the second attempt, following an in-person instructor-led demonstration, illustrates the well-established pedagogical principle that observation of expert modeling followed by deliberate, repeated practice with feedback is a far more potent driver of early skill acquisition than preprocedural instruction by itself.

The design of the study deserves attention because it isolates a specific and practically relevant question. Rather than comparing entire curricula or long-term outcomes, the investigators examined a single instructional sequence: theoretical lesson, first attempt, demonstration, second attempt. This granularity matters for curriculum planners because regulatory frameworks operate at the level of workload distribution, while learning happens at the level of sequenced instructional events. The evidence suggests that remote delivery can occupy a legitimate place in that sequence as the vehicle for conceptual preparation, provided that it is followed by supervised in-person experiences that include demonstration, repetition, and feedback. The comparable improvement between groups during the second attempt further suggests that the benefits of in-person demonstration were not modulated by how the preceding theoretical content had been delivered, reinforcing the idea that remote and in-person elements can be complementary rather than competing.

It is worth situating these results within the broader literature on simulation and skills training in surgical education across species and professions. Research in human surgical training has repeatedly demonstrated that theoretical knowledge and technical skill are only weakly correlated, and that structured skills laboratories, model-based simulation, and progressive mastery learning outperform knowledge-focused preparation for the development of manual competence. Veterinary education faces additional challenges, including the heterogeneity of patient size and anatomy, the ethical and economic constraints on animal use for teaching, and the limited availability of cadaveric and clinical material. In this context, the tenotomy model used in the study is instructive: it is a fundamental procedure that integrates core elements of surgical technique, including aseptic preparation, tissue handling, hemostasis, and closure, while being feasible to teach in a controlled laboratory setting. Findings from such standardized procedures can plausibly generalize to other basic surgical skills, though extrapolation to more complex procedures, live animal surgery, or clinical decision-making under uncertainty should be made cautiously.

The choice of a bovine model also carries practical significance for the Brazilian context, where large animal practice represents a substantial share of professional activity and where curricular reforms affect a large and diverse student population. Third-semester students represent the earliest stage at which surgical exposure typically occurs, making them an appropriate population for studying initial performance rather than refined competence. The restricted sample size, justified by a power analysis based on a large anticipated effect size, is adequate for detecting major differences between groups but limits the precision of estimates and the ability to detect smaller effects or interactions. Readers should therefore interpret the absence of significant differences as an absence of evidence for a modality effect under these conditions, not as definitive proof of equivalence. Replication with larger cohorts, multiple institutions, additional procedures, and longer follow-up would strengthen the evidentiary basis for curricular policy.

The Brazilian regulatory developments that motivated this study reflect a global trend toward flexibility in professional education, driven in part by expanded digital infrastructure, pandemic-era experience with emergency remote teaching, and economic pressures on higher education. However, the study’s conclusions offer a measured counterweight to purely administrative interpretations of that flexibility. If semipresential formats allow theoretical coursework to move online, the implication is not that practical training can be proportionally reduced, but rather that in-person time should be concentrated and protected for the activities that demonstrably require it: demonstration, supervised practice, feedback, and progressive refinement. This reframing could actually improve curricula by making explicit the distinction between knowledge transmission, which digital tools handle well, and skill formation, which depends on physical supervision and repeated deliberate practice. The danger identified in the study’s conclusions, that curricular expansion of non-presential components might erode the quantity and quality of hands-on training, is a real one, and the empirical finding that novices perform poorly without live demonstration provides concrete support for maintaining robust practical components.

The study also highlights the importance of instructional design quality in remote delivery. The theoretical lesson was not a passive lecture but a structured session with standardized visual and verbal guidance, delivered synchronously so that students could interact in real time. Synchronous formats preserve many of the pedagogical affordances of the classroom, including immediate clarification of doubts and instructor awareness of student comprehension, which may explain why remote delivery performed comparably to in-person teaching for knowledge outcomes. This distinction between synchronous and asynchronous digital learning is often blurred in public debate, yet it is likely to be critical in professional programs. Asynchronous content may serve well for review, preparation, and reinforcement, but the real-time guidance examined here more closely mirrors traditional teaching and may be the more appropriate substitute within a blended sequence.

From a methodological standpoint, the use of a standardized assessment before and after demonstration provides a within-subject dimension that strengthens the study beyond a simple between-group comparison. The significant within-group improvement from first to second attempt demonstrates the sensitivity of the practical scoring instrument to genuine performance change, which supports the validity of the between-group null result. Future work could extend this design by adding further practice trials, delayed retention testing, and transfer tasks, which would reveal whether the demonstrated gains persist and generalize. Incorporating validated measures of technical skill, such as structured checklists and global rating scales completed by blinded assessors, as well as objective motion analysis where feasible, would further enrich the evidence base.

Ultimately, the contribution of this study lies less in resolving the debate about remote education than in sharpening its terms. It suggests that the productive question for veterinary curricula is not whether digital delivery is superior or inferior to face-to-face teaching in the abstract, but which learning objectives, at which stages of training, and within which instructional sequences, each modality should carry. For theoretical foundations, the evidence supports the legitimacy of synchronous remote instruction under structured conditions. For initial technical execution among novices, the evidence affirms the indispensability of live modeling and supervised practice. As Brazilian veterinary programs adapt to the new regulatory landscape, studies of this kind, conducted with randomized designs, standardized procedures, and transparent reporting, provide the empirical scaffolding needed to design blended curricula that expand access and flexibility without compromising the practical competence that the profession, and the animals under its care, fundamentally require.

Subject of Research: Initial surgical performance in veterinary training: theoretical instruction modality and practical outcomes before and after instructor-led demonstration

Article Title: Initial surgical performance in veterinary training: theoretical instruction modality and practical outcomes before and after instructor-led demonstration

Article References: Paredes, S. L., Callegarette, N. C., Mendes, R. P., Rocha, P. S., Vallejo, K. A. G., & Correa, R. R. (2026). Initial surgical performance in veterinary training: theoretical instruction modality and practical outcomes before and after instructor-led demonstration. Global Surgical Education – Journal of the Association for Surgical Education, 5(1), Article 175. https://doi.org/10.1007/s44186-026-00582-8

Image Credits: AI Generated

DOI: 10.1007/s44186-026-00582-8

Keywords: Initial, surgical, performance, veterinary, training, theoretical, instruction, modality, practical, outcomes, instructor-led, demonstration

Health literacy is broader than the ability to read. It includes obtaining, processing and understanding health information, then using it to make preventive, diagnostic and treatment decisions. Cancer health literacy is a disease-specific form of that capacity, involving concepts such as diagnosis, prognosis, treatment choices, medication management and risk interpretation. In human oncology, limited cancer health literacy has been associated with lower participation in screening and prevention programs, delays in diagnosis, difficulty making treatment decisions, poorer adherence and reduced quality of life. The Kansas State researchers propose that comparable challenges may occur in veterinary oncology, where owners must often interpret probability, balance benefits and burdens, and decide whether a treatment fits their animal’s needs and their own circumstances. Veterinary decisions also unfold within a distinct healthcare system, with its own terminology, costs, referral pathways and clinical routines. A communication strategy that assumes every client understands these systems may therefore leave important gaps between what clinicians explain and what owners are able to use.

To investigate the issue, the team adapted cancer health literacy instruments developed for human medicine and modified them for pet owners. The resulting English-language questionnaire contained 30 multiple-choice questions assessing cancer health literacy and 14 questions covering demographic characteristics and related experiences. Its content addressed several applied domains, including cancer-specific knowledge, numeracy, risk interpretation, medication and treatment management, interpretation of written and visual information, navigation of healthcare services, and the ability to distinguish cancer myths from evidence-based information. The survey also tested prose literacy, visual literacy, numerical literacy, and information and technological literacy. Before distribution, it was pretested with a subgroup of clients to identify unclear wording, problematic terminology, issues with survey flow and technical problems. The authors based the instrument on previous validated work, but they did not assume that a tool designed for human patients could be transferred unchanged to veterinary care. Changes in audience and context meant that the veterinary version would need its own validation.

The survey was sent online through Qualtrics to adult owners of dogs and cats who had used the routine healthcare service at the Kansas State University Veterinary Health Center in Manhattan, Kansas. Eligible clients lived in Kansas, had a valid email address and had brought a dog or cat to the service for any reason between January 2015 and December 2020. Veterinarians, veterinary students, and current or former hospital staff connected with oncology or small-animal internal medicine were excluded. Of 13,446 invitations, 1,773 responses were received, producing a response rate of 13 percent. A total of 1,548 respondents met the study’s inclusion threshold and were included in the statistical analysis. Nearly all respondents who progressed through the questionnaire completed it: 94.1 percent of the final study population answered every question, although completion times varied widely. The median completion time was 15 minutes, while the mean was 38.6 minutes, with reported times ranging from 5.6 minutes to more than three days.

Participants received one point for each correct answer among the 30 cancer health literacy questions, creating a score from 0 to 30; unanswered items were counted as incorrect. The mean score was 26.69, with a standard deviation of 2.4, and the median was 27. Individual scores ranged from 6 to 30. In initial, single-variable analyses, scores were associated with age, gender, marital status, ethnicity, education, employment status and field of employment. Previous cancer experience also mattered: respondents who reported a cancer diagnosis in a family member or pet showed significant associations with their scores. By contrast, owning a dog rather than a cat, owning both, or having pet insurance was not significantly associated with cancer health literacy. Because 98.3 percent of respondents identified themselves as their pet’s primary caregiver, the researchers could not meaningfully evaluate that characteristic. These findings describe patterns within this particular respondent group; they do not establish that any demographic characteristic causes higher or lower cancer health literacy.

The researchers then used a multivariable regression model to examine several factors simultaneously. The final model included education, age, ethnicity, a reported cancer diagnosis in the family, and an interaction between education and ethnicity. Higher educational attainment was generally associated with higher scores, but the size of that association differed among ethnic groups. Within each ethnic group, respondents with doctorate or professional degrees had higher scores than those with lower levels of education, while respondents with bachelor’s or master’s degrees also generally scored higher than those with an associate, trade, vocational or high-school education. The model also indicated that respondents aged 35 to 44 and 55 to 64 had higher adjusted scores than those older than 65. People reporting cancer in a family member had higher adjusted scores than those who did not report such an experience. The authors caution that ethnicity should not be interpreted as a biological or causal determinant. In this analysis, it may instead reflect intertwined structural, socioeconomic, educational, cultural and linguistic conditions that shape access to information and opportunities to use it.

The study’s implications extend beyond the questionnaire itself. Cancer consultations can involve emotionally charged news, unfamiliar terminology and decisions that depend on values as much as on medical facts. An owner may need to understand a pathology result, compare surgery with other treatments, calculate a medication dose, recognize potential side effects, interpret a graph or decide when a change in symptoms warrants a call. Information delivered in the clinic may later be reviewed at home, discussed with family members or compared with material found online. The authors therefore support communication that uses plain language, avoids unnecessary jargon and acronyms, combines verbal explanations with visual aids, and provides written summaries at an accessible reading level. They also point to teach-back, in which a client explains the information in their own words, as a way to reveal misunderstandings and allow the clinician to clarify them. Such approaches do not place responsibility solely on the owner; health literacy is also shaped by the clarity of providers and by the accessibility of the healthcare system.

Several limitations define what can be concluded from this first investigation. The questionnaire measured written, visual and basic numerical skills, but not listening, verbal communication or advocacy skills. It did not assess the veterinarian’s communication ability or the nature of the provider-client relationship. Respondents were drawn from one academic veterinary center in Kansas, and 94 percent identified as Caucasian, limiting the generalizability of the findings. The survey was offered only in English, and the primary language of participants was not recorded. The 13 percent response rate also raises the possibility of response bias because clients who answered may differ systematically from those who did not. In addition, participants were recruited from routine healthcare visits, often involving reportedly well animals, rather than from owners facing a recent cancer diagnosis; scores might differ during the stress of an oncology consultation. The authors conclude that the instrument requires further psychometric validation and that future research should test whether targeted communication and educational interventions improve owner understanding, satisfaction and clinical outcomes for veterinary cancer patients. For now, the study’s message is straightforward: effective cancer care for animals depends not only on available treatments, but also on whether owners can understand and use the information needed to choose among them.

The questionnaire’s high average score should not be read as evidence that veterinary clients generally face few communication barriers. Scores were concentrated toward the upper end of the 0–30 scale, while the response rate was 13 percent and participants came from a single academic hospital. Clients who chose to complete an online survey, had regular access to email, or felt confident answering cancer questions may have been more likely to participate than clients with different experiences. This creates the possibility that the observed distribution does not represent the broader population of pet owners, particularly people who face language, technology, educational or access barriers.

Validation is important because a reliable questionnaire must do more than produce consistent scores. Researchers must establish whether its questions measure the intended aspects of cancer health literacy, whether scores remain meaningful across demographic and language groups, and whether results correspond to relevant behaviors or outcomes. Future studies could compare questionnaire performance with owners’ understanding after a clinical consultation, their ability to explain treatment instructions, or their recognition of warning signs requiring veterinary attention. Repeated testing could also show whether scores are stable or change after education.

A further research opportunity is to examine cancer communication as an interaction rather than an attribute of the owner alone. The same client may understand information differently depending on stress, the urgency of a decision, the clinician’s explanations, the format of educational materials and the opportunity to ask questions. Studies conducted during actual oncology consultations could therefore complement survey data by analyzing explanations, questions, teach-back responses and follow-up adherence. This approach may help identify practical points at which veterinary teams can reduce misunderstanding before it affects treatment decisions.

Subject of Research: Cancer health literacy among dog and cat owners in veterinary care

Article Title: Initial implementation of a cancer health literacy questionnaire among owners of pet dogs and cats attending a primary veterinary healthcare service: Part I. Cross-sectional evaluation of the cancer health literacy of the study population

Article References: Wouda, R. M., Grimes, E., Dixon, A. L., Hocker, S. E., Higginbotham, M. L., & Cernicchiaro, N. (2026). Initial implementation of a cancer health literacy questionnaire among owners of pet dogs and cats attending a primary veterinary healthcare service: Part I. Cross-sectional evaluation of the cancer health literacy of the study population. Veterinary Oncology, 3(1), Article 22. https://doi.org/10.1186/s44356-026-00073-4

Image Credits: AI Generated

DOI: 10.1186/s44356-026-00073-4

Keywords: cancer health literacy, veterinary oncology, pet owners, veterinary communication, health literacy, dogs, cats, questionnaire, shared decision-making, Initial, implementation, cancer

Health literacy refers to the ability to obtain, process and understand health information and use it when making decisions. Cancer health literacy is a more specific form concerned with concepts encountered in cancer prevention, diagnosis and treatment. In veterinary medicine, the construct applies not to the animal patient directly but to the owner who must interpret professional advice, weigh options and often make decisions on the animal’s behalf. Those decisions can involve surgery, chemotherapy, radiation, palliative care, prognosis and treatment risks. The research team had previously developed a 30-question cancer health literacy questionnaire for veterinary clients. In this second analysis, the investigators examined the statistical behavior of each question and explored whether questions worked differently for groups defined by education and previous experience with cancer.

The survey was distributed remotely through the Qualtrics platform to clients attending the Pet Health Service, the general-practice branch of the Kansas State University Veterinary Health Center. Invitations were sent between January 2015 and December 2020. Of 13,446 emails distributed, 1,773 responses were received, producing a response rate of 13 percent. Researchers included 1,548 respondents who answered at least 75 percent of the 30 cancer health literacy questions and supplied some demographic information. The questionnaire also included 14 demographic questions, although completing every demographic item was not required. Participants’ scores ranged from six to 30 correct answers, with a mean of 26.7 and a median of 27, indicating that most respondents performed near the top of the available range.

That concentration of high scores created a ceiling effect, meaning many participants answered the easiest questions correctly and left relatively little variation for the test to measure. The item-difficulty index used by the researchers was the proportion of respondents answering a question correctly; unlike ordinary language, a high value meant an easy item. Across the questionnaire, the median difficulty index was 0.94, with values ranging from 0.50 for a question about feline leukemia virus risk to 0.99 for several questions, including items concerning the next pill, biopsy, appointment location, cancer stages, inoperable tumors and radiation treatment. The average difficulty index was 0.89. These figures show that the instrument was not demanding for this sample, but ease alone does not determine whether a question is useful.

The researchers therefore also calculated item discrimination, which measures how effectively a question separates respondents who perform strongly overall from those who perform weakly. The index compares correct responses from the highest-scoring 25 percent with those from the lowest-scoring 25 percent. Values can range from minus one to one, with larger positive values indicating stronger discrimination. The median was only 0.05, and the mean was 0.08. Ten questions had negative discrimination, meaning lower-performing respondents were more likely to answer them correctly than higher-performing respondents. Such a result can arise from ambiguous wording, misunderstanding, measurement error or a question that draws on a different skill from the one the test is intended to assess. Only six items exceeded 0.2: questions concerning feline leukemia virus risk, high-calorie diets, book chapters, airborne tumor spread, dose timing and palliative care. These questions appeared to provide the clearest information about differences in ability.

To examine the structure of the questionnaire, the team used item response theory, a family of statistical methods that models the probability of a correct answer as a function of an unobserved trait—in this case, cancer health literacy. Unlike a simple total score, item response theory can estimate how difficult a question is and how sharply it discriminates across the underlying ability scale. Analyses using parallel analysis and the Hull method supported a single underlying factor, or unidimensional structure. Although a three-parameter logistic model could in principle account for guessing on multiple-choice questions, its guessing estimates had large standard errors and the model encountered convergence problems. A likelihood-ratio comparison found no meaningful advantage for the more complex model, while information criteria and overall fit favored a two-parameter logistic model. The researchers used that model for subsequent analyses, finding that it fit the data well and was especially informative at lower ability levels.

The study also tested differential item functioning, or DIF. DIF occurs when people with comparable levels of the underlying ability have different probabilities of answering a particular question correctly because they belong to different groups. Detecting DIF can reveal wording or content that introduces bias unrelated to the construct being measured. Among education groups, seven questions displayed DIF: oral cancer, risk of complications, palliative care, airborne tumor spread, survival rate, feline leukemia virus risk and book chapters. The pattern suggested that some questions relied partly on numeracy, vocabulary, reading comprehension or basic biology in addition to cancer-specific knowledge. However, the combined differences did not produce significant differential test functioning, meaning the questionnaire as a whole did not show a statistically significant education-related scoring bias. Participants with at least a bachelor’s degree scored 1.21 points higher overall, but that difference was not significant.

Personal experience with cancer produced a different pattern. Respondents who had not experienced a cancer diagnosis in a family member scored 1.47 points lower than those who had, while respondents without a cancer diagnosis in a pet scored 1.41 points lower than those who had. Both differences were significant, but they were concentrated among people with lower cancer health literacy; at average and higher ability levels, the groups performed similarly. Individual questions involving inoperable tumors, palliative care and cancer stages showed differences between experienced and inexperienced groups. The investigators caution that some subgroup estimates were imprecise because only a small number of respondents answered certain items incorrectly. For example, the pet-cancer analysis included a group with previous experience, but only two people in that group answered the cancer-stages item incorrectly.

The researchers say the findings could help veterinarians identify owners who may benefit from clearer explanations, teach-back techniques or other communication support, but they do not present the questionnaire as a validated clinical screening tool. The sample came from a single academic veterinary center, was highly educated—70 percent had at least a bachelor’s degree—and was predominantly White or Caucasian, at 93.7 percent. Socioeconomic information was not collected, and the sample was too limited for analyses of differences by race or ethnicity. In addition, more than half of respondents, 879 people or 56.8 percent, reported owning only dogs, raising concerns about the strong performance of the feline leukemia virus question: an incorrect answer might reflect limited cat-specific knowledge rather than low cancer health literacy. Future work must test revised, species-neutral or species-specific versions in larger and more diverse populations. For now, the study’s central message is practical: effective veterinary oncology communication depends not only on the information clinicians provide, but also on how that information functions for owners with different experiences, skills and levels of understanding.

Item response theory is particularly useful when a questionnaire is intended to guide communication rather than simply rank respondents. It treats cancer health literacy as a latent characteristic inferred from response patterns, rather than assuming that every correct answer contributes identical information. In the two-parameter logistic model used here, each question is described by its difficulty and discrimination. A question may be easy overall yet still provide useful information if it distinguishes people near the lower end of the ability continuum. Conversely, a difficult question is not automatically valuable if responses are poorly aligned with the construct being measured.

The distinction between differential item functioning and differential test functioning is important for interpreting the results. DIF flags a question whose response probability differs between groups after accounting for estimated ability; it is therefore a signal for review, not proof that the item is unfair or defective. Differences may reflect vocabulary, numeracy, prior exposure to a clinical setting or genuine differences in relevant knowledge. DTF considers the aggregate effect across the questionnaire. In this study, education-related differences at individual-item level did not accumulate into a statistically significant overall scoring effect, suggesting that the instrument’s total score was more stable across those education groups than some of its component questions.

The findings also illustrate why validation must continue after an instrument has been developed. A questionnaire can have an apparently strong average score while providing limited precision for most respondents if answers cluster near the maximum. Its practical value may instead lie in the lower-ability range, where the study found greater separation between respondents and where communication difficulties may be most consequential. Revisions could therefore focus on replacing redundant, very easy questions with items that probe comprehension without depending unnecessarily on specialist vocabulary or species-specific assumptions. Any revised version would need fresh calibration, because changing wording or content alters item parameters and can change how scores should be interpreted. Testing across different practices, regions, cultural groups and levels of veterinary experience would also help establish whether the observed pattern reflects the questionnaire itself or the particular clientele who completed it.

Subject of Research: Cancer health literacy measurement among dog and cat owners in veterinary oncology

Article Title: Initial implementation of a cancer health literacy questionnaire among owners of pet dogs and cats attending a primary veterinary healthcare service: Part II. Item difficulty and discrimination

Article References: Dixon, A. L., Cernicchiaro, N., Grimes, E., Hocker, S. E., Higginbotham, M. L., & Wouda, R. M. (2026). Initial implementation of a cancer health literacy questionnaire among owners of pet dogs and cats attending a primary veterinary healthcare service: Part II. Item difficulty and discrimination. Veterinary Oncology, 3(1), Article 23. https://doi.org/10.1186/s44356-026-00072-5

Image Credits: AI Generated

DOI: 10.1186/s44356-026-00072-5

Keywords: veterinary oncology, cancer health literacy, pet owners, health communication, item response theory, questionnaire validation, psychometrics, dogs, cats, Initial, implementation, cancer