Surgical Skills Workshops Should Be a Part of the United Kingdom Undergraduate Medical Curriculum

Introduction: Medical students across the United Kingdom (UK) report poor satisfaction with surgical teaching. The Surgical Skills Day (SSD) begins to address this by exposing medical students to surgery through an easily accessible one-day practical workshop. This study shows how the SSD encourages undergraduate engagement in surgery. Method: Feedback forms were emailed to attendees of the SSD and their anonymised responses were used to evaluate the SSD. Results: A total of 144 students attended the SSD across three years and the feedback response rate was 74% (n = 107). Key findings were that 100% of respondents (n = 107) would like the SSD to be an annual event, 79% (n = 83) were more inclined to pursue a surgical career following the event, and 97% (n = 103) would like to see practical surgical skills incorporated into the curriculum. The SSD was able to engage undergraduates with surgery through mentorship, practical skills, specialty exposure, and teaching of the General Medical Council (GMC) mandated skills. Conclusions: Undergraduate surgical teaching in the UK is insufficient. The student-led annual SSD showed improved engagement in practical surgical skills and increased enthusiasm for a surgical career. In light of this, the authors feel the SSD or similar event should be integrated into the UK medical school curriculum.


Introduction
In 2015, the Royal College of Surgeons (RCS) of England highlighted the need for a robust undergraduate surgical education [1]. However, medical students across the United Kingdom (UK) report poor satisfaction with surgical teaching and inadequate preparation for surgical rotations during foundation training when compared to medical rotations [2][3][4]. Furthermore, many junior doctors lack competency in basic surgical skills, such as skin suturing, which are mandated by the General Medical Council (GMC) for all newly qualified UK doctors [5][6][7][8]. Surgical skills workshops are a promising initiative to compensate for the aforementioned lack of formal undergraduate surgical education; it not only improves medical students' proficiency in suturing but also exposes them to surgical specialties and stimulates their interests in surgery as a career option [9][10].
The annual Surgical Skills Day (SSD), organised by the University of Bristol Surgery Society (SCRUBS), is a student-led surgical skills workshop. This article reports conclusions from three annual SSDs (2016 -2018), based on feedback from the University of Bristol medical students.

Materials And Methods
The SSD is a one-day practical course aimed at the University of Bristol medical students. The day is comprised of a range of diverse practical surgical skill stations, each one hour in duration. The instructors running the workshop stations are surgeons of different grades from trainee to consultant level. The event was priced at five pounds (lunch inclusive) to help with equipment hire and food purchase. Across the three years of running the SSD, workshop stations have included laparoscopic simulation, dynamic hip screw placement using model femurs, burr hole drilling on model skulls, tracheostomy insertion on mannequins, trauma scenarios focusing on conducting a primary survey, porcine aortic re-anastomosis, tendon repair, and suturing using porcine models (see Table 1 below for details on stations provided each year). After completion of the SSD, attendees were asked to complete an anonymised feedback form (see Appendix) in exchange for a certificate of workshop completion, to incentivise students to provide feedback.

Results
We have listed some of the key details below from the 2016 -2018 SSD feedback responses.
Over the course of three years, an average of 48 participants (2016 -2018 average (standard deviation (SD): 6.48)) attended the SSD each year for a total of 144 students. In 2016, 57 students attended, with 42 in 2017 and 45 in 2018. The mean response rate for feedback was 74% (n = 107) (2016 -2018 average (SD: 10.5)). Attendance was divided 47% (n = 50) and 53% (n = 56) between males and females (2016 -2018 average (SD: 1.83)), respectively. The percentage of students either in the first, second, or third year was an average of 64% (n = 68); the remaining 36% (n = 38) of attendees were in their fourth or fifth year of study (2016 -2018 average (SD: 13.9)).  The feedback questionnaire required attendees to score each workshop station for overall satisfaction, on a rating scale of 1 to 10, with 10 being the highest. The mean rating for each station is shown below in Figure 2. The feedback questionnaire asked students to comment on the surgeons who were instructing the workshops. Table 2 below shows the percentage of positive and negative comments regarding instructor performance for the 2018 SSD. Feedback comments for instructor performance and interactions are detailed below in Table 3 (2016 and 2017 data cannot be provided as instructor performance was not assessed during these years).   Table 4 below shows the student feedback comments across the three years on aspects they felt were particularly good about the SSD.

Wanted to Change
Students were asked to identify a favourite station and then comment as to why they chose that particular station. These comments were coded and grouped into categories. Categories were then assigned percentage values based on the number of respondents that mentioned them in their feedback. Table 6 shows this information.

Discussion
The SSD aims to improve surgical education at medical school and engage undergraduates in surgery at an early stage of their career. This builds enthusiasm for the profession and encourages students to make better-informed career choices.
The SSD provides an informal environment for students to network with surgeons and develops mentor-mentee relationships. Mentorship in surgery is crucial for career development and the benefits of developing such relationships are two-way: mentorship provides personal and career enrichment to the mentee and provides satisfaction and further opportunities for the mentor [11]. Unfortunately, many students view experiences with surgeons as intimidating which is a major barrier to student engagement with the profession [12][13]. Meeting surgeons in a non-clinical setting led by students, such as the SSD, helps reduce levels of intimidation. Student comments (71.5%) reported positive interactions with the surgeons at the 2018 event ( Table 2).
There is cogent evidence describing the benefits of kinaesthesia in optimising learning experiences [14]. The SSD provides kinaesthetic-style learning with "hands-on" practicality, which was deemed the most valuable aspect of the event by 38.5% of students (Table 4). Furthermore, the three highest ranked stations were tendon repair, burr hole drilling, and laparoscopic simulation (Figure 2), selected due to tactile learning opportunities; "hands-on" practicality made up 54.8% of student comments, as preferential reasons for these three stations (mean of 51.6%, 46.2%, and 66.7% for tendon repair, burr hole drilling, and laparoscopic simulation, respectively) ( Table 6).
These findings corroborate with previous studies suggesting that personal contact with surgeons, in addition to the acquisition of practical skills, is an important part of learning for undergraduates [15][16]. These learning aspects are the key components of the SSD.
The SSD exposes undergraduates to a variety of practical stations in different surgical specialties. The most valuable aspect of the SSD was reported by 24.9% of the students to be the variety of specialty exposure ( Table 4). This exposure facilitates students in identifying a specialty of interest. For example, 50% and 42.9% of students reported trauma scenarios and dynamic hip screw as their favourite stations, respectively, due to interest being triggered in the specialty ( Table 6). The value of exposing medical students to skills relevant to a particular surgical specialty has been reported in the literature in the context of increasing student engagement in cardiothoracic surgery [17]. In developing a surgical specialty interest, students are more likely to consider a career in surgery. This is evident in our study, with 79% of students more inclined to pursue a surgical career following the SSD (Figure 1).
In addition, the SSD provides teaching on skin suturing, an interventional procedure mandated by the GMC for all UK graduating medical students [8]. Unfortunately, the UK medical school curriculum leaves many new doctors with a lack of confidence in performing basic suturing techniques [16]. A UK national survey reported 86.5% of students received inadequate suturing training at medical school, with 21.9% feeling obliged to pay for additional surgical skills workshops [18]. The SSD addresses this issue by providing a skin suturing station in an organised workshop, teaching students GMC mandated suturing techniques. Students see the value of learning this skill, as 31.3% of attendees who identified suturing as their favourite station did so because they felt it is a useful skill for future work ( Table 6).
In light of the SSD improving undergraduate engagement in surgery through mentorship, practical skills, specialty exposure, and teaching of GMC mandated skills, SCRUBS suggests an analogous event be implemented into the UK medical school curriculum. This is supported by national reviews on the medical school curriculum, as well as our attendees, 100% of whom would like the SSD to be an annual event and 97% would like to see practical surgical skills incorporated into the curriculum as shown by Figure 1 [3 , 16].

Conclusions
Surgical teaching provided to undergraduate medical students in the UK is insufficient, with regards to providing experience of practical surgical skills and teaching of GMC mandatory suturing techniques. The SSD is a student-led initiative to address these deficiencies, providing greater specialty exposure in a welcoming environment for students and surgeons to meet. In light of this, the authors suggest the SSD or similar event be integrated into the UK medical school curriculum.