Surgery Open Science 10 (2022) 148–155

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Surgery Open Science

journal homepage: https://www.journals.elsevier.com/surgery-open-science

Research Paper

Impact of an in-person small group surgical skills course for preclinical

medical students in an era of increased e-learning
Louise Kuo, MBBS, iBSc ⁎, Nadia Liber Salloum, MBChB, BMedSci 1, Benjamin Kennard, MBChB 1,
James Robb, MBChB, MA, Paula Vickerton, PhD, BSc, PGCert
Queen Mary University of London, Mile End Rd, London E1 4NS, United Kingdom

a r t i c l e i n f o a b s t r a c t

Article history: Objective: The COVID-19 pandemic led to a dramatic decrease in face-to-face teaching. This can particularly im-
Received 11 August 2022 pact medical students' skills development. This prompted development of an in-person surgical skills course as
Accepted 19 September 2022 guided by the General Medical Council "Outcomes for Graduates" facilitated by tutors with surgical experience.
Available online 26 September 2022 This study aimed to primarily assess participant confidence in surgical skills following the course.
Design: This was an interventional study assessing both qualitative and quantitative data collected prior to, dur-
ing, and post course completion. Data were collected from students via online forms, which included a mixture of
"Yes/No" responses, self-assessed confidence levels via Likert scales, and free type questions.
Setting: The study assessed feedback for a 5-session surgical skills course delivered at the authors' institution. This
is a newly designed course using low-cost materials which was free for all attendees.
Participants: Participants were all in the first or second year of medical school. There was capacity for 60 students,
and all attendees provided informed consent to participate.
Results: A total of 446 students applied for the course with 58 participants in the final study, 31% of whom had
prior surgical skills experience. There was a statistically significant increase in student confidence levels following
the course for all taught surgical skills (P = .0001). Participants were also more confident that they possessed the
skills required for clinical placements (P = .0001) and to work as a junior doctor (P = .01). Thematic qualitative
analysis revealed a reliance on third parties for previous surgical experience; this course improved knowledge
and skills for future practice. Limitations included session duration and equipment choice.
Conclusion: This study demonstrates high demand and student satisfaction from this course, offering a potential
framework to improve undergraduate surgical skills teaching. The results presented here have the potential to
inform wider curricula development across medical schools in the future.
Competencies: Medical knowledge; practice-based learning and Improvement.
Crown Copyright © 2022 Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).

INTRODUCTION minimum level of surgical achievement on completion of medical

school. Cited outcomes include an ability to recognize common surgical
The General Medical Council (GMC) "Outcomes for Graduates" [1] presentations and competence in practical skills such as the use of local
stipulates that all graduating doctors acquire surgical and procedural anesthetics, skin suturing, and wound care. A robust surgical education
skill competence. This has recently been highlighted by the Royal for all undergraduate medical students is essential irrespective of
College of Surgeons in their development of a "National Undergraduate subsequent career path. Not only do surgical conditions represent a
Curriculum in Surgery" [2] which seeks to raise standards by defining a significant proportion of elective and emergency referrals within the
National Health Service [3,4], but surgical principles and skills are trans-
Abbreviations: A&E, Accident and Emergency; COVID-19, coronavirus disease caused ferrable within all aspects of medicine including interventional special-
by SARS-CoV-2 virus; e-learning, electronic learning; GEP, graduate entry program; ties, emergency medicine, and general practice [5]. Effective surgical
GMC, General Medical Council; GP, general practitioner; MBBS, Bachelor of Medicine, education is therefore imperative for the continued provision of safe
Bachelor of Surgery; NHS, National Health Service; RCS, Royal College of Surgeons; UK, care for future patients.
United Kingdom.
⁎ Corresponding author.
A national United Kingdom review of surgical and procedural
E-mail address: [email protected] (L. Kuo). skills training at medical schools conducted in 2014 [6] found that
1
Co-first authors: These authors have contributed equally to the work. skills cross-referenced against GMC documentation were provided by

https://doi.org/10.1016/j.sopen.2022.09.004
2589-8450/Crown Copyright © 2022 Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
L. Kuo, N.L. Salloum, B. Kennard et al. Surgery Open Science 10 (2022) 148–155

medical schools and supplemented by extracurricular student surgical in an informal manner with verbal feedback provided by the tutors at
societies. Basic surgical skills modules incorporated as part of an under- the time. This included the use of tasks to review and assess students'
graduate curriculum for first year students have been found to have a competencies such as a quiz in the final session (Table 1).
positive impact on technical skill development [7]. Furthermore, greater
benefit has been demonstrated when surgical skills teaching is provided
Equipment and Resources. Consumable equipment was supplied by
in a distributive manner with weekly practice when compared with an
either local surgical departments or course tutors. All other equipment
intense 1-day course [8]. These studies suggest the efficacy of surgical
was available within the department. Artificial wounds were made
skills introduced and practiced early in medical schools. Established
using the RCS-approved low-cost construct for suturing practice [18]
educational theory applied in the context of surgical education [9]
as seen in Fig 1.
include the (1) acquisition and retention of motor skills [10], (2) impor-
tance of availability of expert assistance [11], and (3) learning within
communities of practice [12]. Data Collection. Data were collected from the participants via online,
The educational landscape has rapidly evolved due to the recent anonymized feedback using a Microsoft Form. As part of this, partici-
COVID-19 pandemic [13]. In an era with reduced opportunity for in- pants used a random number generator to acquire a unique identifier
person teaching, there has been an exponential growth of online "e- which was used on all feedback forms to allow pairing of these
learning" which offers the additional benefits of flexible scheduling data. These were completed before the course, after each session, and
and increased accessibility to educational materials. E-learning has a de- after the course's conclusion, allowing comparison between the various
monstrable role within surgical education as an educational tool [14]; stages of course progression. Feedback was collected using a mixture of
the use of virtual patients, graphics, and videos can significantly enrich dichotomous questions, Likert scales, and open questions (Appendix 1).
the learning experience of trainees. However, e-learning may offer little Using various approaches allowed us to collect data that were easily
in the way of hands-on-skills or individualized instruction and perfor- comparable, such as via Likert scales, but also subjective opinion-
mance feedback [15]. This supports previous literature in favor of based responses that could be analyzed using thematic qualitative
"blended" learning strategies integrating both traditional in-person analysis. These same data from open-ended questions could also be
teaching with online learning [13,16,17]. used to improve the sessions as we went along, thus enhancing the
The reduced availability of in-person teaching during the COVID-19 experience of the students. Students were provided with the link to
pandemic has prompted our development of an in-person surgical skills the feedback forms at the end of every session for postsession question-
course. Herein, we aim to provide early-year medical students with for- naires; for the pre- and postcourse questionnaires, the links were pro-
malized teaching on basic surgical skills as guided by the GMC "Out- vided via email.
comes for Graduates" facilitated by tutors with surgical experience.
Primary outcomes include an assessment of participant confidence in
Data Analysis. Pre- and postcourse questionnaire responses were
surgical skills, early consideration of a career in surgery, and engage-
analyzed using R (version 3.6.1) [19]. For those who completed both
ment with the course. Secondary outcomes relate to student percep-
pre- and postcourse questionnaires, nonparametric statistical testing
tions of current in-person and online teaching modalities during the
was carried out using a paired Wilcoxon signed-rank test with Holm
pandemic.
correction. Comparison of career considerations was carried out using
Fisher exact test. Results reported include the test statistic (Z), P value,
MATERIAL AND METHODS
and corrected P value. For qualitative analysis, we conducted thematic
analysis of the 4 free text questions within the postcourse questionnaire
Participants. The surgical skills program was offered to medical stu-
using Braun and Clarke's [20] established method. The intention of this
dents in phase 1 of their study at Queen Mary University of London.
process is to seek understanding of the experiences and thoughts of
Phase 1 refers to first and second year undergraduate program students
student participants. Responses to each question were analyzed for
and first year Graduate Entry Program students. We advertised to all
their semantic meaning and coded accordingly. Themes were then con-
phase 1 students via their cohort mailing list. An online sign-up form
structed from these codes through an iterative process. The approach to
using Microsoft Forms was distributed to this cohort of students, and se-
the thematic analysis was inductive, though we note that the relatively
lection was based on a first-come-first-served basis. There was capacity
short answers provided by respondents' limit the scope of analysis.
for a total of 60 students to complete the course. Of those that signed up
to the course, participation in the study was voluntary. All attendees re-
ceived a written information sheet regarding the study (see Appendix RESULTS
1) and provided written informed consent to participate. Ethical
approval for the study was obtained from the Queen Mary Ethics of Demographics. A total of 446 individuals applied to attend the course,
Research Committee and the Institute for Health Sciences Education for which there was available space for 60 participants. The final cohort
Peer Review Committee. of course participants consisted of 55.2% Year 1 students, 39.7% Year
2 students, and 5.2% Graduate Entry Programme Year 1 students,
Course Design. The course consisted of five 1-hour sessions and was which was roughly equal to the proportion of students in these
free to attend. Each session was modeled on the Practical Skills and Pro- years currently enrolled at the university. Of those who attended
cedures subsection of the GMC "Outcomes for Graduates" [1], and the the course, 96.7% (n = 58) completed the precourse questionnaire,
structure of each session is outlined in Table 1. These sessions took 51.7% (n = 30) of whom we were able to pair with a corresponding
place on the university campus when students had no other scheduled postcourse questionnaire.
university teaching. Each session had the capacity for 20 students and Prior to the course, participants reported having considered a range
was repeated 3 times to accommodate all participants. The course ran of career paths as shown in Table 2.
from November 2021 to March 2022. Sessions were delivered by 6 cur- Eighteen students (31.0%) had previous experience in surgical skills,
rent or past clinical teaching fellows at the medical school. All tutors had 88.9% of which was mostly or entirely delivered in an in-person setting.
completed their UK Foundation training and had clinical experience in Free text responses from all students who had experience in surgical
all procedural skills covered in this course through surgical or emer- skills reported that this experience had taken place outside the MBBS
gency department jobs. Sessions were designed such that there were curriculum. Of those that had prior surgical skills experience, 11.1%
7–8 students per tutor. Sessions contained practical components had experience in scrubbing and infection control, 5.6% had experience
where students could attempt all taught skills. Students were assessed with basic surgical equipment, 55.6% had experience suturing, 22.2%

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Table 1
Session designs including timing and learning objectives

Session 1 Session 2 Session 3 Session 4 Session 5

Hand washing, scrubbing up, infection control Intro to surgical instruments, Local anesthetics—tutorial Basic suturing (interrupted, Wound care +
blades/safe disposal of and practical procedure mattress), knot tying removal of sutures and
sharps, sutures staples

Timing & Introduction: 10 min Introduction: 5 min Introduction: 10 min Introduction: 5 min Introduction: 10 min
content
Group stations: 45 min (15 min per station, 3 Group activity: 30 min Group activity: 30 min Group activity: 30 min Group activity: 30 min
stations)
Timed challenge: 15 min Introduction to knot Local anesthetic: 20 min Wound after care +
tying: 10 min quiz 15 min
Learning To be able to demonstrate how to effectively To be familiar with the To be able to perform a Perform a single-handed Discuss indications
objectives hand wash/scrub for theater using soap/water commonly used surgical simple interrupted suture surgeon's knot and benefits of basic
(± alcohol-based solution) equipment wound management
To be able to demonstrate Discuss indications for local
To be able to demonstrate how to To be able to recognize the an instrument tie anesthetic Understand the basic
appropriately gown and glove for surgery terms for different devices principles of wound
To understand the main Understand the principles of management
To be able to describe when standard hand To be able to demonstrate steps in performing a drawing up local anesthetic
washing versus aseptic nontouch technique how to blade a scalpel and 2-handed surgeon's knot and calculating doses Perform wound
versus sterile conditions are appropriate dispose of blades safely irrigation and apply
To be able to handle and Perform local anesthetic surgical dressings
To be able to demonstrate how to maintain a To be able to handle and pass sharps safely and infiltration
sterile field and handle equipment accordingly pass sharps safely and securely Understand principles
to maintain this securely of wound after-care
To be able to describe and
To be able to describe and demonstrate the proper Perform suture
demonstrate the proper handling of sutures removal
handling of sutures

had experience knot tying, 5.6% had experience with local anesthetics, Although they overall felt that the course increased their exposure to
and 11.1% had experience with wound management and dressing. surgery and surgical teaching, it had no apparent impact on whether
they had considered a career in surgery (Table 3).
Teaching Modality. The precourse questionnaire, distributed in Octo- Following each session, feedback was obtained from participants on
ber 2021 when teaching remained multimodal due to the COVID-19 the session itself including session content, design, and delivery, the
pandemic and associated restrictions, showed that most students prefer median scores of which are shown in Table 4.
multimodal (55.2%) or in-person (41.4%) teaching delivery methods. Overall, following the course, 63.3% of participants felt that the
The perceived proportion of teaching delivered in-person at the time surgical skills course had a very or extremely large impact on their
is shown in Fig 2. overall confidence levels carrying out basic surgical skills.

Surgical Skills Course Impact. The increase in student confidence levels Qualitative Thematic Analysis
postcourse, as compared to precourse, was statistically significant for Reliance on Third Parties for Surgical Experience
all surgical skills outcomes, as outlined in the GMC "Outcomes for All respondents identified that existing surgical teaching within the
Graduates" (Fig 3). They were also more confident that they had the skills phase 1 curriculum was lacking, although it should be noted that there
required for clinical placements and to later work as a junior doctor. is variability in the experience of respondents because this course was

Fig 1. RCS low-cost construct for suturing practice.

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Table 2 school. Because I have more knowledge than before in surgical skills,
Career paths considered by participants I feel as though I'll be able to engage more in the surgical placements
Career path Precourse Postcourse Fisher and get more out of it.
exact P
Number Percentage Number Percentage
value
(n = 58) (%) (n = 30) (%)
The familiarity with scrubbing in and aseptic equipment handling
Surgery 48 82.8 23 76.7 .5722 has been hugely beneficial. I recently undertook a two week place-
Medicine 19 32.8 13 43.3 .3512 ment with a surgical team and was given the opportunity to scrub
General practice 11 19.0 5 16.7 1.0000
in and assist. Being able to have done this before was great and really
Anesthetics/critical 19 32.8 10 33.3 1.0000
care allowed me to have confidence going in to this experience.
A&E 16 27.6 5 16.7 .3014
Obstetrics and 12 20.7 2 6.6 .1259 Moreover, several students reported that being taught by junior doc-
gynecology tors gave them a better insight into the realities of life as a junior doctor
Pediatrics 11 19.0 7 23.3 .7811
and how their new skills might be employed.
Psychiatry 7 12.1 0 0 .0902
Other 3 5.2 1 3.3 1.0000 A more realistic idea of what small procedures and jobs doctors do in
their day and that early exposure will help me improve these skills
offered to students from years 1 to 2. Demand for surgical education is for real patients.
high, with a significant number of respondents seeking out surgical A significant number of students expressed that they had enjoyed
education opportunities from third parties such as societies, work expe- the course, felt it was well run, and would recommend it to others.
rience, and student-selected components to meet this gap. Several highlighted that they felt the course content would be rele-
vant to all students and not just to those with a desire to pursue a
Aside from this course there is not much exposure to surgical teach- surgical career.
ing in pre-clinical years. I have had to sign up to extra curricular Really enjoyed the course. As GEPs we don't get much opportunity
events in order to experience surgical skills so would be good to in- for the applicable part of medicine in our first year, and I think it's
corporate into the curriculum even in pre clinical years. to the detriment of the university course. A course like this would
be really appreciated for the whole year I think, even those not nec-
essarily interested in surgery.
Knowledge and Skills for Future Practice
All respondents clearly identified that they had learned new surgical
skills and knowledge from the course. Students reported that the new Well designed and helpful course, I highly recommend to all, even
knowledge and skills acquired gave them greater confidence going those with no interest in surgery because of the practical skills and
into clinical placements and empowered them to make the most of knowledge taken away from it.
learning opportunities.
I feel like I've gained more confidence in surgical skills, so I'll be more
Limitations. There were, however, limitations to the benefit of the
prepared when it comes to surgical placements later on in medical
course. The most common area that students highlighted was the
need for more time to practice the new and complex skills they
were learning. In addition, several highlighted that they would prefer
more realistic prosthetic materials for practicing suturing and anes-
thetic infiltration
Time and equipment were limited. Maybe working with more skin
like models could have been useful. But I understand timings and
budget may be issues! So not much of a complaint. Learning-wise,
it was super useful. More suturing practice could have been fun. That
felt a little rushed.

DISCUSSION

This study has shown that there is an unmet desire for preclinical
surgical skills education and high demand for this course. Both quantita-
tive and qualitative data show increased confidence levels postcourse
among participants in all core GMC "Outcomes for Graduates" [1]
covered by the course, which was statistically significant for all skills
taught. Participants also felt more prepared for future practice in medi-
cal student clinical placements as well as beyond. Moreover, through
familiarization with some of these surgical skills, students felt more
comfortable seeking opportunities on placements. Additionally, the re-
sults show that students prefer at least a proportion of their teaching
to be in-person, which appeared to correlate with the positive feedback
received for the sessions of this in-person surgical skills course.
Most students that undertook the course had no prior surgical
experience. This reflects a general trend in the limited availability of
Fig. 2. A, Perceived current proportion of teaching delivered in-person. B, Satisfaction with undergraduate surgical education in the UK resulting in graduates feel-
current ratio of in-person to online teaching. ing ill-prepared for surgical Foundation jobs [21]. The study shows that

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Fig 3. Impact of course on students' confidence levels related to surgical skills and impression of preparedness for future practice (* P = .05, ** P = .01, *** P = .001, **** P = .0001).

participants who did have prior surgical experience had accessed it sample size. Furthermore, the precourse proportion of students inter-
through noncore opportunities such as student-selected components, ested in a surgical career was already high. That said, the benefit of a
societies, and taster sessions. Several studies have found similar results, preclinical surgical skills course extends beyond those who wish to
with aspiring surgeons relying on student societies to gain sufficient pursue surgical careers, however. The techniques taught in this course
experience in skills which the GMC mandates as essential [1,6,22]. Un- are applicable to other specialties including aspiring GPs who wish to
surprisingly, students who had attended previous surgical skills courses undertake minor procedures, dermatologists, and emergency depart-
had higher self-confidence ratings regarding technical skills. ment clinicians [29].
This course was the first introduction to surgical skills for many This course was led by early-career doctors who had recently com-
participants and specifically targeted preclinical medical students. Al- pleted the Foundation program. Our results contribute to the growing
though it is evidently not representative of a career in surgery, students body of evidence demonstrating positive outcomes from surgical skills
reported that their informal interactions with course tutors gave them courses run by junior doctors and senior medical students [27,30].
an insight into the realities of life as a junior doctor. A primary aim of Near-peer-led courses offer a relaxed learning environment for partici-
this phase 1 course was to facilitate greater student participation during pants with evidence of increased educational attainment [31]. They con-
surgical attachments due to increased confidence in basic skills, a pro- fer the additional benefit of reducing the burden on senior surgeons of
cess which can increase self-efficacy and student learning [23]. These teaching relatively simple surgical concepts while offering valuable
results support existing literature demonstrating that early exposure teaching opportunities to junior doctors [30]. These factors provide a
to surgical specialties increases student engagement during medical strong pedagogical and practical rationale for implementing a junior-
school [24]. Specifically, students reported that undertaking a surgical led course.
skills course prior to surgical attachments would maximize the educa- The study took place at a time when the increased use of online
tional benefit [25]. Helping students to develop basic surgical skills learning strategies has become the norm. Participants in this study
prior to their clinical placements increases self-efficacy and confidence, favored multimodal teaching above online-only tuition, in line with
permitting them to make use of real-life learning opportunities [25]. findings that medical students desire increased face-to-face teaching
This is especially pertinent in an era when the time medical students postpandemic [32]. The COVID-19 pandemic accelerated research
spend in the clinical environment is declining, along with opportunities in e-learning, and the switch to online learning is likely to persist in
to practice surgical skills. many aspects of medical education thanks to positive findings for
Data from the study do not support previous findings that under- knowledge-based learning [33,34]. However, data to support the use
graduate surgical skills courses can increase desire to pursue surgical of e-learning in surgical skills tuition have been equivocal, with only 1
careers [26–28]. This may be partially explained by the relatively small study in a systematic review reporting noninferior objective outcomes

Table 3
Impact of course on students' views of surgery and surgical teaching

Category Sample size (n) Test statistic (Z) P value Adjusted P value Significance (adjusted P value)

Have had sufficient exposure to surgical teaching so far 30 229 0.005 0.014 *
Have had the opportunity to meet current surgeons 30 22 0.005 0.014 *
Have considered a surgical career 30 0 0.346 0.346 NS

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Table 4 avoid clashes with the formal timetable; however, this also made it
Session design and delivery feedback: median score shown; Likert scale from 1, strongly challenging for some students to attend due to university society com-
disagree, to 5, strongly agree
mitments. This may be mitigated if a surgical skills course was incorpo-
Session rated within the formal curriculum for all students to attend.
1 2 3 4 5 Another limitation was the terminology used in the questionnaire
Likert scales. In hindsight, the 5-point scale used may have introduced
Content was at an appropriate level 5 5 5 5 5
Content was relevant 5 5 5 5 5 bias as it was not balanced and ranged from "not at all confident" to "ex-
Clear introduction 5 5 5 4 5 tremely confident." Less biased terminology could have been "very
Aims and objectives outlined 5 5 5 5 5 unconfident," unconfident," neutral," "confident," and "very confident."
Well-organized session 5 5 5 5 5 A viable alternative to the classical model is the Visual Analog Scale as
Clear summary 5 5 5 5 5
Interactivity 5 5 5 5 5
suggested by Bishop et al [38]. This system requires participants to
Effective use of resources 4 4 5 4.5 5 grade themselves on a scale between 2 set points, allowing the repre-
Session pacing 5 5 5 5 5 sentation of smaller changes. However, this scale is more subjective,
Session duration 5 5 5 5 5 and what counts as confident for one student may be at a different
point in the scale for another.
Finally, as participants were phase 1 students, they were likely to
have low confidence levels initially due to a shown lack of surgical expo-
compared to an in-person course [35]. The success of e-learning courses sure. Therefore, any surgical teaching has a high chance of improving
is highly contingent on robust technological resources, equipment this. This could have been addressed by assessing confidence levels
dissemination, and complicated logistics such as to review the quality among more senior medical students who had experienced clinical
of student suturing [35]. These challenges are compounded by the placements in surgery, in addition to the participant cohort. Alterna-
more general problems associated with distance learning, including tively, confidence levels of the participant cohort could be reassessed
distractions at home and internet issues, both of which will impact following commencement of clinical placements and compared to col-
students from lower socioeconomic groups to a greater extent leagues who had not completed the course.
[36,37]. On balance, the favorable results from this study align with In conclusion, this study has shown that there is benefit in incorpo-
the literature in support of in-person provision of surgical skills rating a surgical skills course to improve student exposure and confi-
teaching, although it is likely that the quality of e-learning will con- dence in basic surgical skills prior to starting surgical placements.
tinue to evolve. Additionally, we have shown that there is benefit to this being delivered
A key strength of this study design lies in the alignment of the course in an in-person setting in the context of the COVID-19 pandemic. Future
with GMC outlined skills and the fact that it was specifically targeted work could assess similar outcomes across all enrolled year 1 and 2
to achieve core skills required of medical graduates. Crucially, course medical students following a trial of this course incorporated within
sign-up was advertised to all year 1 and year 2 medical students at the a phase 1 curriculum. Furthermore, in addition to assessing confi-
authors' institution and was free to attend, providing an accessible dence levels, ability to perform surgical skills could be assessed
means of obtaining surgical skills teaching. Here we have successfully prior to and following the course. If a positive impact continues to
modeled a low-resource intensive course featuring reusable and more be shown from this proposed future work, in the long-term, we envi-
sustainable practices as compared with tissue-based courses, which sion a course such as this being incorporated within all medical
may be feasibly implemented within different institutions. Further- school curriculums.
more, as this course is based on surgical skills required of all medical
graduates, a benefit of this course is that it could be taught by a doctor Author Contribution
of any level and would be compatible with near-peer teaching. How-
ever, as in this course, tutors with prior surgical experience could be Louise Kuo: Conceptualization, Methodology, Formal analysis,
used to provide a higher level of expertise. It is recognized that this Writing – original draft. Nadia Liber Salloum: Conceptualization, Meth-
course was run using a high staff-to-student ratio which was felt to be odology, Writing – original draft. Benjamin Kennard: Conceptualization,
beneficial to the educational experience. However, this may represent Methodology, Writing – original draft. James Robb: Methodology,
a challenge if upscaled should the course be implemented within the Writing – original draft. Paula Vickerton: Writing – reviewing & editing.
formal curriculum. Additionally, although this course has been designed
as low-cost, there were some overheads due to consumable equipment. Funding Source
These would also become more significant and would need to be fac-
tored into an institution's budget. None.
Another strength of the study is that it involved the collection of
paired data. Through allocation of each participant with a randomized Ethics Approval
identification number, students were followed up with responses be-
fore and after the surgical skills course directly compared. This serves Approval for this study has been provided by the Queen Mary Ethics
to strengthen subsequent statistical analysis. Additionally, inclusion of Committee
both quantitative and qualitative data allowed for a more complete un-
derstanding of participant responses to the course. Conflict of Interest
A limitation of the study does include the relatively small sample
size. One factor reducing the sample size was that of participant drop- None.
off. This included students that failed to attend all sessions and those
that stopped providing feedback. In addition to reducing the data col- Acknowledgments
lected, the authors acknowledge that this also runs the risk of introduc-
ing bias as students who continued to attend or complete feedback were The authors of this paper would like to acknowledge Dr Fares Tellisi
likely more engaged in the course. To avoid this issue in the future, data and Dr Alex Meredith-Hardy for their assistance in tutoring during the
collection could be partially anonymized with trackable feedback com- course. The authors would also like to thank the staff at Queen Mary
pletion. Another factor that could have influenced the drop-off rates University of London for providing the venue and nonconsumable
was the timing of each session. Wednesday afternoons were chosen to equipment used throughout the course.

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Appendix 1. Questionnaire 21. Do you feel you have had the opportunity to meet/talk to current
surgeons as part of your training? (not at all, slightly, moderate,
Surgical Skills Course Questionnaire very, extremely)
PRECOURSE QUESTIONNAIRE
Random number generator POSTSESSION QUESTIONNAIRE
Please go to RANDOM.ORG - True Random Number Service and
1. Name of session
set the number generator range from 1 to 10,000. Generate random
2. Personal course ID number
number.
3. Please answer all the statements according to the following scale
- Enter randomly generated number here: (strongly disagree, disagree, neutral, agree, strongly agree)
a. The content was at an appropriate level
b. The content was relevant to my training
c. There was a clear introduction to the subject
(Please note this is your assigned ID number for the remainder of
d. The aims and objectives were clearly stated
this course—it is important you keep this safe as you will need it for
e. The material was well organized
future feedback forms)
f. There was a clear summary and conclusion
1. Which year of medical school are you in? (Year 1, Year 2, GEP) g. The presenter appeared well informed about the subject
2. What proportion of your current medical school teaching is in h. The presenter appeared enthusiastic about the subject
person? (0%–25%, 26%–50%, 51%–75%, 76%–100%) i. Audience participation and interaction were encouraged
3. Which mode of teaching do you feel is more beneficial for your j. There was effective use of audiovisual aids/handouts
learning? (e-learning, in-person, multimodal, indifferent) k. The presentation was given at the right pace
4. How satisfied are you with the present ratio between in person and l. The presentation was of a reasonable length
online teaching? (not at all, slightly, moderate, very, extremely) m. Overall, this teaching session was of a high quality
5. Which of the following medical career pathways are you currently
considering? (ie, Medicine, Surgery, A&E, Critical care, Anesthetics, 4. Relevant question(s) to the specific session from:
General practice, Psychiatry, Obstetrics and Gynecology, etc) Please
list all that apply. (free text) - How confident do you feel with surgical scrubbing techniques and
6. Have you considered a career in surgery? (yes/no) considering infection control measures?
7. Have you had any previous experience in surgical skills? (yes/no) - How confident do you feel with managing surgical equipment such
8. If so, which of the following? (tick all that apply) as sutures, forceps, scalpels, etc.?
a. Surgical scrubbing and infection control - How confident do you feel with deciding on and administering local
b. Managing surgical equipment (sutures, forceps, scalpels, etc) anesthetic?
c. Local anesthetics - How confident do you feel with carrying out basic sutures
d. Basic suturing (interrupted and mattress)?
e. Basic surgical knot tying - How confident do you feel with basic surgical knot tying?
f. Basic wound management and dressings - How confident do you feel managing surgical wounds?
- How confident do you feel about different wound dressings?
9. What proportion, if any, took place in person? (0%–25%, 26%–50%,
51%–75%, 76%–100%) 5. I liked the following things about the session: (free text)
10. How confident do you feel with surgical scrubbing techniques 6. The session might be improved by: (free text)
and considering infection control measures? (not at all, slightly, 7. Other comments? (free text)
moderate, very, extremely)
11. How confident do you feel with managing surgical equipment such POSTCOURSE QUESTIONNAIRE
as sutures, forceps, scalpels etc? (not at all, slightly, moderate, very, 1. Personal course ID number
extremely)
12. How confident do you feel with deciding on and administering local 2. How confident do you feel with surgical scrubbing techniques and
anesthetic? (not at all, slightly, moderate, very, extremely) considering infection control measures? (not at all, slightly, moderate,
13. How confident do you feel with carrying out basic sutures very, extremely)
(interrupted and mattress)? (not at all, slightly, moderate, very, 3. How confident do you feel with managing surgical equipment such
extremely) as sutures, forceps, scalpels, etc? (not at all, slightly, moderate, very,
14. How confident do you feel with basic surgical knot tying? (not at all, extremely)
slightly, moderate, very, extremely) 4. How confident do you feel with deciding on and administering local
15. How confident do you feel managing surgical wounds? (not at all, anesthetic? (not at all, slightly, moderate, very, extremely)
slightly, moderate, very, extremely) 5. How confident do you feel with carrying out basic sutures
16. How confident do you feel about different wound dressings? (not at (interrupted and mattress)? (not at all, slightly, moderate, very,
all, slightly, moderate, very, extremely) extremely)
17. Do you feel you have had sufficient exposure to surgical teaching so 6. How confident do you feel with basic surgical knot tying? (not at
far? (not at all, slightly, moderate, very, extremely) all, slightly, moderate, very, extremely)
18. Please provide reasons for your answer to the above question. 7. How confident do you feel managing surgical wounds? (not at all,
(free text) slightly, moderate, very, extremely)
19. How confident are you that you have the surgical skills required for 8. How confident do you feel about different wound dressings? (not
starting your clinical placements? (not at all, slightly, moderate, very, at all, slightly, moderate, very, extremely)
extremely) 9. Which of the following medical career pathways are you currently
20. How confident are you that you have the surgical skills required for considering? (ie, Medicine, Surgery, A&E, Critical care, Anesthetics,
starting as a junior doctor? (not at all, slightly, moderate, very, General practice, Psychiatry, Obstetrics and Gynecology, etc) Please
extremely) list all that apply. (free text)

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L. Kuo, N.L. Salloum, B. Kennard et al. Surgery Open Science 10 (2022) 148–155

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