Teaching Force Application to Medical Students in Surgical Clerkships - Scoping Review

2. REVIEW OBJECTIVES AND RESEARCH QUESTION 2.1 Primary Objective To systematically map the available evidence on teaching force application to medical students during surgical clerkships, identify knowledge gaps in current educational practices, and explore related evidence from adjacent fields that could inform future interventions. 2.2 Research Question What is known about teaching force application to medical students to improve surgical skills? 2.3 PCC Framework This scoping review will be guided by the Population-Concept-Context (PCC) framework: Element Description Population Medical students in surgical clerkships or rotations. Studies with mixed populations (e.g., students and residents) will be included if student data are separable or if methods are applicable to medical students. Concept Teaching force application to improve surgical skills. This includes force application techniques, retraction techniques, tissue handling methods, teaching methodologies, educational technology (haptic devices, simulation platforms), assessment approaches, and skill development frameworks. Secondary concepts include psychological factors affecting force application and patient safety considerations. Context Any surgical setting (operating room, simulation laboratory), any surgical specialty, any geographic location. Studies published from 2000 onwards in English language. 2.4 Specific Review Questions This scoping review will address the following specific questions: 1. What educational interventions and teaching methods have been described for teaching force application to medical students? 2. What types of educational technology (e.g., haptic simulation, force-sensing devices, virtual reality) have been used to teach force application to medical students? 3. How is force application skill assessed in medical students, and what assessment tools or methods are used? 4. What learning outcomes related to force application have been measured in medical students? 5. What are the identified gaps, challenges, or barriers in teaching force application to medical students? 3. METHODS 3.1 Study Design This protocol follows the methodological framework proposed by the Joanna Briggs Institute. The review will adhere to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist. This protocol will be registered with the Open Science Framework (OSF) or an appropriate registry prior to commencing the review. 3.2 Eligibility Criteria 3.2.1 Inclusion Criteria Population: Medical students in surgical clerkships or rotations. Studies with mixed populations (including residents, fellows, or other learners) will be included if medical student data can be separately identified or if the teaching methods are explicitly applicable to medical students. Concept: Studies addressing teaching or learning of force application to improve surgical skills. This includes studies on force application techniques, retraction techniques, tissue handling methods, teaching methodologies (didactic, simulation-based, mentorship), educational technology (haptic feedback devices, force sensors, virtual reality, augmented reality), assessment methods and tools, skill development and acquisition, and curriculum design. Studies addressing acceleration as a measured learning outcome for force or technique control will be included. Context: Any surgical setting including operating rooms, simulation laboratories, or skills training centers. Any surgical specialty. Any geographic location. Study Designs: All study designs will be included: randomized controlled trials, quasi-experimental studies, observational studies (cohort, case-control, cross-sectional), qualitative studies (interviews, focus groups, ethnography), mixed-methods studies, systematic reviews and scoping reviews, conference abstracts and proceedings, curriculum descriptions, and educational program evaluations. Publication Characteristics: Studies published from 2000 onwards in English language. 3.2.2 Exclusion Criteria Studies will be excluded if they: Do not include medical students as participants and are not applicable to medical student education Are not related to surgery Do not on force application, retraction, or tissue handling Focus exclusively on psychological outcomes or patient safety without an educational component related to teaching force application Were published before 2000 Are not available in English Are quantitative studies with fewer than 10 participants Are animal or cadaver studies without reporting learner outcomes Are opinion pieces, editorials, or commentaries that do not identify knowledge gaps or propose educational frameworks Address acceleration measurement but not as part of a teaching intervention or learning objective for force control 3.2.3 Rationale for Eligibility Criteria Language restriction: English-only inclusion is imposed due to resource constraints and will be acknowledged as a limitation. This restriction may introduce language bias and limit the international scope of findings. Date restriction: The year 2000 was selected as it marks the beginning of the modern era of surgical education, characterized by increased emphasis on competency-based education, widespread adoption of simulation technology, and development of force-sensing educational devices. This timeframe captures relevant contemporary educational practices while maintaining review feasibility. 3.3 Information Sources The following databases will be systematically searched from January 1, 2000 to the date of search execution: • PubMed • Embase • Web of Science • Scopus Additional sources: Hand-searching reference lists of included studies and relevant reviews Expert consultation to identify additional relevant studies The search will be executed in December 2024 with no auto-alerts for new studies during the review process. The date of the most recent search will be reported in the final manuscript. 3.4 Search Strategy A comprehensive search strategy will be developed in consultation with a health sciences librarian. The search strategy will combine three main concept groups using Boolean operators: 3.5 Selection of Sources of Evidence Study selection will follow a two-stage process: 3.5.1 Stage 1: Title and Abstract Screening Two independent reviewers will screen all titles and abstracts against the eligibility criteria using a standardized screening guide. Prior to formal screening, the review team will conduct a pilot test on a random sample of 100 citations to calibrate understanding of the eligibility criteria and refine the screening guide as needed. The pilot results will be discussed, and disagreements resolved through consensus. The screening guide will include four quick screening questions to facilitate efficient and consistent decision-making: 1. Are medical students mentioned or implied? If no, are methods applicable to students? 2. Is the study surgery-related? 3. Does the study inform teaching of force application or tissue handling? 4. Does the study meet basic criteria (English, 2000+, n≥10 for quantitative)? A liberal approach will be adopted at this stage; any citation marked as 'include' by either reviewer will proceed to full-text review. When in doubt, citations will be included for full-text assessment. Disagreements will be resolved through discussion and, if necessary, consultation with a third reviewer. 3.5.2 Stage 2: Full-Text Screening Two independent reviewers will assess full-text articles for eligibility against the complete inclusion and exclusion criteria. A pilot test of 10 full-text articles will be conducted to ensure consistency in application of criteria. Disagreements will be resolved through discussion and consensus, with a third reviewer consulted if needed. For studies with mixed populations (e.g., medical students and residents combined), full-text review will determine whether student-specific data are reported separately or whether the educational methods are applicable to medical students. Reasons for exclusion at the full-text stage will be documented using standardized exclusion codes: • P1: No medical students included • P2: Mixed population with no separable student data • C1: Does not address force application • C2: No educational component • C3: Psychological outcomes only • C4: Patient safety outcomes only • C5: Non-surgical focus • T1: Published before 2000 • T2: Not available in English • E1: Animal study without learner outcomes • E2: Cadaver study without learner outcomes • E3: Opinion piece without gap identification • E4: Full text not available Inter-rater reliability will be calculated using Cohen's kappa statistic for both screening stages. Target agreement is κ ≥ 0.60, indicating substantial agreement. If agreement falls below this threshold, additional calibration sessions will be conducted. The study selection process will be documented using a PRISMA flow diagram showing the number of records identified, screened, excluded (with reasons), and included at each stage. 3.6 Data Charting Process Data extraction (charting) will be conducted by two independent reviewers using a standardized data extraction form developed in Microsoft Excel or Covidence. The form will be pilot-tested on 5-10 included studies and refined as needed based on team discussion. The pilot testing process will ensure the form captures all relevant data elements and that reviewers have consistent interpretation of data items. Data extraction will be performed independently by two reviewers for all included studies. Discrepancies will be resolved through discussion and consensus, with consultation of a third reviewer if needed. For missing or unclear data, study authors may be contacted for clarification when feasible. The data extraction form will be iteratively updated as the review progresses if new relevant data items emerge. Any modifications to the form will be documented, and pr