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ORIGINAL ARTICLE
Acquisition of suture skills during medical graduationby instructor-directed training: a randomized controlledstudy comparing senior medical students and faculty surgeons
Rafael Denadai • Andreia Padilha Toledo •
Marie Oshiiwa • Rogerio Saad-Hossne
Received: 14 August 2012 / Accepted: 16 January 2013 / Published online: 13 February 2013
� Springer-Verlag Italia 2013
Abstract Due to shortage of time and limited availability
of faculty surgeons to teach basic surgical skills during
medical graduation, the search for alternative ways of
simulated training with feedback is needed. The purpose of
this study was to compare the simulated teaching of suture
skills to novice medical students by senior medical students
and by experienced faculty surgeons. Forty-eight novice
medical students were randomly assigned to three practice
conditions on bench model (n = 16): self-directed suture
training (control), senior medical student-directed suture
skills’ training, or experienced faculty surgeon-directed
suture skills’ training. Pre- and post-tests were applied.
Global Rating Scale with blinded evaluation and self-per-
ceived confidence based on Likert scale were used to assess
all suture performances in pre- and post-training. Effect
size was also calculated. The analysis made after training
showed that the students who received feedback from the
instructors had better performance based on the Global
Rating Scale (all p \ 0.0000) and felt more confident to
carry out sutures (all p \ 0.0000) when compared to the
control. There was no significant difference (all p [ 0.05)
between the student-directed teaching and faculty-directed
teaching groups. The magnitude of the effect (instructor-
directed training suture) was considered large ([0.80) in all
measurements. The acquisition of suture skills after stu-
dent-directed training was similar to the training supervised
by faculty surgeon, and the increase in suture performances
of trainees that received instructor administered training
was superior to self-directed learning.
Keywords Feedback � Medical education �Medical student � Surgery � Sutures � Teaching
Introduction
Once the suture technique is the foundation upon which
most surgical skills will be built [1] and suture basic skill is
not acquired by a large percentage of medical students [2],
suture skills’ training become an important component of
the undergraduate training period [3].
In order to teach sutures and bearing in mind that the
performance of basic surgical skills’ training on live
patients (traditional apprenticeship model) may violate
ethical and medico-legal aspects [4], learning technical
skills on low-cost bench models [5–10] is becoming widely
used during medical education [11].
In this sense (simulated training), a combination of self-
directed training with feedback was recently described as
an excellent method to teach basic technical skills [12]. On
surgical training, concurrent (or process) and summary (or
outcome) feedback is associated with better and faster
learning, and also with greater long-term knowledge
retention [13]. Feedback can be performed by computers
R. Denadai
Institute of Plastic and Craniofacial Surgery, Brazilian Society
of Research and Assistance to Craniofacial Rehabilitation
Hospital (SOBRAPAR), Campinas, SP, Brazil
R. Denadai � A. P. Toledo � R. Saad-Hossne
Department of Surgery, Botucatu Medical School, University
of the State of Sao Paulo (UNESP), Botucatu, SP, Brazil
R. Denadai (&)
Paula Fabiana Tudela 161–Esmeralda, 17516-707 Marılia,
Sao Paulo, Brazil
e-mail: [email protected]
M. Oshiiwa
Department of Statistics, Faculty of Technology,
FATEC, Marilia, SP, Brazil
123
Updates Surg (2013) 65:131–140
DOI 10.1007/s13304-013-0199-y
[14], physicians such as experienced faculty surgeons [1,
12, 14–16], and residents [17], and non-physicians such as
laboratorial technicians [18, 19], and medical students [20].
Especially, medical student-directed learning has the
benefit of being a more informal teaching and allowing
students to solve their doubts without feeling foolish [20,
21]. Besides, in general, students enjoy being taught by
other students because the interaction is easier and often
the way in which the skill is taught is placed in context for
their level of experience [21, 22].
Although several researches [20, 23–27] have descri-
bed similar effectiveness between medical student-assis-
ted learning and faculty expert-assisted learning, the
understanding of the impact and effectiveness of specific
suture technique teaching on bench models by medical
students evaluated in an objective manner is relatively
unknown.
Such information led us to hypothesize that the teaching
of suture skills by senior medical students will be as
effective as the traditional methodology administered by
faculty surgeons. The purpose of this study was to compare
senior medical students with experienced faculty surgeons
in the teaching of suture skills to novice medical students
on inanimate bench models, by means of a randomized
controlled blinded study.
Methods
Subjects
The protocol consisted of 48 first- and second-year medical
students with no surgical skills background (novices) from
a single academic center that volunteered to participate in
the study, enrolled upon a consent form signed by them, in
accordance with the Helsinki Declaration of 1975, as
amended in 1983. Local institutional research ethics board
approval was obtained for this study.
Study design
The design was a randomized controlled study with
blinding of expert examiners, including a pre-test, a 1-h
practice phase, and a post-test (Fig. 1). The pre- and post-
tests were identical and consisted of the manufacture of
five simple interrupted sutures (bidimensional; simple
wound closure) and one running subcuticular suture (tri-
dimensional; advanced wound closure) for the closure of
two elliptical incisions measuring 8 9 2 cm each on ox
tongue. Each student was tested individually and had a
total of 5 min for each task. No verbal feedback was pro-
vided during both pre- and post-tests.
Pre testing
On the day of the experiment, all participants were taught
how to use surgical instruments, as well as the techniques
for both types of sutures (simple interrupted sutures and
running subcuticular sutures) required by means of an
instructional video [28] presentation that was repeated and
commented for 1 h (verbal teaching based on video)
[1, 14]. Next, all participants underwent a pre-test.
Group assignment and training phase
Immediately after the pre-test, all students were randomly
allocated via a computer-generated process to one of the
three study groups (n = 16). All three groups remained
in separated rooms so they were unable to communicate
with each other. In group 1 (control), students were given
a self-directed suture training on bench model based on
didactic materials (manuscripts, textbooks, on-line text
and on-line narrated expert demonstration videos) on the
handling of surgical instruments and the manufacture of
sutures. The rest of the participants received guidance on
the handling of surgical instruments and trained sutures
in a repetitive and deliberative manner on bench models
directly supervised by a senior medical student (group 2)
or by an experienced faculty surgeon (group 3). This
stage lasted 1 h [1, 14] for all the three groups.
Apparatus for hands-on training
The whole process of teaching, learning, and training of
sutures given to students of the three groups was performed
on synthetic ethylene–vinyl acetate bench model (Fig. 2)
according to features recently described by our group
[7–9]. The original article [7] on the ethylene–vinyl acetate
bench model was translated into the native language of
students from group 1 (Brazilian Portuguese) in order to be
adopted as a teaching tool.
Instructors and feedback
The medical students chosen to be instructors were vol-
unteers recruited from the group of final-year (senior)
students; they were interviewed and selected according to
the criteria described by Wadoodi and Crosby [20] and by
Sobral [29]. The faculty surgeons, working as instructors,
had more than 10 years of experience in teaching basic and
advanced surgical skills to students and residents; they are
not co-authors of this study and did not participate in the
process of blinded evaluation of maneuvers carried out in
pre- and post-tests.
132 Updates Surg (2013) 65:131–140
123
In order to standardize the teaching and learning in
groups 2 and 3, it one instructor for every four students [1]
was used; all instructors were randomly allocated via a
computer-generated process to one of eight semi-groups
with four students each. On standardized didactic seminar,
all instructors were told to teach the suture skills using the
same method; during concurrent and summary feedback
important aspects to promote good wound healing and good
aesthetic results (e.g., instrument handling, correct posi-
tioning of the needle in the needle holder, angle of needle
entry in the ‘‘skin’’, exit of the needle at a point equidistant
from the insertion point for both pricks, approximation of
the ‘‘wound edges’’ with appropriate tension level, eversion
and apposition of the ‘‘wound edges’’, and meticulous
‘‘tissue’’ handling) [30, 31] were taught to all students.
Post-testing
Immediately after the training phase, all medical students
were randomly allocated to post-test.
Fig. 1 Pre- and post-training study design
Fig. 2 Synthetic ethylene–vinyl acetate bench model simulating (a, b) a ‘‘cutaneous wound’’, a (c, d) simple interrupted suture, and (e, f) a
running subcuticular suture
Updates Surg (2013) 65:131–140 133
123
Study blinding
All 192 pre- and post-test maneuvers were recorded
(images focusing only on hand movements) and saved.
These digital videos were archived for later analysis and
codified using randomly assigned numbers by one of the
investigators. All digital videos were evaluated in a blinded
fashion independently by two experienced surgical spe-
cialists that had no prior knowledge on the groups and that
did not take part in the training processes.
Outcome measures
All 48 study participants completed pre- and post-training
questionnaires aimed at measuring self-perceived confidence
in performing sutures; they rated their confidence level on a
5-point Likert Scale [6], the lowest rating (‘‘very unconfi-
dent’’) being 1 and the highest being 5 (‘‘very confident’’).
The quantitative evaluation was based on the number of
students that completed one or more stitches and on the
number of stitches finalized for each group; only after the
ends of the two surgical threads were cut, the stitch was
considered finalized. The Global Rating Scale (Table 1)
[32, 33] was used to evaluate objectively (qualitative
assessment) the suture performance of each student in eight
main areas, each of which was rated on a behaviorally
anchored 5-point scale; with 1 being the minimum score
and 5 the maximum score for a total maximum score of 40.
Statistical analysis
In the descriptive analysis, data were summarized as mean
values, medians, standard deviations, 1st and 3rd quartiles,
minimum and maximum values. Bioestat� for Windows
version 5.0 was used to perform statistical analyses. Stu-
dent’s t test was used for measurable variables and Fisher’s
test for the analysis of categorical variables, due to the
small sample set. Values were considered significant for a
confidence interval of 95 % (p \ 0.05). Effect sizes were
also calculated to identify the magnitude of the intervention
effect regardless of the sample size; effect sizes exceeding
0.80 were considered large [34].
Results
Quantitative suture skills’ assessment
During pre-test none of the 48 participants was able to
carry out any of the two proposed types of sutures and
Table 1 Global Rating Scale [32, 33] used to assess qualitatively and objectively all suture performances
Please rate the candidate’s performance on the following scale
1 2 3 4 5
Respect
for tissue
Frequently used unnecessary
force on tissues or caused
damage by inappropriate
instrument use
Careful handling of tissue,
but occasional
inadvertent damage
Consistently handled
tissues appropriately
with minimal damage
Time in
motion
Many unnecessary moves Efficient time and motion,
but some unnecessary
moves
Clear economy of
movement and
maximum efficiency
Instrument
handling
Repeatedly makes tentative
or awkward moves with
instruments
Competent use of instruments,
but occasionally awkward
Fluid movements
Suture skill Awkward and unsure with
poor knot tying,
and inability to
maintain tension
Competent suturing with
good knot placement
and appropriate tension
Excellent suture control
with correct suture
placement and tension
Flow of
operation
Frequently stopped operating,
seemed unsure of next move
Demonstrated some forward
planning and reasonable
progression of procedure
Obviously planned
operation
Knowledge
of procedure
Inefficient knowledge
of procedure. Looked
unsure and hesitant
Knew all important
steps of procedure
Demonstrated familiarity
of all steps of procedure
Final product Final product of
unacceptable quality
Final product of
average quality
Final product
of superior quality
Overall
performance
Very poor Competent Very good
Total score: ()
n.s. means that p [ 0.05
134 Updates Surg (2013) 65:131–140
123
therefore, there are no differences in the comparative
analyses among all the three groups (all p [ 0.05). In the
post-test, a larger number of students (all p \ 0.05) of
groups 2 and 3 carried out a greater number of both types
of sutures (all p \ 0.05) when compared with group 1
(Table 2); there were no differences in the comparisons
between groups 2 and 3 (all p [ 0.05). Comparing pre-test
with post-test, a larger number of students (all p \ 0.05) of
groups 2 and 3 made a greater number of both suture types
in the post-test (all p \ 0.05), and there were no differ-
ences for group 1 (all p [ 0.05).
Objective suture skills’ evaluation
In blinded evaluations of all maneuvers performed in pre-
and post-training, no inter-observer difference was detected
among the examiners on the qualitative evaluation of mean
values in all the three groups for both types of sutures (all
p [ 0.05).
In all performances, the mean values of qualitative
assessments performed in the pre-test were \8.25, and
there were no differences between group-to-group com-
parisons (all p [ 0.05) (Table 3). The objective and qual-
itative analysis of simple interrupted sutures and running
subcuticular sutures performances in the post-training
showed that groups 2 and 3 compared to group 1 presented
a better performance (all p = 0.0000). There was no dif-
ference (all p [ 0.05) in the comparison between groups 2
and 3 for both suture performances (Table 3; Fig. 3).
Comparing pre-test and post-test, there was a better per-
formance of all three groups in the manufacture of simple
interrupted sutures (p = 0.0029 for group 1; p = 0.0000
for groups 2 and 3) and of running subcuticular sutures
(p = 0.0000 for groups 2 and 3) in the post-training, except
in group 1 (p = 0.4391) (Table 3; Fig. 4).
Effect sizes
The evaluation of the intervention magnitude (suture
training) was considered large (C0.80) in all measurements
made, except for the manufacture of running subcuticular
sutures by students in group 1 (Table 3).
Self-perceived confidence
Regarding the perception of students about their confidence
to perform both suture techniques, all 48 students were
very unconfident (all mean values equal to 1.0) before
training; therefore, there are no differences in the group-
to-group comparisons (all p = 0.5000) (Table 4). After
training, although students from groups 2 and 3 were
similar (p [ 0.05) among themselves, they felt more con-
fident (all p = 0.0000) to perform both types of sutures
when compared to trainees from group 1 (Table 4; Fig. 5).
When comparing pre- and post-training, there was
increased confidence (all p \ 0.05) in all three groups to
perform both suture techniques after training (Table 4;
Fig. 6).
Discussion
Since the majority of general practitioners that perform
minor surgical procedures such as cutaneous surgery do not
have any formal surgical training [31], and the ability to
close a wound correctly is an essential and important skill
in the general practice setting, because poor suturing
technique is directly related to adverse wound healing and
increased scarring [30, 31], it is necessary to teach suturing
to undergraduates [3]. In addition, current acquisition
of suture skills outside the operating environment on
Table 2 Quantitative comparison between the number of students that completed at least one stitch and the number of stitches performed in
post-training by each group
Variable Simple interrupted sutures Running subcuticular sutures
Group 1
N (%)
Group 2
N (%)
Group 3
N (%)
p value Group 1
N (%)
Group 2
N (%)
Group 3
N (%)
p value
Students who have stitches
(N = 16)
4 (25) 16 (100) 16 (100) * 0 16 (100) 16 (100) *
Total number of stitches (N = #) 4 (5.0) 40 (50) 42 (52.5) * 0 16 (100) 16 (100) *
Number of stitches for student
(M ± SD)
0.25 ± 0.46 2.5 ± 0.75 2.625 ± 0.51 0 1.0 ± 0 1.0 ± 0
Group 1, self-directed suture training (Control); Group 2, senior medical student-directed suture training; Group 3, faculty-directed suture
training
M mean, SD standard deviation* p \ 0.05 for all comparisons between all three groups (Group 1 \ Group 2 = Group 3), except for group 2 versus group 3 (p [ 0.05)# N = 80 for simple interrupted sutures and N = 16 for running subcuticular sutures
Updates Surg (2013) 65:131–140 135
123
Table 3 Mean of the objective and qualitative assessments based on Global Rating Scale pre- and post-training and the effect size (suture
training) of both suture performances
Variable Simple interrupted sutures Running subcuticular sutures
Group 1 Group 2 Group 3 Group 1 Group 2 Group 3
Pre-test (M ± SD)� 8.25 ± 0.45 8.25 ± 0.45 8.125 ± 0.34 8.125 ± 0.34 8.125 ± 0.34 8.25 ± 0.45
Post-test (M ± SD)¥ 10.44 ± 1.55 22.81 ± 2.61 22.94 ± 2.51 8.31 ± 0.34 20.5 ± 2.19 20.56 ± 1.82
Mean difference 2.19 14.56 14.82 0.19 12.38 12.31
p value* 0.0029 0.0000 0.0000 0.4391 0.0000 0.0000
Effect size# 4.87 32.35 43.58 0.56 36.41 27.36
Group 1, self-directed suture training (Control); Group 2, senior medical student-directed suture training; Group 3, faculty-directed suture
training
M mean, SD standard deviation� p [ 0.05 for all comparisons between all three groups (Group 1 = Group 2 = Group 3)¥ p = 0.0000 for all comparisons between all three groups (Group 1 \ Group 2 = Group 3), except for group 2 versus group 3 (p [ 0.05)* Should be considered statistically significant (pre-test versus post-test) if p \ 0.05# Should be considered a large effect if [0.80
Fig. 3 Boxplot showing the dispersion of the mean values of all (left)simple interrupted suture performances and (right) running subcutic-
ular suture performances in the post-test based on Global Rating
Scale. Groups 2 (senior medical students-directed training) and 3
(faculty-directed training) were similar to each other, but presented a
significantly better performance compared to control group 1. The
diamond symbol represents the mean value. The heavy line is the
median. The bars represent the data range. The symbol ‘‘asterisk’’
indicates the outliers
Fig. 4 Mean of all (left) simple interrupted suture performances and
(right) running subcuticular suture performances in pre- and post-tests
based on Global Rating Scale. Groups 2 (senior medical student-
directed training) and 3 (faculty-directed training) were similar to
each other (all p [ 0.05), but improved their qualitative performance
significantly more (all p = 0.0000) than control group 1
136 Updates Surg (2013) 65:131–140
123
inanimate bench models is recommended prior to proce-
dures on live patients [4].
In this context (teaching sutures on simulators), since it
was showed that retention of surgical skills is stronger when
acquired in a manner interspersed with rest periods (several
training sessions), instead of teaching at one time [35], this
form of teaching should be adopted to retain and improve
the skills of learned sutures [12, 35]. However, some factors
such as high financial costs [35], lack of time, and avail-
ability of faculty experts [12, 15, 19, 36] have been
Table 4 Students’ perception on their confidence to perform sutures in pre- and post-training based on 5-point Likert scale
Variable Simple interrupted sutures Running subcuticular sutures
Group 1 Group 2 Group 3 Group 1 Group 2 Group 3
Pre-training (M ± SD)� 1.0 ± 0 1.0 ± 0 1.0 ± 0 1.0 ± 0 1.0 ± 0 1.0 ± 0
Post-training (M ± SD)¥ 1.37 ± 0.52 3.125 ± 0.64 3.25 ± 0.71 1.25 ± 0.46 2.625 ± 0.52 2.625 ± 0.52
p value* 0.0398 0.0000 0.0000 0.0852 0.0000 0.0000
Group 1, self-directed suture training (Control); Group 2, senior medical student-directed suture training; Group 3, faculty-directed suture
training
M mean, SD standard deviation� p [ 0.05 for all comparisons between all three groups (Group 1 = Group 2 = Group 3)¥ p = 0.0000 for all comparisons between all three groups (Group 1 \ Group 2 = Group 3), except for group 2 versus group 3 (p [ 0.05)* Should be considered statistically significant (pre-training versus post-training) if p \ 0.05
Fig. 5 Boxplot showing the dispersion of the mean values of
students’ perceptions about their confidence to perform (left) simple
interrupted sutures and (right) running subcuticular sutures in the
post-training based on 5-point Likert scale. Groups 2 (senior medical
student-directed training) and 3 (faculty-directed training) were
similar to each other, but presented significantly better confidence
than control group 1. The diamond symbol represents the mean value.
The heavy line is the median. The bars represent the data range
Fig. 6 Mean of students’ perceptions, all of the three groups, on their
confidence to perform (left) simple interrupted sutures and (right)running subcuticular sutures pre- and post-training based on 5-point
Likert scale. Groups 2 (senior medical student-directed training) and 3
(faculty-directed training) were similar to each other (all p [ 0.05),
but improved their confidence significantly more (all p = 0.0000)
than control group 1
Updates Surg (2013) 65:131–140 137
123
described as limiting factors for the implementation of this
teaching strategy over a predetermined period (weeks or
months).
In recent years, in order to reduce partially the financial
costs, different alternative methodologies such as training on
low-cost inanimate bench models have been proposed, dis-
cussed, and evaluated by our group [7–10] and by others [5, 6].
Availability of time, however, remains an issue for experi-
enced faculty surgeons that are removed from the patient care
setting to teach in simulation environments [12, 36].
Computer-generated feedback can be an option to
reduce the learning time supervised by faculty surgeons.
However, besides the high cost the retention of skills over
time is significantly greater when learned from direct
feedback from an instructor [15], and it has been demon-
strated that computer-assisted feedback is not effective for
teaching two-handed square knots to novice medical stu-
dents [37]. Alternatives that can also help to reduce
supervised teaching time would be increasing the intervals
between training sessions [38] and encouraging the prac-
tice outside the classroom (e.g., at home) [7–10].
Moreover, the incorporation of residents as teachers [17]
can also decrease the need for expert-administered training.
However, as residents also have limited time devoted to
teaching students [39] and resident-assisted teaching was
described as similar to student-assisted teaching [21],
medical students [20] appear as alternatives that may reduce
the number of faculty experts and residents that are trans-
ferred from surgical practice to the simulation laboratory.
Although there is the intuitive belief that the acquisition
of suture skills with the faculty surgeon-directed surgeon
training is superior to the student-directed training, such
statement cannot be merely subjective [40] because it does
not express the real level of acquired skills [41]. Moreover,
in the training of surgical skills the acquisition of compe-
tences should be assessed by an objective method [40, 42].
Thus, in the present study, the previously validated Global
Rating Scale [32, 33] was used as a tool for measurement
and certification to evaluate objectively all the suture per-
formances. This scale is part of the Objective Structured
Assessment of Technical Skills [32, 33], which is consid-
ered the gold standard for objective assessment of technical
surgical skills [40, 42].
In the present study, the conduction of a pre-test after
viewing an instructional video [1, 14, 16, 35] and the use of
a control group with self-directed didactic training on
bench model [12, 14, 16] were based on studies about
teaching basic surgical skills to medical students or resi-
dents. For the blind evaluation of the 192 recorded videos,
the evaluators were able to fast-forward through the tapes,
a procedure that shortened evaluation time and that has
been shown to be as effective as viewing the entire skill at
its natural pace [43]. Bi- and tridimensional sutures were
evaluated due to the existence of different complexities for
teaching and learning such techniques [7, 9, 10].
During the regular practical activities in our academic
center and during the course of previous studies [7–10], it
was subjectively noted that some medical students that
mastered the sutures techniques could help in the teaching
of those with less technical mastery. Therefore, this study
was designed to investigate objectively if senior medical
students are effective to teach sutures on bench models to
novice medical students.
Final-year medical students (year 6) were recruited to be
trainers because they had received training of suture skills
on inanimate bench models [7–10] and put the learned
skills into practice on living patients at different times such
as stages of instrumental technique (year 3), ambulatory
surgery (years 3 and 4), emergency room (years 5 and 6),
and clinical surgery (years 4, 5 and 6). Besides, since
medical students express interest in learning teaching skills
and teaching during medical graduation [44], the use of
students as instructors has been proposed not only to help
meet the increasing demand for experienced faculty sur-
geons, but also to serve as a useful educational tool for
senior students as they prepare for careers that may involve
teaching such as faculty [23].
Although several studies [12, 14–16] in the surgical
literature have evaluated important aspects of surgical
skills’ training based on feedback, according to an English
literature review (Medline, Scopus and Embase databases)
this is one of the few studies that have evaluated objec-
tively if the acquisition of suture skills by novice medical
students from senior student-directed learning is as effec-
tive as the learning from experienced faculty surgeon; there
are similar reports on medical students teaching other
technical skills [21, 23–27].
As observed in other studies [6, 14], before the training
phase the students were not able to perform the proposed
tasks quantitatively and qualitatively. Comparing the pre-
test with the post-test, a larger number of trainees that
received feedback from senior medical students (group 2)
and from faculty surgeon (group 3) showed quantitative
and qualitative increase in suture performance when com-
pared with the self-directed training group (control).
No differences were observed when comparing the
instructor-assisted groups (2 similar to 3), demonstrating
that senior medical student-directed training is a successful
method for learning suture procedures on bench models,
and it can be as effective as the training provided by
experienced faculty surgeon. Similar results on the acqui-
sition of different technical skills, such as internal medicine
skills [23–25], advanced life support [26], and others [27]
have been described.
In the present study, the effect sizes (instructor-directed
suture training) were large, indicating that the significant
138 Updates Surg (2013) 65:131–140
123
improvement was most likely related to the intervention
and not to sample size [34]. The evaluations of all 192
suture performances carried out by two independent and
blinded raters decreased the possibility that this increase in
performances was a result of rater bias or expectations
from the non-blinded faculty surgeon raters [6]. This study
also showed that after 1-h training session there was an
increase in confidence levels for the execution of the two
suture skills taught, similar to that observed by others [18].
Based on similar results found in the present study
(suture teaching by senior medical student was similar to
by faculty surgeon) and on the teaching methodology
adopted at Southern Illinois University (non-physician
skills coach help in the training of students and residents)
[18], the authors believe that senior medical students that
master the techniques of suture can be incorporated in an
alternative and complementary way to the teaching by
faculty experts. Thus, medical students would be respon-
sible only for the technical skill teaching (suture training),
and faculty surgeons would focus on teaching complex
tasks, complete procedures, and cognitive aspects of clin-
ical teaching (decision making) that are not duties of the
non-physician instructor [18].
The present study assessed only a basic surgical skill
(suture training) and does not meet all the needs of medical
students in training, which should include the acquisition of
other tasks and surgical skills, such as performing knot-
tying, dissection, excision, and ligating structures [12] that
can also be trained in simulation environments [36];
therefore, care should be taken about the generalization of
results to other technical skills.
The limitations of our study include the relatively small
number of first- and second-year medical students and
instructors. Although similar to a number of other studies
which also evaluated surgical skills [12, 19, 32], this should
be considered when reviewing the results of this study. A
prospective study including a larger number of both sub-
jects and instructors should be encouraged and designed to
verify and support our findings. Moreover, further studies
are required to measure the retention of suture skills taught
by final-year medical students over time, the transferability
to surgical practice, and to access if students in other levels
of training (e.g., third- and fourth-year medical students)
may also be incorporated as instructors in the process of
teaching and learning of suture skills.
In summary, the present study demonstrated that the
acquisition of bi- and tridimensional suture skills on
inanimate bench models by novice medical students after
senior medical student-directed training was similar to the
training supervised by faculty surgeon, and the quantita-
tive/qualitative increase of suture performances in partici-
pants that received instructor-directed training was superior
to self-directed learning.
Conflict of interest None.
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