Feasibility and Effectiveness of a Simulation-Based Flipped Classroom for Teaching Surgical Suturing Skills in a Low-Resource Setting

Abstract

Background: Surgical skills training in low-resource settings, such as Uganda, often relies on traditional didactic methods with limited hands-on experience, resulting in competence gaps among graduates. The flipped classroom model, a student centered approach where foundational content is learned outside the classroom, and in-class time is used for active practice, offers a promising alternative, particularly for skill-based instruction. This study explored the feasibility and effectiveness of a simulation-based flipped classroom in teaching surgical suturing skills to third-year medical students at Soroti University. Methods: This was a quasi-experimental study in which 55 third-year students participated in a flipped learning module that incorporated pre-class materials (videos, readings, and suturing kits) and in-class simulations using porcine skin. Outcomes were measured through pre-, post-, and 3-month follow-up multiple-choice tests for knowledge, as well as Objective Structured Assessment of Technical Skills (OSATS) scores for skill performance. Results: Post-test knowledge scores showed a marked improvement compared to pre-test scores (mean gain = 39.9, P < 0.0001), with a normalization gain of 70%. In the OSATS observation checklist, most students were rated as competent (49%) or excellent (33%) immediately after training. At 3 months, knowledge retention was 88% despite a statistically significant decline (P < 0.0001). Interestingly, OSATS performance scores improved at 3-month follow-up (+3 points, P=0.0011), suggesting procedural consolidation over time. Conclusion: The flipped simulation model appears feasible and may be effective in enhancing early surgical skill, and knowledge acquisition and retention among medical students in low-resource settings. It fosters experiential learning and improves both cognitive and psychomotor competence. These findings support the potential for expansion to other skills and subsequent integration of this approach into undergraduate surgical training curricula in LMICs.