Virtual suturing skills learning: role of verbal versus written feedback in surgery rotation clerkship

Figures & data

Table A1. Intervention feedback questionnaire

Questions	Possible answers
Did you learn the assessment instrument before submitting the pre-test video?	Yes	No
Is the assessment instrument help you to do standardize suturing skills?	Yes	No
Number of training before Pre-test	None	1–2	3–4	≥5
Number of training before Post-test	None	1–2	3–4	≥5
Name of assessors
Is feedback considered useful? (give reason)	Yes	No
Rate your satisfaction with the learning method (1 being highly unsatisfied, 5 being highly satisfied)	1	2	3	4	5
Please provide feedback for us to improve the learning method
Is the suturing video shows clear instructions?	Yes	No
Is the suturing instruction well developed?	Yes	No
Is the assessment instrument clear and understandable?	Yes	No

Table A2. Guide for simple interrupted suturing procedure

Guide for Simple Interrupted Suturing Procedure
1	Use the needle holder to hold the needle at the needle body, 1/3 proximal from the swaged end
2	The needle is placed at the tip of the needle holder
3	Apply the suture thread with a ratio of 2/3 and 1/3, or use an atraumatic needle if available.
4	Hold the needle holder with your dominant hand, on the distal phalanx of the index and ring finger
5	Hold the forceps with a non-dominant hand, hold it as if you’re holding a pen (use thumb, index and middle finger). Forceps are held at the mid-forceps
6	Place forceps to clamp the edge of the wound, insert needle perpendicular to the mannequin. Note that the hand should be pronated.
7	Advance the needle by pronating the hand, following the curvature of the needle
8	When the tip of the needle is visible on the inner side of the wound, pull out the needle with forceps until the whole needle is outside the wound.
9	Clamp the needle as per instructions 1 to 5
10	Hold the other edge of the wound with the forceps
11	Insert the needle from the inner side of the wound by supinating the hand
12	Once the tip of the needle is seen on the skin, pull it out until the whole needle is outside the skin
13	Pull the suture thread until you reach the desired length. You now have a long end on one side and a short end on the other
14	Place the forceps and needle on sterile area
15	Hold the long end of the suture thread with a non-dominant hand, while the dominant hand is holding the needle holder
16	Place the needle holder in between the two suture threads
17	Make a surgical knot on the needle holder by encircling the long end of the suture thread on the needle holder twice
18	With the needle holder, clamp the short end of the suture thread
19	Pull the short end of the suture thread opposite to the original place (the short end of the suture thread is pulled to the side of the long end of the suture thread). Now you have the first knot.
20	For the second knot, first place the needle holder is placed in between the suture thread
21	Encircle the long end of the suture thread once on the needle holder
22	With the needle holder, clamp the short end of the suture thread
23	Pull the short end of the suture thread opposite to the original place (the short end of the suture thread is pulled to the side of the long end of the suture thread)
24	Place the knot on either edge of the wound
25	The suture should be a non-tension suture. Edges of the wound are expected to be right next to each other and should not be inverted or overlapped
26	Pull the two ends of the needle thread with a non-dominant hand, while the dominant hand hold the thread scissors
27	Hold the thread scissors with the distal phalanx of the thumb and ring fingers
28	Cut the excessive suture thread with the tip of the thread scissors.
29	Suture threads are cut approximately 1 cm above the knot, cut with a 45° angle.

Table A3. Assessment tools

No.	Variable	Rating
	Suturing Checklist	1	2	3	4		5
1.	Handling of the needle holder	Mostly incorrect	75% incorrect	50% incorrect	75% correct		Mostly correct
2.	Handling of tissue forceps
3.	Loading of the needle to the needle holder
4.	Piercing the skin surface
5.	Pulling needle from the tissue
6.	Knotting
7.	Handling of surgical scissor
8.	Cutting
	Global Rating Scale	1		3		5
1.	Respect for tissue	Often used unnecessary force on tissue or caused damage by inappropriate use of instruments		Careful handling of tissue but occasionally caused inadvertent damage		Consistently handled tissues appropriately, with minimal damage
2.	Time and motion	Many unnecessary moves		Efficient time and motion, but some unnecessary moves		The economy of movement and maximum efficiency
3.	Instrument handling	Repeatedly makes tentative or awkward moves with instruments		Competent use of instruments, although occasionally appeared stiff or awkward		Fluid moves with instruments and no awkwardness
4.	Knowledge of instruments	Frequently asked for the wrong instrument or used an inappropriate instrument		Knew the names of most instruments and used appropriate instruments of the task		Obviously familiar with the instruments required and their names
5.	The flow of operation and forward planning	Frequently stopped operating or needed to discuss next move		Demonstrated ability for forward planning with a steady progression of the operative procedure		Obviously planned course of operation with effortless flow from one move to the next
6.	Knowledge of Specific Procedure	Deficient knowledge. Needed specific instructional most operative steps		Knew all important aspects of the operation		Demonstrated familiarity with all aspects of the operation

Table A4. Demographical data of the participants

	Gender		TOTAL
Interventional Groups	Male	Female
Verbal	36	50	86
Written	30	66	96
TOTAL	66 (36.3%)	116 (63.7%)	182

Figure B1. Frequency of training conducted before assessments.