Factors Associated with Self-Reported Surgical Skill Comfort in a Longitudinal Integrated Clerkship

Technical Summary: Factors Associated with Self-Reported Surgical Skill Comfort in a Longitudinal Integrated Clerkship

Problem Statement
Technical skill development is a core component of undergraduate surgical education, yet medical students often enter operative environments with variable readiness. While foundational skills such as sterile technique, instrument handling, knot tying, and suturing do not equate to operative competence, self-reported comfort with these tasks influences learner engagement, help-seeking behavior, and participation in supervised care. Although structured simulation and workshops have been shown to improve confidence, less is known about how surgical skill comfort develops within required, longitudinal clinical curricula. Specifically, the relationship between the breadth of clinical exposure to surgical disease topics, learner career interest, and self-reported comfort in a Longitudinal Integrated Clerkship (LIC) setting remains under-described.

Methodology
The authors conducted a cross-sectional survey study in August 2025 involving 123 second-year medical students at a single academic institution who had just completed a surgical LIC and were entering their third year. The LIC structure included longitudinal pairing with a surgical preceptor, four to five half-days per month in clinic or operating rooms, a two-week inpatient immersion, and structured educational activities.

• Data Collection: A survey assessed three domains: (1) self-reported comfort in eight foundational surgical skills (gowning/gloving, forceps handling, needle driver handling, instrument tying, one-handed tying, two-handed tying, simple interrupted suturing, and mattress suturing); (2) exposure to ten selected core surgical disease topics (e.g., appendicitis, cholecystitis, hernias); and (3) post-LIC career interest.
• Variables: Clinical exposure breadth was calculated as the count of disease topics encountered through direct clinical settings (0–10 score). Skill comfort was dichotomized into "comfortable" (combining "comfortable" and "very comfortable") and "not comfortable" (combining "neutral," "uncomfortable," and "never done").
• Statistical Analysis: Fisher's exact tests examined associations between post-LIC surgical career interest and skill comfort. Unadjusted logistic regression models assessed the association between clinical exposure breadth and comfort for each skill. Statistical significance was set at $p < 0.05$, with p-values adjusted for multiple testing using the Holm procedure.

Key Results
Of 123 eligible students, 120 responded (98% response rate).

• Skill Comfort Levels: Students reported the highest comfort with gowning and gloving (98.3%), forceps handling (83.3%), instrument tying (83.3%), needle driver handling (80.0%), and simple interrupted suturing (75.0%). Comfort was notably lower for two-handed tying (62.5%), one-handed tying (50.8%), and mattress suturing (37.5%).
• Career Interest Association: Students expressing post-LIC interest in a surgical career reported significantly greater comfort in needle driver handling ($p=0.024$), simple interrupted suturing ($p=0.020$), one-handed tying ($p<0.001$), two-handed tying ($p=0.020$), and mattress suturing ($p=0.020$) compared to non-surgical peers. No significant association was found for gowning/gloving, forceps handling, or instrument tying.
• Exposure Breadth Association: Greater clinical exposure breadth was associated with higher odds of reporting comfort in six of the eight skills. Significant associations were observed for forceps handling, needle driver handling, instrument tying, simple interrupted suturing, one-handed tying, and two-handed tying. Exposure breadth was not significantly associated with comfort in gowning/gloving or mattress suturing.

Key Contributions
This study extends prior literature by examining surgical skill comfort within a required longitudinal clinical curriculum rather than discrete simulation courses or elective interventions. The primary contribution is the identification of two distinct factors associated with self-reported procedural readiness:

1. Learner Orientation: Post-LIC surgical career interest is a significant predictor of comfort in complex technical tasks (knot tying and suturing).
2. Curricular Exposure: The breadth of direct clinical exposure to core surgical disease topics is positively associated with comfort in foundational skills, suggesting that longitudinal structures allowing repeated, spaced clinical participation support skill confidence.

The study also highlights a "ceiling effect" for basic skills (gowning/gloving) and a potential gap for advanced skills (mattress suturing) that exposure breadth alone does not resolve, implying a need for targeted instruction beyond opportunistic clinical encounters.

Significance and Claims
The authors claim that surgical skill comfort following an LIC reflects a combination of learner career orientation and the breadth of authentic clinical exposure. They posit that while self-reported comfort is not a substitute for objective technical competence, it serves as a relevant learner-centered proxy for procedural self-efficacy and readiness.

The paper concludes that LIC structures may support procedural learning by allowing students to revisit operative environments and build familiarity with teams and workflows over time. However, the authors explicitly state that their findings do not imply exposure breadth alone generates skill comfort; rather, it serves as a marker of a broader surgical learning ecology. They emphasize that future work must pair these self-reported outcomes with objective assessments (e.g., direct observation, OSATS) to validate the relationship between perceived comfort and actual technical proficiency. The study suggests that LIC programs should consider tracking meaningful technical participation and balancing continuity with exposure breadth to support all students, regardless of their eventual career path.