{"paper_id":"1a6758ec-ae9f-4029-9da1-db972894ab49","body_text":"Teaching methods used by general surgeons in simulation or formative assessment leading to improved surgical skill acquisition in UK surgical trainees: a scoping review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Teaching methods used by general surgeons in simulation or formative assessment leading to improved surgical skill acquisition in UK surgical trainees: a scoping review Amina Akhtar, Michelle Machado This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8310571/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background: The UK general surgery (GS) training faces challenges despite curriculum reforms, this includes varied teaching quality, limited simulation teaching, reduced training opportunities and curriculum flaws. Recent national surveys highlight discrepancies between GS trainees’ dissatisfaction in comparison to other specialities. The aim is to identify teaching methods in simulation or formative assessment leading to improved surgical skill acquisition in GS. Methods: A scoping review, following the PRISMA-ScR guidelines, identified studies from the last decade using Pubmed/Medline, EMBASE, ERIC and Web of Science. Data was extracted into tables and reviewed using basic numerical analysis. The charted data was analysed using narrative synthesis and categorized using the Kirkpatrick model, with alignment to Miller’s Pyramid, to assess effectiveness of competency. Results: 31 studies highlighted a range of simulation and assessment strategies. 26% were categorized into the lowest form of competency, Kirkpatrick Levels 1(Miller’s “Knows”) and showed enhanced trainee confidence. 3% were graded as level 4 (Miller’s “Does”) and demonstrated competency through clinical outcomes. 35% were a mix of methods to assess learning on multiple levels simultaneously allowing in-depth multimodal assessment of learning. Conclusion: This paper suggests that an imbalance exists between the quantity of research versus the quality of research that formally assesses surgical skills acquisition at higher levels of competency. Thereby suggesting a demand for higher and reliable research to bridge the current gap in research and develop a more competency-based curriculum embedded with validated tools aligning with the higher levels of competency and supporting surgical autonomy and patient safety. General surgery simulation formative assessment surgical education scoping review UK training Figures Figure 1 Figure 2 Figure 3 Figure 4 INTRODUCTION Over the past two decades, it has become increasingly recognized that the historically rooted \"see one, do one, teach one\" model is no longer sufficient for preparing modern surgeons( 1 )]. In the United Kingdom (UK), the General Surgery (GS) curriculum underwent significant reforms, including a more holistic approach and more flexibility within training pathways. Despite these efforts, challenges persist. These include limited low fidelity simulation practice, absence of research in surgical education and inconsistent guidance on training( 2 ). The burden on trainees is intensified by financial pressures, staff shortages and lack of dedicated teaching times; all of which influence motivation and career decisions( 3 ). These systemic issues require a change in the current curriculum to a more structured, uniform format with standardized and researched high-quality teaching methods across the UK. Without such modifications, not only does one risk trainee burnout and disparities in training but also nationwide inconsistencies in surgical competence and patient care. Intercollegiate Surgical Curriculum Programme (ISCP) The national UK Surgical training pathway begins with the two-year Foundation Programme (FY1–FY2) and is then followed by the Core Surgical Training (CST). The latter also spans two years and exposes trainees to broad surgical exposure to core technical and non-technical skills. The following entry into GS specialty training (ST3-8) is highly competitive and signals the movement towards independent clinical practice. The training path is structured by the ISCP and overseen by the Joint Committee on Surgical Training (JCST). Competence progression must be demonstrated in key index procedures such as appendicectomies, emergency laparotomies and hernia repairs, through Work-based assessments (WBAs) and Procedure-Based Assessments (PBAs). Their purpose is to evaluate operative planning, performance and post-op reflections. To attain the ability for unsupervised practice, a trainee must demonstrate these skills to a level 4 PBA( 4 ) in all index procedure and record operations in a log-book to lead to completion of training, also known as ‘ Certificate of Completion of Training’ (CCT). The current form of WBAs function as formative and summative are suggested to align with Miller’s Pyramid [Figure 1 ], a model to assess clinical competence that moves from the more theoretical based assessments to more real-life clinical performance( 5 , 6 ). However, research suggests that concerns remain over their effectiveness( 7 ), prompting a need for further research. UK GS training Issues Further training issues include external pressure, especially the COVID-19 pandemic as it exacerbated pressure on an already strained system and therefore resulted in significant loss of operative exposure and diminished opportunities for training progression( 9 ). Consequences of this led to disruptions in the ‘ Annual Review of Competency Progressio n’ outcomes and thus extended training periods( 10 ). A UK study found that 81% of surgical trainees reported a decline in mental well-being during the pandemic ( 11 ). This coincided with a broader dissatisfaction demonstrated in the 2023/24 JCST survey, demonstrating a disparity between GS and other specialities. Only 52%, a 5% further decline from the previous year, of GS trainees felt that theatre-based quality indicators were met; they scored the lowest among all surgical specialties( 12 ). In addition, only 45% felt their clinical goals were achieved, with only vascular surgery scoring worse( 12 ). Despite the formal requirement of two-hourly weekly protected teaching times, only 70% of trainees reported this as being met. Similarly, only 69% of GS trainees reported the opportunities for mandatory simulation training, in contrast to 92% of Ears, Nots and Throat and 86% of paediatric trainees. The trainee dissatisfaction and inconsistencies across different specialities is demonstrating a variability in teaching quality across different specialities( 12 ) and thus runs the risk of discrepancies in patient outcomes subjected to different specialities. These trends demonstrate an urgent demand to re-evaluate the GS educational programme. Surgeon as Educators Mastery of surgical skills does not develop from theory alone but through repetitive, hands-on practice( 13 , 14 ), hence the pivotal role of a senior in shaping the progression of a trainee through direct supervision. In spite of this expected role, surgeons are not required to obtain a qualification in pedagogy( 15 ). NHS England’s 2024 review demonstrated that neither CST nor ST curriculum mandates such formal qualification( 15 , 16 ), this throws light on the systematic gap in the curriculum( 17 ). With the aforementioned curriculum issues, this lack of standardized teaching runs the risk of undermining both patient care( 18 ) and the sustainability of surgical training itself( 19 , 20 ). Surgical Education Learning Theories Understanding of the theoretical frameworks that underpin effective teaching is crucial in improving surgical educational outcomes. Kolb’s Experiential Learning Theory( 21 ) is particularly suited to surgery, outlining a four-stage cycle: concrete experience, reflective observation, abstract conceptualisation, and active experimentation; demonstrated by a trainee performing a procedure, reflecting on it, identifying improvements, and applying these to future scenarios. Reflection is a central process widely promoted in the medical field and supports the transfer of cognitive to clinical knowledge and thus progression of learning( 22 ). Dewe’s (1933) concept of reflective thinking depicts it as a response to cognitive doubt prompting problem-solving and has been a foundation in defining critical thinking( 23 ). This suggests that critical reflection in surgical training could drive continual self-improvement and adaptation( 24 , 25 ). Reflection is seemingly incorporated into the progression of Miller’s Pyramid of competency[FIgure 1 ] from cognitive knowledge to clinical performance( 5 ). Further research into curriculum and teaching methods should be based on such foundational learning theories and pedagogy. Gap in Literature A review of current literature reveals a significant gap in GS curriculum and effective teaching methods. Whilst some research explores surgical assessment strategies( 26 ), there is a lack of teaching methodologies focusing on GS trainees within the UK. This is significant given the notable discrepancies in reported satisfaction of GS trainees compared to other specialities( 12 ). In addition, UK training carries its own hurdles that must be researched in isolation to other countries. To date, no scoping or systematic review has comprehensively examined teaching and assessment methods specific to UK GS to ascertain competence and whether the current WBA based strategies are most appropriate. This review seeks to address this disparity. Aim, Research Question Research Question What teaching methods used by general surgeons in simulation or formative assessment lead to improved surgical skill acquisition in UK surgical trainees? Objectives To identify specific teaching methods employed by general surgeons. To contrast effective and ineffective teaching in terms of improved surgical skill acquisition. To analyse existing research to inform and optimise future teaching strategies in surgical education. METHODOLOGY A scoping review was performed due to limited volume of existing research, therefore making a full systematic review unsuitable( 27 ). This approach allows the mapping and organization of a vast topic whilst also identifying current gaps within the current literature( 28 ). The five-stage methodological framework outlined by Arksey and O'Malley( 27 ) was followed, which includes (a)research question identification, (b) identification of relevant studies, (c) study selection, (d) data charting, and (e) collating and reporting the results. The review was conducted in accordance with PRISMA-ScR guidelines for scoping reviews( 29 ). Eligibility criteria Studies required to meet the eligibility criteria to be included. Firstly, GS trainees in the UK were the target population as the research question is addressing this population specifically. International studies were excluded as they vary in curriculum, funding, training duration, available resources, training equipment and possibly teaching qualifications. Medical students were also excluded due to discrepancies in their curriculum and learning objectives. The target trainees were defined as postgraduate doctors pursuing a career in GS, including those without an official training post (e.g., trust-grade doctors). Eligible teaching methods encompassed any form of simulation or formative assessment strategy that could lead to surgical skill acquisition. Search strategy A systematic search was performed on the 18th February 2025 of Pubmed/Medline, EMBASE, ERIC and Web of Science. The following Boolean operators were used to identify the papers via OVID: GB OR Great Britain OR UK OR United Kingdom) AND (Teaching OR Teach* OR training OR mentoring OR mentor*) AND(General surg* OR colorectal OR HPB OR hepato-pancreato-biliary OR UGI OR Upper gastrointestinal) AND (Simulation OR formative OR assessment) AND (Surg* skill* OR technical OR competence) AND (Surgical trainee* OR surgical resident* OR Student OR graduate). Web of Science was not accessible via OVID and hence the same search was completely using the same terms. The search was limited to the last ten years and to the English language. Additional relevant papers were identified through tracking references to enhance literature saturation. Grey literature (e.g. abstracts) were considered as these suggested innovative topics with robust outcomes. Screening The identified files were exported in RIS file and imported to Zotero reference manager( 30 ). This facilitated the upload to Rayyan( 31 ), a research collaboration platform that supports systematic reviewing of papers. The first author (AA) screened the eligibility of the retrieved papers based on title, abstract and then full paper; this was then followed by a second blinded reviewer (EH), using the same eligibility criteria, to increase reliability, Charting Data from the selected studies was tabulated in Microsoft Excel and categorized under major subheadings: paper ID, study design, aim and outcomes. A simple numerical analysis was conducted, followed by a qualitative narrative synthesis organizing the studies according to the four levels of training evaluation of Kirkpatrick’s framework. This widely used model assesses the effectiveness of educational programs( 32 ) starting with the learners’ immediate reaction to learning (level 1); followed by the evaluation of learning by testing the gain of knowledge (level 2). In level 3, it evaluates application of a new skill, and finally, it measures the broader impact of learning e.g. patient outcomes (level 3)( 32 ) (Fig. 2 ). Table 1 Summary of Articles Reviewed categorized by Kirkpatrick level Level Study,Year,Trainee,level Study design Aim Outcome 1 ( 33 ) Aawsaj, Y., et al. (2025), N:10, ST 3–8 Simulation assessment + semi-structured interview Trainee perceptions of laparoscopic simulation as a summative tool Simulation built confidence but there was no substitute for live experience. Barriers included NHS pressures, trainer resistance, and dissatisfaction with PBAs. 1 ( 34 ) Shalhoub, J., et al. (2017), N:10, CST Semi Structured interviews Trainee views on the value and use of PBAs PBAs are seen as inconsistent and variable by grades. Concerns over validity, especially self-completion. But useful for tracking progress if supported well. 1 ( 35 ) Blackhall, V., et al. (2019), N:43, CST Home simulation + online module; focus group feedback Identify barriers in engagment to home-based simulation Engagement limited by motivation, trainer input, and system pressures. Metric feedback felt impersonal; low-fidelity tools and 'tick-box' culture limited perceived value. 1 ( 36 )Singh, P., et al.(2015), N:51, ST1-3 Regional Survey using S-QAT / Likert score Identify variation in training quality across centers. Supervision was rated highly, but access to cases, outpatient goals, and teaching varied. Recommendations: protected theatre time and improved training structure. 1 ( 37 ) Fleming, C., et al. (2019), N:24, ST? Descriptive Study with live polling. Explore opinions on GS fellowships. Trainees supported fellowships as OOPT, preferred international options, and favoured post-CCT structure within a standardised curriculum. 1 ( 38 )Gaunt, A., et al. (2018), N:42, ST1-8 Qualitative multicentre focus groups Explore trainees' feedback-seeking behavior. WBAs driven by self-motives; formative assessment aided self-improvement, WBAS could limit honest reflection. Authors called for feedback reform to support openness. 1 ( 39 ) Room, H.J., et al. (2020), N:39, CST Simulation camp + satisfaction questionnaire Teach core surgical trainees basic entry level skills. Trainees valued the camp’s timing, relevance, and consultant-led feedback. Enhanced confidence and mentorship was value. 1 ( 40 )Skervin, A.L., and Scott, H.J., et al. (2021), N:74, CST + ST3-8 Self-report questionnaire on use of MR. Assess MR use amongst trainees and consultants. MR used by 91.5%, especially for complex cases. Reported benefits included improved focus, clarity, planning, and anticipation. 1 + 2 ( 41 ) Shariff, U., et al, (2015), N:59, ST1-8 RCT, post-intervention knowledge test and evaluation Assess multimedia tool vs. traditional teaching for colorectal surgery Both groups improved knowledge equally; trainees appreciated the tool for enhancing decision-making and anatomical understanding. 2 ( 42 )Kailavasan, M., et al. (2020), N:93, ST Simulation bootcamp with abdominal wall model; post-simulation Likert questionnaires Assess face validity of a low-fidelity simulator for laparoscopic port insertion Trainees and faculty rated the model highly; it was deemed effective for port training in both urology and GS with no validity concerns. 2 ( 43 )Hand, F., et al. (2017), N:17, ST1-3‌ Retrospective analysis; similarity between admission and discharge diagnoses Assess if structured handover reflects diagnostic skill Diagnostic accuracy improved using the handover tool; scores were based on concordance of key findings, plan and diagnosis. 2 ( 44 )Yiasemidou, M., et al. (2017), N:20, CST Case controlled study on MR; metrics of simulator: time, motion, safety Assess impact of 3D visual aids in MR on surgical performance 3D MR improved efficiency (time, movement, path length) vs. controls; no safety differences; authors recommended combining mental imagery with anatomical models 2 + 3 ( 45 )Yule, S., et al. (2015), N:16, ST4-6 RCT on simulation; NOTSS scoring for laparoscopic cholecystectomy Assess the effect of coaching on non-technical skills in a simulated theatre Coaching improved NOTSS scores and crisis responses; no change in time + path length. 2 + 3 ( 46 )Ramjeeawon, A., et al. (2020), N:16, ST1-3 & MD students Simulation with structured debrief; NOTSS, OTAS, STAI Assess impact of immersive simulation and debrief on teamwork, stress and technical skills. Teamwork, technical performance, radiation safety, and psychological state improved post-debrief across all training levels. 3 ( 47 ) JCST,. (2023), N:?, ST1-8 Report on improving surgical training (IST) pilot trainee feedback Summary of UK IST trainee Feedback English trainees reported fewer ST3 opportunities; concerns less common in Scotland/Wales. Most IST posts are being phased out in GS. 3 ( 48 )Allum, W., et al. (2020), N20, ST1-8 Report on IST pilot trainee feedback Identify areas for improvement in IST programme Recommended dedicated rota time for training, more elective/sim access in curriculums. Limited Trainer time due to service pressure. Suggested ACP/SCP role expansion, requiring training and HEE support. 3 ( 49 )Clarke, R., et al. (2024), N:26, ST3 Prospective analysis; simulation, lectures, labs; self-assessment using Likert feedback Develop GS bootcamp to support ST3 transition Trainees reported significant skill improvement in endoscopy, laparoscopy, open surgery, and non-technical areas. Confidence rises post-course, especially in laparoscopic suturing (77%), ulcer repair (69%), and stress management. 3 ( 50 )Clarke, R., et al. (2024), N:25, ST3 -Simulation with pig tissue model -Feedback questionnaire Assess face-validity of a low-cost model for teaching acute proctology during the ST3 general surgical bootcamp. Confidence rose across key proctology tasks; 80% rated the model highly for realism and training value. 3 ( 51 )Metcalfe, K., et al. (2021), N16, CST Office admin simulation; post-course questionnaire Evaluate admin simulation for developing non-technical consultant skills Trainees rated the pilot programme as useful and felt it prepared them for consultant roles. All supported adding it to regional teaching, finding it relevant and well received. 3 ( 52 )Boyle, M., et al. (2021), N?, FY/TG One-day workshop; pre/post-course questionnaires Assess clinical decision-making and technical readiness for acute surgical care All trainees found it useful and relevant; authors encourage inclusion in regional training. 3 ( 53 )Hosny, S.G., et al. (2017), N:37, ST3-8 Multinational qualitative study; semi-structured interviews Identify barriers/facilitators to uptake of simulation programmes. Simulation valued for safety and assessment, but hindered by time, cost, motivation; trainees less confident in its high-stakes validity. 3 ( 54 )Rajaratnam, V., et al. (2021) NA Review of modular laparoscopic training; motor learning theories Propose evidence-based model for surgical skill acquisition. Advocates low-cost, self-directed model using mental imagery, deliberate practice, and instructional design to build skill with limited simulation. 3 + 4 ( 55 )Shalhoub, J., et al. (2015), N:?, ST1-8 Descriptive analysis; ISCP usage data Examine WBA use by region, specialty, and training level WBA use increased sevenfold (2007–2013); CSTs completed more than STs. PBAs were preferred by STs, with regional variation in volume and type. 3 + 4 ( 56 ) Brown, C., et al. (2017), N:84, ST3-8 Service evaluation; PBA trajectory vs. case volume Evaluation of performance trajectory of index procedures in relation to operative experience, indicative numbers, and training time Learning curves and PBA timing varied. Few PBAs completed post CCT. Level 4, limiting assessment beyond minimum competence. 3 + 4 ( 57 )Abdelrahman, T., et al. (2016), N69, ST3-8 Service evaluation on PBA learning curve gradients of index procedures Examine relationship between index numbers and PBA attainment in key procedures Laparotomy targets deemed sufficient; complex cases like Hartmann’s required > 3× target to reach competence. Authors suggest revising JCST indicative numbers. 3 + 4 ( 58 )De Siqueira, J. R., and Gough, M.J., et al. (2016), N:121, ST3-8 Descriptive analysis; ISCP and eLogbook review Correlate operative volume with trainer-assessed competence PBA scores aligned with case volume, but many trainees failed to reach Level 4 despite index numbers. Highlights inconsistency in progression and questions validity of certification. 3 + 4 ( 59 )Abdelrahman, T., et al. (2015), N:89, ST?? Descriptive analysis; ISCP data review Assess whether GS trainees meet CCT operative and academic targets Most achieved procedural and academic targets. Authors advise early support and simulation use for underperforming trainees. 3 + 4 ( 60 )Elsey, E.J., et al, (2019), N:311, FY1-2&CST Cohort study; ISCP and e-logbook review Assess operative experience and competency progression using national data Trainees progressed to unsupervised basic procedures through training; complex cases required longer. Training data reflects evolving competence and decision-making. 3 + 4 ( 61 ) Abdel-dayem, M., et al. (2021), N:35, CST&SHO Structured modular training; progression metrics and trainee questionnaire Develop a reproducible laparoscopic Colorectal Surgery (LCS) training model supporting independent practice 98% satisfaction; most achieved independent LCS. Low conversion rates and good outcomes reported. Keen to maintain the programme. Staffing shortages noted as a barrier. 1–4 ( 62 )James, H. K., et al. (2019), N: 2002 Systematic review; assessed cadaveric simulation across Kirkpatrick levels Evaluate evidence for cadaveric simulation in postgraduate training Improved confidence, test scores, and procedural skills. Behavioural transfer inconsistent; limited long-term evidence for patient-level impact. 4 ( 63 ) Hanna, G.B., et al, (2022), N:108 Case-control study; comparing clinical outcomes of colorectal cases performed by lapco-vs non-lapco surgeons. Examine impact of national training programme LAPCO clinical outcome performed by Lacpco surgeons after training completion Increased rates of laparoscopic colorectal cancer surgery, reduced mortality and morbidity. In-training competency assessment tools predicted clinical performance after training. A list definition can be found in [Appendix 1]. RESULTS The initial search generated 201 papers and an additional 3 were identified through alternative sources, after removing 48 duplicates in ovid and 5 in Rayyan, 151 papers remained. After screening the titles and abstracts against the eligibility criteria, 78 and 5 papers were excluded respectively to leave 67 records for full text analysis(Fig. 3 ). A further 36 records were removed during the full-text article review, due to incorrect geography (n = 29), incorrect population (n = 2) e.g. med students, and wrong intervention (n = 5) e.g. endoscopy. Despite endoscopy being performed by many GS surgeons, the training follows a different curriculum and was therefore excluded. Some studies often included other geography/population in their study, they were only included if the majority of studies were relevant. One urology paper was not excluded, as the procedure tested was equally performed by GS trainees. A vascular paper was not excluded as GS and vascular training paths only separated in 2022( 64 ). One scoping review was removed, yet the decision was made to keep one systematic review as it matched this paper’s methodology perfectly, capturing all Kirpatrick’s levels. This left 31 final studies for the scoping review. Study design and setting The included studies fell into five broad methodological categories: self-report measures, objective or performance-based assessments, descriptive analyses, and multi-methods. Thirteen used self-reported data, three through interviews, seven via questionnaires, two with focus groups and one via polling. Seven studies employed objective assessments: five assessed technical performance, while others used tools such as S-QAT (a self-assessment tool appraising training quality), OSATS (evaluating surgical technical skills), STAI (measuring state and trait anxiety), debrief scores, and NOTSS (assessing non-technical surgical skills). Eight were descriptive in design, including six studies analysing ISCP and/or eLogbook data and two based on training reports. One paper was a systematic review. Distribution by Kirkpatrick level The papers were then categorised according to Kirkpatrick's Four Levels of Training Evaluation (Fig. 2 ); many papers assessment incorporated multiple levels. They were distributed most commonly in level 1 with eight papers, then eight in level 3 and seven were under a combination of levels 3 and 4. Three papers were categorized as level 2. Two fell into level2/3 and then one paper in each of the following categories: level1/2, level 1/2/3/4, level 4(Fig. 4 ). Level 1[Table 1 ] Eight studies [Figure 4 ] assessed trainee reactions to simulation or formative assessment interventions, focusing on perceptions, confidence, and engagement rather than measurable outcomes. Data were largely qualitative, drawn from interviews and questionnaires. Trainees often reported increased motivation and confidence, particularly following simulation-based teaching such as bootcamps and skills camps. There was strong support for structured, modular, and mental rehearsal-based approaches ( 40 ), though barriers to engagement included service demands, trainer resistance, and a tick-box WBA culture (e.g.33–35). Level 2[Table 1 ]– Learning Three studies [Figure 4 ] measured evaluation of learning through knowledge e.g., impact of 3D diagnostic skills( 43 ) and visual aids( 44 ). Outcomes were demonstrated with objective metrics like post-test scores, NOTTS, S-QAT and OSATS. Improvements were seen especially if combined with mental rehearsal ( 44 ) structured debrief ( 46 ). Multimedia, 3D visual aids, and mental imagery enhanced performance, confidence, and reduced errors( 44 ). Level 3[Table 1 ]– Behaviour Eight studies assessed evaluation of skills [Figure 4 ]. Evidence was largely anecdotal or inferred, based on questionnaires or post-training interviews. A consensus was pro-simulation training. Reported changes included improved operative confidence and patient safety in simulations ( 45 – 46 , 49 – 54 ). Improvements in independence were enhanced further by increased fidelity of model ( 50 ), dedicated training program.s ( 51 ) and deliberate practice ( 54 ). However, cost and limited trainer and training time were common barriers ( 47 , 48 , 53 ). Mixed levels[Table 1 ] Eleven papers used multi-methods to assess learning on multiple evaluation levels simultaneously allowing in-depth multimodal assessment of learning. Level3/4, being the most common combination, offered the opportunity to evaluate new skills in the clinical field, often via formative assessment PBAs. Competence progression across training years was shown with a gradual decrease in supervision, especially for less complex procedures ( 55 – 60 ). Learner’s increased level of autonomy could infer positive clinical outcome, but not guarantee it, hence the level3/4 grade as opposed to level4. Level2/3 tested NOTSS skills and tested these via objective post sim methods, coaching improved real-time decision-making and teamwork ( 45 , 46 ). A training module was able to evaluate independent skill progression through questionnaires and test clinical outcome metrics objectively( 61 ). One cadaveric review also reviewed the Kirkpatrick levels and therefore ( 62 ) provided: strong trainee approval, knowledge gains, procedural improvement and modest real-world outcome effects, to address all four levels of the training experience(Fig. 2 ). Level 4[Table 1 ] – Results Only one study [Figure 4 ] evaluated solely the clinical impact ( 63 ), this study examined the impact of a national training programme and noted improved in-training competency and improved real-time patient outcomes. The remaining studies were tested in conjunction with level 4. Strength of Evidence of each Kirkpatrick Level In this scoping review, the strength of evidence for each Kirkpatrick Level was assessed using a combination of methodological accuracy, data type, and the depth of outcome measurement reported in included studies and which type of levels and teaching opportunities would be best to improve surgical skill acquisition[Table 2 ]. Eight papers were rated low and were in Level 1 as it relied on subjective trainee perceptions( 33 – 40 ). Level 2 papers involvin were categorized as moderate, if studies included objective, quantifiable outcomes ( 41 – 46 ). Papers in level 3 with self-rated outcomes through questionnaires were graded moderate due to their clinical relevance ( 49 – 53 ). However, papers scored high when clinical outcomes were measured directly which only one paper qualified for ( 62 ) and was categorized as level 4. Studies spanning multiple levels were assessed contextually, with the highest level of rigorously collected and validated outcome data informing their overall strength. Papers in level 3/4 were rated moderate-high and contained eight papers that relied on large-scale datasets such as national trainee progression records. PBAs ratings of independence could indirectly support good clinical outcome ( 55 – 60 ). This evaluative strategy aligns with well-known best-practice frameworks for educational evidence synthesis and therefore could relate to effective skill acquisition and potential for further research. Table 2 Kirkpatrick framework summary for surgical training evaluation Kirkpatrick Level Focus Outcome Type Data Sources Strength of Evidence Limitations Level 1: Reaction Trainee satisfaction, perception of value Subjective (opinions, confidence) Surveys, focus groups, interviews, Likert scales Low ● No direct measure of learning or competence ● Highly variable- Susceptible to social desirability bias Level 2: Learning Cognitive or psychomotor gains Objective (task scores, post-tests, NOTSS) Simulators, technical task analysis, pre/post MCQs, video scoring Moderate ● May not translate to behavior ● Studies often lack long-term follow-up ● Mixed fidelity of simulation methods Level 3: Behavior Transfer to real-world practice Observational/self-report, performance logs Simulation follow-up, post-course self-assessments Moderate to high ● Self-reporting bias ● Hard to isolate effect of training alone ● Confidence ≠ competence Level 4: Results Institutional/patient outcomes, system change Clinical outcomes, operative independence, progression data E-logbook data, national audits, PBA records, completion rates High ● Resource intensive ● Rarely performed ● Hard to attribute causality Mixed Levels Multi-domain outcomes Subjective + objective + behavioral Literature reviews, multi-level studies (e.g., cadaveric sims). ISCP portfolios. Varies by level ● Methodological inconsistency- Attribution across levels can be imprecise Discussion This scoping review aimed to identify which teaching methods used by GS in simulation and formative assessment contribute most effectively to surgical skill acquisition in UK trainees and which gaps remain in the current limited research surrounding this topic. The Kirkpatrick model( 32 ) and Miller’s Pyramid( 7 ) provided a valuable conceptual scaffold to interpret the nature and depth of learning outcomes revealed in this scoping review, while the Kirkpatrick Model enabled categorisation of educational interventions based on their evaluative impact, Miller’s framework clarifies the type of competence being developed at each stage. By using Kirkpatrick’s model to interpret the outcomes, an uneven distribution of evidence strength and a dominance of lower-level evaluation was identified. By using Miller’s pyramid it was still possible to highlight the progression from \"knows\" and \"knows how\", through cognitive gains and improved procedural understanding and \"shows how\" via simulation or structured assessment( 65 – 67 ). Level 1 ( 33 – 40 ) outcomes were the most frequently reported, capturing trainee perceptions, satisfaction, and confidence e.g., via Likert scales or interviews. Trainees often reported increased motivation and confidence, particularly following simulation-based teaching such as bootcamps and skills camps. While many trainees valued simulation such as teaching camps for building confidence, some questioned its realism and educational value( 39 ). There was strong support for structured, modular, and MR approaches ( 40 ), though barriers to engagement included service demands, trainer resistance, and a tick-box WBA culture ( 35 ). MR was regarded as valuable across all levels( 40 ). Level 1 outcomes, although high in quantity, most were single-centre, underpowered and were reliant on subjective tools to determine outcome. As a result of the subjective nature of their outcome they were classified as a weaker form of evidence. Their generalisability was limited and they failed to assess actual knowledge attainment or long-term clinical relevance The deliberate proactive engagement suggested in Kolb’s cycle of reflection leads to the transfer of cognitive knowledge to clinical knowledge( 22 ), one could argue that this was executed through self-reporting outcomes. Insights into attitude could indicate confidence, motivation and readiness(Kirkpatrick level1) but offered little measurable indication of learning, hence unable to confirm knowledge acquisition was achieved (Miller’s base). Level 2 ( 41 – 46 ) studies demonstrated more objective improvements across the cognitive domain, particularly with moderate-fidelity simulation and blended training models. Objective learning outcomes were assessed via post-intervention knowledge tests, diagnostic skill assessments, NOTTS, S-QAT and OSATS. They offered a means to demonstrate statistically significant improvements in post-intervention test scores. This level of evaluation provided stronger evidence for the acquisition of knowledge. Significant gains were seen with support of coaching( 45 ), 3D visual aids and mental imagery to enhance performance, confidence, and reduced errors( 44 ). The strength was rated moderate, when using objective tools, to assess technical and cognitive acquisition. Limitations of its effectiveness in teaching included lack of long-term follow-up and over-reliance on surrogate endpoints like confidence or task completion and lack of skills assessment in the clinical field limited mixed simulation fidelity constrained broader application. Level 2 tools evaluated knowledge gains and skill acquisition and mapped with Miller’s \"Knows” when testing knowledge( 41 – 44 ) and the “Knows How\" stage, when testing knowledge through clinical problem solving( 45 – 46 ). Level 2 teaching methods can be considered more effective due to their reliance on objective testing to assess knowledge retention yet are still flawed due to their lack of direct skill assessment. Level 3 ( 47 – 54 ) appraised skill attainment and predominantly explored behaviour change in the workplace, often self-reported through post-course feedback engagement. These studies linked simulation training to improved workplace preparedness, particularly in procedural confidence and clinical decision-making( 51 ). Objective assessment tools such as post-test scores, simulation metrics and timed laparoscopic tasks were occasionally employed to measure time, accuracy and error rates e.g., laparoscopic exercises( 54 ). However, most relied on self-reported post-course questionnaires to demonstrate improved skill improvement, confidence( 49 , 51 , 52 , 53 ) and teamwork dynamics( 46 ). Simulation courses led to increased confidence and perceived readiness for registrar-level tasks( 49 ). Simulation was identified as a driver of workplace behavioural change when structured feedback and debrief were included( 46 ). The evidence was graded moderate as outcomes were mostly deducted from self-reported growth without observational objective verification. In addition, fidelity of a simulation could affect the transferability of skill. Furthermore, minimal long-term follow-ups undermined the reliability of these paper’s findings. Interventions involving high-fidelity simulation, mental rehearsal, and modular training allowed trainees not only to understand a procedure but to demonstrate it in controlled environments. When learners demonstrate skills in a simulated or structured setting, they “show how” (Miller’s) behaviour could change (Kirkpatrick’s level3). One may interpret the potential for good learning progression to the intermediate levels by demonstrating some behaviour changes indicative of competence and skill development. Level 4 was demonstrated, in isolation, only by one paper( 63 ) and evaluated clinical impact. It highlighted the benefits of a dedicated training programme in laparoscopic colorectal cancer surgery through demonstrating both the clinical benefits through mortality and morbidity reduction; as well clinical performance through assessment tools( 63 ). This extended on previous papers where trainees call for such dedicated programs and structures(36,46,48,51,52,61) and should be incorporated into further curriculum work. Trainees, almost unanimously, called for dedicated teaching time, trainers, and incorporation into the training programs( 11 , 36 , 46 , 48 , 51 , 52 , 61 ). Despite the low quantity of papers, the sole paper( 63 ) was considered a higher grade in strength due to high fidelity and thus skill transferability. Measuring clinical patient outcomes is arguably the most reliable way of testing skill outcomes. Reliability was high due to the three years follow up to monitor trainee’s competency. Level 4 of Kirpatrick model matched with the maximum competence (“Does”) stage of Miller pyramid by demonstrating patient outcomes. It could be assumed to be the most rigorous form of assessment of skill attainment. One can infer the rarity of such papers to be secondary to logistical, ethical and financial challenges in measuring patient outcomes. Overall, level 4 papers were underrepresented, reinforcing the need for more longitudinal, mixed-method studies; with the capability of delineating impact of simulation and formative assessments from training environments to real-world clinical practice. Majority of papers used multiple methods to address multiple levels of learning categories, which allowed insights across multiple levels. For example, level2/3( 45 , 46 ) deducted objective skill acquisition assessment and measured the broader impact of training outcome. The most common form was level3/4, which used large-scale national datasets from ISCP and eLogbook platforms to demonstrate index operative experience and achievement of a third level 4 competence that leads to CCT( 56 – 60 ). Being based on real patient operations one can assume, indirectly, that increased level of independent operating (behaviour) is related to better patient outcome. Their long-term follow-up was associated with increased reliability. Interestingly, many trainees failed to obtain WBAs indicative of independence in their index procedures, suggesting that indicative numbers alone could fail to confirm true competence thereby questioning the validity of CCT by using WBAs( 57 , 58 , 59 ). Furthermore, WBAs were often pre-filled by the trainees and inconsistently validated by their trainers( 38 ). A recurring concern was the perceived ineffectiveness of WBAs/PBAs, with trainees reporting these often being used as ‘tick-box’ assessments( 35 ), countering their educational intent. Mixed levels studies evidence strength depended on the type of outcomes measured. Level 4 outcomes, alone or with level 3, provided rigorous generalisable data and insight into long-term impact on learning due to their large data, duration and reliability. In contrast, these were often associated with subjective or inconsistent validation means thereby lowering their evidence strength. If behavioural change through clinical application in real-world settings was demonstrated, then the \"Does\" level of Miller’s Pyramid was reached. However, post-certification(CCT) performance was poorly tracked therefore, making it difficult to assess competency, at the ultimate phase of integration into practice. Arguably, mixing the forms of assessments may yield valuable data, which is less ethically challenging than pure level 4 studies. Interest persists in creating more higher level competence-based assignments and to revise current WBAs given the current collated negative feedback. This review has several limitations, firstly, the inclusion of heterogeneous study designs, populations (e.g., CTs, STs, SAS), and simulation modalities complicated direct comparison. Secondly, many included studies were observational, underpowered, or single-institution, limiting the external validity of findings. Thirdly, the nature of a scoping review precludes formal quality appraisal or meta-analysis. Fourthly, data focused solely on UK-based data, which, while relevant to the research question, may omit valuable international insights. Finally, reporting bias may exist, as negative or inconclusive studies are less likely to be published. By linking Kirkpatrick’s levels with Miller’s ascending hierarchy of competence, the review supports that true surgical skill acquisition is multidimensional, requiring not just improved learner satisfaction or knowledge gain, but demonstrable procedural capability and transfer into practice. Integrating both models in curriculum and teaching design enables a more comprehensive evaluation of medical education from trainee satisfaction to patient outcome. Pursuing research into level 3 and 4(/“Shows How” and “Does”) is likely to be the most effective means to identify solutions to improving surgical skill acquisition. Conclusion This scoping review maps the current landscape of simulation and formative assessment in UK general surgery training, using the Kirkpatrick model to evaluate effectiveness of educational interventions whilst also describing the progression of knowledge to performance with Miller’s Pyramid of competency. Linking Kirkpatrick’s model with Miller’s pyramid underscores the need for educational strategies that move beyond early-stage gains to demonstrate actual competence in clinical settings. While simulation and formative assessment improve trainee confidence and technical ability (Levels 1–2, “Knows”/“Knows How”), fewer studies assess behavioural change or real-world performance (Levels 3–4, “Shows How”/“Does”). Future research should prioritise prospective, longitudinal designs capable of tracking performance into independent practice and thereby focusing on Levels 3–4, “Shows How”/“Does”, criteria as it demonstrates more ingrained learning for surgical skill acquisition. 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Mental practice enhances surgical technical skills: a randomized controlled study. Ann Surg. 2012;255(6):1181–7. Appendix. 1- List definitions. Supplementary Files Appendixs.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 21 Dec, 2025 Reviewers invited by journal 15 Dec, 2025 Editor invited by journal 14 Dec, 2025 Editor assigned by journal 13 Dec, 2025 First submitted to journal 08 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Model(32)\\u003c/em\\u003e\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"floatimage2.jpeg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8310571/v1/2f3a77558c03dc75a815ab69.jpeg\"},{\"id\":98756802,\"identity\":\"ffbfc3ab-ad0f-4a6a-9238-6931a6cbc033\",\"added_by\":\"auto\",\"created_at\":\"2025-12-22 09:35:24\",\"extension\":\"png\",\"order_by\":3,\"title\":\"Figure 3\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":57325,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003e\\u003cem\\u003ePRISMA diagram of included studies\\u003c/em\\u003e\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"floatimage3.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8310571/v1/00e9b32dfe6420460293e4c5.png\"},{\"id\":98779759,\"identity\":\"c047eabe-e2ab-4ba0-857f-2f572e93ccd5\",\"added_by\":\"auto\",\"created_at\":\"2025-12-22 12:30:42\",\"extension\":\"png\",\"order_by\":4,\"title\":\"Figure 4\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":60721,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003e\\u003cem\\u003eBar chart of study distribution across Kirkpatrick levels\\u003c/em\\u003e\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"floatimage4.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8310571/v1/bbf854f302e91012696fb67e.png\"},{\"id\":98783283,\"identity\":\"9c2723a1-87cb-4e34-a881-4c267120d183\",\"added_by\":\"auto\",\"created_at\":\"2025-12-22 12:41:40\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":1031315,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8310571/v1/580d56c3-e530-4fb9-b4b4-7cd73d82be06.pdf\"},{\"id\":98756788,\"identity\":\"59253fc7-2e8b-4c96-8830-f5107370dc80\",\"added_by\":\"auto\",\"created_at\":\"2025-12-22 09:35:21\",\"extension\":\"docx\",\"order_by\":1,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":34748,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"Appendixs.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8310571/v1/af8e0a867fbedc8bdf0b4501.docx\"}],\"financialInterests\":\"\",\"formattedTitle\":\"\\u003cp\\u003eTeaching methods used by general surgeons in simulation or formative assessment leading to improved surgical skill acquisition in UK surgical trainees: a scoping review\\u003c/p\\u003e\",\"fulltext\":[{\"header\":\"INTRODUCTION\",\"content\":\"\\u003cp\\u003eOver the past two decades, it has become increasingly recognized that the historically rooted \\\"see one, do one, teach one\\\" model is no longer sufficient for preparing modern surgeons(\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e)]. In the United Kingdom (UK), the General Surgery (GS) curriculum underwent significant reforms, including a more holistic approach and more flexibility within training pathways. Despite these efforts, challenges persist. These include limited low fidelity simulation practice, absence of research in surgical education and inconsistent guidance on training(\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e). The burden on trainees is intensified by financial pressures, staff shortages and lack of dedicated teaching times; all of which influence motivation and career decisions(\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e). These systemic issues require a change in the current curriculum to a more structured, uniform format with standardized and researched high-quality teaching methods across the UK. Without such modifications, not only does one risk trainee burnout and disparities in training but also nationwide inconsistencies in surgical competence and patient care.\\u003c/p\\u003e \\u003cp\\u003eIntercollegiate Surgical Curriculum Programme (ISCP)\\u003c/p\\u003e \\u003cp\\u003eThe national UK Surgical training pathway begins with the two-year Foundation Programme (FY1\\u0026ndash;FY2) and is then followed by the Core Surgical Training (CST). The latter also spans two years and exposes trainees to broad surgical exposure to core technical and non-technical skills. The following entry into GS specialty training (ST3-8) is highly competitive and signals the movement towards independent clinical practice. The training path is structured by the ISCP and overseen by the Joint Committee on Surgical Training (JCST).\\u003c/p\\u003e \\u003cp\\u003eCompetence progression must be demonstrated in key index procedures such as appendicectomies, emergency laparotomies and hernia repairs, through Work-based assessments (WBAs) and Procedure-Based Assessments (PBAs). Their purpose is to evaluate operative planning, performance and post-op reflections. To attain the ability for unsupervised practice, a trainee must demonstrate these skills to a level 4 PBA(\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e) in all index procedure and record operations in a log-book to lead to completion of training, also known as \\u0026lsquo;\\u003cem\\u003eCertificate of Completion of Training\\u0026rsquo;\\u003c/em\\u003e (CCT).\\u003c/p\\u003e \\u003cp\\u003eThe current form of WBAs function as formative and summative are suggested to align with Miller\\u0026rsquo;s Pyramid [Figure \\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e], a model to assess clinical competence that moves from the more theoretical based assessments to more real-life clinical performance(\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e). However, research suggests that concerns remain over their effectiveness(\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e), prompting a need for further research.\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003cp\\u003eUK GS training Issues\\u003c/p\\u003e \\u003cp\\u003eFurther training issues include external pressure, especially the COVID-19 pandemic as it exacerbated pressure on an already strained system and therefore resulted in significant loss of operative exposure and diminished opportunities for training progression(\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e). Consequences of this led to disruptions in the \\u0026lsquo;\\u003cem\\u003eAnnual Review of Competency Progressio\\u003c/em\\u003en\\u0026rsquo; outcomes and thus extended training periods(\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e). A UK study found that 81% of surgical trainees reported a decline in mental well-being during the pandemic (\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e). This coincided with a broader dissatisfaction demonstrated in the 2023/24 JCST survey, demonstrating a disparity between GS and other specialities. Only 52%, a 5% further decline from the previous year, of GS trainees felt that theatre-based quality indicators were met; they scored the lowest among all surgical specialties(\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e). In addition, only 45% felt their clinical goals were achieved, with only vascular surgery scoring worse(\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e). Despite the formal requirement of two-hourly weekly protected teaching times, only 70% of trainees reported this as being met. Similarly, only 69% of GS trainees reported the opportunities for mandatory simulation training, in contrast to 92% of Ears, Nots and Throat and 86% of paediatric trainees.\\u003c/p\\u003e \\u003cp\\u003eThe trainee dissatisfaction and inconsistencies across different specialities is demonstrating a variability in teaching quality across different specialities(\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e) and thus runs the risk of discrepancies in patient outcomes subjected to different specialities. These trends demonstrate an urgent demand to re-evaluate the GS educational programme.\\u003c/p\\u003e \\u003cp\\u003eSurgeon as Educators\\u003c/p\\u003e \\u003cp\\u003eMastery of surgical skills does not develop from theory alone but through repetitive, hands-on practice(\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e), hence the pivotal role of a senior in shaping the progression of a trainee through direct supervision. In spite of this expected role, surgeons are not required to obtain a qualification in pedagogy(\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e). NHS England\\u0026rsquo;s 2024 review demonstrated that neither CST nor ST curriculum mandates such formal qualification(\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e), this throws light on the systematic gap in the curriculum(\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e). With the aforementioned curriculum issues, this lack of standardized teaching runs the risk of undermining both patient care(\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e) and the sustainability of surgical training itself(\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eSurgical Education Learning Theories\\u003c/p\\u003e \\u003cp\\u003eUnderstanding of the theoretical frameworks that underpin effective teaching is crucial in improving surgical educational outcomes. Kolb\\u0026rsquo;s Experiential Learning Theory(\\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e21\\u003c/span\\u003e) is particularly suited to surgery, outlining a four-stage cycle: concrete experience, reflective observation, abstract conceptualisation, and active experimentation; demonstrated by a trainee performing a procedure, reflecting on it, identifying improvements, and applying these to future scenarios. Reflection is a central process widely promoted in the medical field and supports the transfer of cognitive to clinical knowledge and thus progression of learning(\\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e). Dewe\\u0026rsquo;s (1933) concept of reflective thinking depicts it as a response to cognitive doubt prompting problem-solving and has been a foundation in defining critical thinking(\\u003cspan citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e). This suggests that critical reflection in surgical training could drive continual self-improvement and adaptation(\\u003cspan citationid=\\\"CR24\\\" class=\\\"CitationRef\\\"\\u003e24\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR25\\\" class=\\\"CitationRef\\\"\\u003e25\\u003c/span\\u003e). Reflection is seemingly incorporated into the progression of Miller\\u0026rsquo;s Pyramid of competency[FIgure\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e] from cognitive knowledge to clinical performance(\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e). Further research into curriculum and teaching methods should be based on such foundational learning theories and pedagogy.\\u003c/p\\u003e \\u003cp\\u003eGap in Literature\\u003c/p\\u003e \\u003cp\\u003eA review of current literature reveals a significant gap in GS curriculum and effective teaching methods. Whilst some research explores surgical assessment strategies(\\u003cspan citationid=\\\"CR26\\\" class=\\\"CitationRef\\\"\\u003e26\\u003c/span\\u003e), there is a lack of teaching methodologies focusing on GS trainees within the UK. This is significant given the notable discrepancies in reported satisfaction of GS trainees compared to other specialities(\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e). In addition, UK training carries its own hurdles that must be researched in isolation to other countries. To date, no scoping or systematic review has comprehensively examined teaching and assessment methods specific to UK GS to ascertain competence and whether the current WBA based strategies are most appropriate. This review seeks to address this disparity.\\u003c/p\\u003e \\u003cp\\u003eAim, Research Question\\u003c/p\\u003e\\n\\u003ch3\\u003eResearch Question\\u003c/h3\\u003e\\n\\u003cp\\u003e \\u003cul\\u003e \\u003cli\\u003e \\u003cp\\u003eWhat teaching methods used by general surgeons in simulation or formative assessment lead to improved surgical skill acquisition in UK surgical trainees?\\u003c/p\\u003e \\u003c/li\\u003e \\u003c/ul\\u003e \\u003c/p\\u003e \\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eObjectives\\u003c/h2\\u003e \\u003cp\\u003e \\u003cul\\u003e \\u003cli\\u003e \\u003cp\\u003eTo identify specific teaching methods employed by general surgeons.\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003eTo contrast effective and ineffective teaching in terms of improved surgical skill acquisition.\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003eTo analyse existing research to inform and optimise future teaching strategies in surgical education.\\u003c/p\\u003e \\u003c/li\\u003e \\u003c/ul\\u003e \\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"METHODOLOGY\",\"content\":\"\\u003cp\\u003eA scoping review was performed due to limited volume of existing research, therefore making a full systematic review unsuitable(\\u003cspan citationid=\\\"CR27\\\" class=\\\"CitationRef\\\"\\u003e27\\u003c/span\\u003e). This approach allows the mapping and organization of a vast topic whilst also identifying current gaps within the current literature(\\u003cspan citationid=\\\"CR28\\\" class=\\\"CitationRef\\\"\\u003e28\\u003c/span\\u003e). The five-stage methodological framework outlined by Arksey and O'Malley(\\u003cspan citationid=\\\"CR27\\\" class=\\\"CitationRef\\\"\\u003e27\\u003c/span\\u003e) was followed, which includes (a)research question identification, (b) identification of relevant studies, (c) study selection, (d) data charting, and (e) collating and reporting the results. The review was conducted in accordance with PRISMA-ScR guidelines for scoping reviews(\\u003cspan citationid=\\\"CR29\\\" class=\\\"CitationRef\\\"\\u003e29\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eEligibility criteria\\u003c/p\\u003e \\u003cp\\u003eStudies required to meet the eligibility criteria to be included. Firstly, GS trainees in the UK were the target population as the research question is addressing this population specifically. International studies were excluded as they vary in curriculum, funding, training duration, available resources, training equipment and possibly teaching qualifications.\\u003c/p\\u003e \\u003cp\\u003eMedical students were also excluded due to discrepancies in their curriculum and learning objectives. The target trainees were defined as postgraduate doctors pursuing a career in GS, including those without an official training post (e.g., trust-grade doctors). Eligible teaching methods encompassed any form of simulation or formative assessment strategy that could lead to surgical skill acquisition.\\u003c/p\\u003e\\n\\u003ch3\\u003eSearch strategy\\u003c/h3\\u003e\\n\\u003cp\\u003eA systematic search was performed on the 18th February 2025 of Pubmed/Medline, EMBASE, ERIC and Web of Science. The following Boolean operators were used to identify the papers via OVID: \\u003cem\\u003eGB OR Great Britain OR UK OR United Kingdom) AND (Teaching OR Teach* OR training OR mentoring OR mentor*) AND(General surg* OR colorectal OR HPB OR hepato-pancreato-biliary OR UGI OR Upper gastrointestinal) AND (Simulation OR formative OR assessment) AND (Surg* skill* OR technical OR competence) AND (Surgical trainee* OR surgical resident* OR Student OR graduate).\\u003c/em\\u003e Web of Science was not accessible via OVID and hence the same search was completely using the same terms. The search was limited to the last ten years and to the English language. Additional relevant papers were identified through tracking references to enhance literature saturation. Grey literature (e.g. abstracts) were considered as these suggested innovative topics with robust outcomes.\\u003c/p\\u003e \\u003cp\\u003eScreening\\u003c/p\\u003e \\u003cp\\u003eThe identified files were exported in RIS file and imported to Zotero reference manager(\\u003cspan citationid=\\\"CR30\\\" class=\\\"CitationRef\\\"\\u003e30\\u003c/span\\u003e). This facilitated the upload to Rayyan(\\u003cspan citationid=\\\"CR31\\\" class=\\\"CitationRef\\\"\\u003e31\\u003c/span\\u003e), a research collaboration platform that supports systematic reviewing of papers. The first author (AA) screened the eligibility of the retrieved papers based on title, abstract and then full paper; this was then followed by a second blinded reviewer (EH), using the same eligibility criteria, to increase reliability,\\u003c/p\\u003e \\u003cp\\u003eCharting\\u003c/p\\u003e \\u003cp\\u003eData from the selected studies was tabulated in Microsoft Excel and categorized under major subheadings: paper ID, study design, aim and outcomes. A simple numerical analysis was conducted, followed by a qualitative narrative synthesis organizing the studies according to the four levels of training evaluation of Kirkpatrick\\u0026rsquo;s framework. This widely used model assesses the effectiveness of educational programs(\\u003cspan citationid=\\\"CR32\\\" class=\\\"CitationRef\\\"\\u003e32\\u003c/span\\u003e) starting with the learners\\u0026rsquo; immediate reaction to learning (level 1); followed by the evaluation of learning by testing the gain of knowledge (level 2). In level 3, it evaluates application of a new skill, and finally, it measures the broader impact of learning e.g. patient outcomes (level 3)(\\u003cspan citationid=\\\"CR32\\\" class=\\\"CitationRef\\\"\\u003e32\\u003c/span\\u003e) (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eSummary of Articles Reviewed categorized by Kirkpatrick level\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"5\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eLevel\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eStudy,Year,Trainee,level\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eStudy design\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eAim\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eOutcome\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e(\\u003cspan citationid=\\\"CR33\\\" class=\\\"CitationRef\\\"\\u003e33\\u003c/span\\u003e) Aawsaj, Y., et al. (2025), N:10, ST 3\\u0026ndash;8\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eSimulation assessment\\u0026thinsp;+\\u0026thinsp;semi-structured interview\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eTrainee perceptions of laparoscopic simulation as a summative tool\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eSimulation built confidence but there was no substitute for live experience. Barriers included NHS pressures, trainer resistance, and dissatisfaction with PBAs.\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e(\\u003cspan citationid=\\\"CR34\\\" class=\\\"CitationRef\\\"\\u003e34\\u003c/span\\u003e) Shalhoub, J., et al. (2017), N:10, CST\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eSemi Structured interviews\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eTrainee views on the value and use of PBAs\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003ePBAs are seen as inconsistent and variable by grades. Concerns over validity, especially self-completion. But useful for tracking progress if supported well.\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e(\\u003cspan citationid=\\\"CR35\\\" class=\\\"CitationRef\\\"\\u003e35\\u003c/span\\u003e) Blackhall, V., et al. (2019), N:43, CST\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eHome simulation\\u0026thinsp;+\\u0026thinsp;online module; focus group feedback\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eIdentify barriers in engagment to home-based simulation\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eEngagement limited by motivation, trainer input, and system pressures. Metric feedback felt impersonal; low-fidelity tools and 'tick-box' culture limited perceived value.\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e(\\u003cspan citationid=\\\"CR36\\\" class=\\\"CitationRef\\\"\\u003e36\\u003c/span\\u003e)Singh, P., et al.(2015), N:51, ST1-3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eRegional Survey using S-QAT / Likert score\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eIdentify variation in training quality across centers.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eSupervision was rated highly, but access to cases, outpatient goals, and teaching varied. Recommendations: protected theatre time and improved training structure.\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e(\\u003cspan citationid=\\\"CR37\\\" class=\\\"CitationRef\\\"\\u003e37\\u003c/span\\u003e) Fleming, C., et al. (2019), N:24, ST?\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eDescriptive Study with live polling.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eExplore opinions on GS fellowships.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eTrainees supported fellowships as OOPT, preferred international options, and favoured post-CCT structure within a standardised curriculum.\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e(\\u003cspan citationid=\\\"CR38\\\" class=\\\"CitationRef\\\"\\u003e38\\u003c/span\\u003e)Gaunt, A., et al. (2018), N:42, ST1-8\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eQualitative multicentre focus groups\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eExplore trainees' feedback-seeking behavior.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eWBAs driven by self-motives; formative assessment aided self-improvement, WBAS could limit honest reflection. Authors called for feedback reform to support openness.\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e(\\u003cspan citationid=\\\"CR39\\\" class=\\\"CitationRef\\\"\\u003e39\\u003c/span\\u003e) Room, H.J., et al. (2020), N:39, CST\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eSimulation camp\\u0026thinsp;+\\u0026thinsp;satisfaction questionnaire\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eTeach core surgical trainees basic entry level skills.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eTrainees valued the camp\\u0026rsquo;s timing, relevance, and consultant-led feedback. Enhanced confidence and mentorship was value.\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e(\\u003cspan citationid=\\\"CR40\\\" class=\\\"CitationRef\\\"\\u003e40\\u003c/span\\u003e)Skervin, A.L., and Scott, H.J., et al. (2021), N:74, CST\\u0026thinsp;+\\u0026thinsp;ST3-8\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eSelf-report questionnaire on use of MR.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eAssess MR use amongst trainees and consultants.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eMR used by 91.5%, especially for complex cases. Reported benefits included improved focus, clarity, planning, and anticipation.\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e1\\u0026thinsp;+\\u0026thinsp;2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e(\\u003cspan citationid=\\\"CR41\\\" class=\\\"CitationRef\\\"\\u003e41\\u003c/span\\u003e) Shariff, U., et al, (2015), N:59, ST1-8\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eRCT, post-intervention knowledge test and evaluation\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eAssess multimedia tool vs. traditional teaching for colorectal surgery\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eBoth groups improved knowledge equally; trainees appreciated the tool for enhancing decision-making and anatomical understanding.\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e(\\u003cspan citationid=\\\"CR42\\\" class=\\\"CitationRef\\\"\\u003e42\\u003c/span\\u003e)Kailavasan, M., et al. (2020), N:93, ST\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eSimulation bootcamp with abdominal wall model; post-simulation Likert questionnaires\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eAssess face validity of a low-fidelity simulator for laparoscopic port insertion\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eTrainees and faculty rated the model highly; it was deemed effective for port training in both urology and GS with no validity concerns.\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e(\\u003cspan citationid=\\\"CR43\\\" class=\\\"CitationRef\\\"\\u003e43\\u003c/span\\u003e)Hand, F., et al. (2017), N:17, ST1-3\\u0026zwnj;\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eRetrospective analysis; similarity between admission and discharge diagnoses\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eAssess if structured handover reflects diagnostic skill\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eDiagnostic accuracy improved using the handover tool; scores were based on concordance of key findings, plan and diagnosis.\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e(\\u003cspan citationid=\\\"CR44\\\" class=\\\"CitationRef\\\"\\u003e44\\u003c/span\\u003e)Yiasemidou, M., et al. (2017), N:20, CST\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eCase controlled study on MR; metrics of simulator: time, motion, safety\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eAssess impact of 3D visual aids in MR on surgical performance\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e3D MR improved efficiency (time, movement, path length) vs. controls; no safety differences; authors recommended combining mental imagery with anatomical models\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e2\\u0026thinsp;+\\u0026thinsp;3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e(\\u003cspan citationid=\\\"CR45\\\" class=\\\"CitationRef\\\"\\u003e45\\u003c/span\\u003e)Yule, S., et al. (2015), N:16, ST4-6\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eRCT on simulation; NOTSS scoring for laparoscopic cholecystectomy\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eAssess the effect of coaching on non-technical skills in a simulated theatre\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eCoaching improved NOTSS scores and crisis responses; no change in time\\u0026thinsp;+\\u0026thinsp;path length.\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e2\\u0026thinsp;+\\u0026thinsp;3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e(\\u003cspan citationid=\\\"CR46\\\" class=\\\"CitationRef\\\"\\u003e46\\u003c/span\\u003e)Ramjeeawon, A., et al. (2020), N:16, ST1-3 \\u0026amp; MD students\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eSimulation with structured debrief; NOTSS, OTAS, STAI\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eAssess impact of immersive simulation and debrief on teamwork, stress and technical skills.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eTeamwork, technical performance, radiation safety, and psychological state improved post-debrief across all training levels.\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e(\\u003cspan citationid=\\\"CR47\\\" class=\\\"CitationRef\\\"\\u003e47\\u003c/span\\u003e) JCST,. (2023), N:?, ST1-8\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eReport on improving surgical training (IST) pilot trainee feedback\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eSummary of UK IST trainee Feedback\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eEnglish trainees reported fewer ST3 opportunities; concerns less common in Scotland/Wales. Most IST posts are being phased out in GS.\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e(\\u003cspan citationid=\\\"CR48\\\" class=\\\"CitationRef\\\"\\u003e48\\u003c/span\\u003e)Allum, W., et al. (2020), N20, ST1-8\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eReport on IST pilot trainee feedback\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eIdentify areas for improvement in IST programme\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eRecommended dedicated rota time for training, more elective/sim access in curriculums. Limited Trainer time due to service pressure. Suggested ACP/SCP role expansion, requiring training and HEE support.\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e(\\u003cspan citationid=\\\"CR49\\\" class=\\\"CitationRef\\\"\\u003e49\\u003c/span\\u003e)Clarke, R., et al. (2024), N:26, ST3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eProspective analysis; simulation, lectures, labs; self-assessment using Likert feedback\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eDevelop GS bootcamp to support ST3 transition\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eTrainees reported significant skill improvement in endoscopy, laparoscopy, open surgery, and non-technical areas. Confidence rises post-course, especially in laparoscopic suturing (77%), ulcer repair (69%), and stress management.\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e(\\u003cspan citationid=\\\"CR50\\\" class=\\\"CitationRef\\\"\\u003e50\\u003c/span\\u003e)Clarke, R., et al. (2024), N:25, ST3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e-Simulation with pig tissue model\\u003c/p\\u003e \\u003cp\\u003e-Feedback questionnaire\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eAssess face-validity of a low-cost model for teaching acute proctology during the ST3 general surgical bootcamp.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eConfidence rose across key proctology tasks; 80% rated the model highly for realism and training value.\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e(\\u003cspan citationid=\\\"CR51\\\" class=\\\"CitationRef\\\"\\u003e51\\u003c/span\\u003e)Metcalfe, K., et al. (2021), N16, CST\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eOffice admin simulation; post-course questionnaire\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eEvaluate admin simulation for developing non-technical consultant skills\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eTrainees rated the pilot programme as useful and felt it prepared them for consultant roles. All supported adding it to regional teaching, finding it relevant and well received.\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e(\\u003cspan citationid=\\\"CR52\\\" class=\\\"CitationRef\\\"\\u003e52\\u003c/span\\u003e)Boyle, M., et al. (2021), N?, FY/TG\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eOne-day workshop; pre/post-course questionnaires\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eAssess clinical decision-making and technical readiness for acute surgical care\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eAll trainees found it useful and relevant; authors encourage inclusion in regional training.\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e(\\u003cspan citationid=\\\"CR53\\\" class=\\\"CitationRef\\\"\\u003e53\\u003c/span\\u003e)Hosny, S.G., et al. (2017), N:37, ST3-8\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eMultinational qualitative study; semi-structured interviews\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eIdentify barriers/facilitators to uptake of simulation programmes.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eSimulation valued for safety and assessment, but hindered by time, cost, motivation; trainees less confident in its high-stakes validity.\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e(\\u003cspan citationid=\\\"CR54\\\" class=\\\"CitationRef\\\"\\u003e54\\u003c/span\\u003e)Rajaratnam, V., et al. (2021) NA\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eReview of modular laparoscopic training; motor learning theories\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003ePropose evidence-based model for surgical skill acquisition.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eAdvocates low-cost, self-directed model using mental imagery, deliberate practice, and instructional design to build skill with limited simulation.\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e3\\u0026thinsp;+\\u0026thinsp;4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e(\\u003cspan citationid=\\\"CR55\\\" class=\\\"CitationRef\\\"\\u003e55\\u003c/span\\u003e)Shalhoub, J., et al. (2015), N:?, ST1-8\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eDescriptive analysis; ISCP usage data\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eExamine WBA use by region, specialty, and training level\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eWBA use increased sevenfold (2007\\u0026ndash;2013); CSTs completed more than STs. PBAs were preferred by STs, with regional variation in volume and type.\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e3\\u0026thinsp;+\\u0026thinsp;4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e(\\u003cspan citationid=\\\"CR56\\\" class=\\\"CitationRef\\\"\\u003e56\\u003c/span\\u003e) Brown, C., et al. (2017), N:84, ST3-8\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eService evaluation; PBA trajectory vs. case volume\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eEvaluation of performance trajectory of index procedures in relation to operative experience, indicative numbers, and training time\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eLearning curves and PBA timing varied. Few PBAs completed post CCT. Level 4, limiting assessment beyond minimum competence.\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e3\\u0026thinsp;+\\u0026thinsp;4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e(\\u003cspan citationid=\\\"CR57\\\" class=\\\"CitationRef\\\"\\u003e57\\u003c/span\\u003e)Abdelrahman, T., et al. (2016), N69, ST3-8\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eService evaluation on PBA learning curve gradients of index procedures\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eExamine relationship between index numbers and PBA attainment in key procedures\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eLaparotomy targets deemed sufficient; complex cases like Hartmann\\u0026rsquo;s required\\u0026thinsp;\\u0026gt;\\u0026thinsp;3\\u0026times; target to reach competence. Authors suggest revising JCST indicative numbers.\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e3\\u0026thinsp;+\\u0026thinsp;4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e(\\u003cspan citationid=\\\"CR58\\\" class=\\\"CitationRef\\\"\\u003e58\\u003c/span\\u003e)De Siqueira, J. R., and Gough, M.J., et al. (2016), N:121, ST3-8\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eDescriptive analysis; ISCP and eLogbook review\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eCorrelate operative volume with trainer-assessed competence\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003ePBA scores aligned with case volume, but many trainees failed to reach Level 4 despite index numbers. Highlights inconsistency in progression and questions validity of certification.\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e3\\u0026thinsp;+\\u0026thinsp;4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e(\\u003cspan citationid=\\\"CR59\\\" class=\\\"CitationRef\\\"\\u003e59\\u003c/span\\u003e)Abdelrahman, T., et al. (2015), N:89, ST??\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eDescriptive analysis; ISCP data review\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eAssess whether GS trainees meet CCT operative and academic targets\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eMost achieved procedural and academic targets. Authors advise early support and simulation use for underperforming trainees.\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e3\\u0026thinsp;+\\u0026thinsp;4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e(\\u003cspan citationid=\\\"CR60\\\" class=\\\"CitationRef\\\"\\u003e60\\u003c/span\\u003e)Elsey, E.J., et al, (2019), N:311, FY1-2\\u0026amp;CST\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eCohort study; ISCP and e-logbook review\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eAssess operative experience and competency progression using national data\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eTrainees progressed to unsupervised basic procedures through training; complex cases required longer. Training data reflects evolving competence and decision-making.\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e3\\u0026thinsp;+\\u0026thinsp;4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e(\\u003cspan citationid=\\\"CR61\\\" class=\\\"CitationRef\\\"\\u003e61\\u003c/span\\u003e) Abdel-dayem, M., et al. (2021), N:35, CST\\u0026amp;SHO\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eStructured modular training; progression metrics and trainee questionnaire\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eDevelop a reproducible laparoscopic Colorectal Surgery (LCS) training model supporting independent practice\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e98% satisfaction; most achieved independent LCS. Low conversion rates and good outcomes reported. Keen to maintain the programme. Staffing shortages noted as a barrier.\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e1\\u0026ndash;4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e(\\u003cspan citationid=\\\"CR62\\\" class=\\\"CitationRef\\\"\\u003e62\\u003c/span\\u003e)James, H. K., et al. (2019), N: 2002\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eSystematic review; assessed cadaveric simulation across Kirkpatrick levels\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eEvaluate evidence for cadaveric simulation in postgraduate training\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eImproved confidence, test scores, and procedural skills. Behavioural transfer inconsistent; limited long-term evidence for patient-level impact.\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e(\\u003cspan citationid=\\\"CR63\\\" class=\\\"CitationRef\\\"\\u003e63\\u003c/span\\u003e) Hanna, G.B., et al, (2022), N:108\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eCase-control study; comparing clinical outcomes of colorectal cases performed by lapco-vs non-lapco surgeons.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eExamine impact of national training programme LAPCO clinical outcome performed by Lacpco surgeons after training completion\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eIncreased rates of laparoscopic colorectal cancer surgery, reduced mortality and morbidity. In-training competency assessment tools predicted clinical performance after training.\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cb\\u003eA list definition can be found in [Appendix 1].\\u003c/b\\u003e \\u003c/p\\u003e\"},{\"header\":\"RESULTS\",\"content\":\"\\u003cp\\u003eThe initial search generated 201 papers and an additional 3 were identified through alternative sources, after removing 48 duplicates in ovid and 5 in Rayyan, 151 papers remained. After screening the titles and abstracts against the eligibility criteria, 78 and 5 papers were excluded respectively to leave 67 records for full text analysis(Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig3\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e). A further 36 records were removed during the full-text article review, due to incorrect geography (n\\u0026thinsp;=\\u0026thinsp;29), incorrect population (n\\u0026thinsp;=\\u0026thinsp;2) e.g. med students, and wrong intervention (n\\u0026thinsp;=\\u0026thinsp;5) e.g. endoscopy. Despite endoscopy being performed by many GS surgeons, the training follows a different curriculum and was therefore excluded. Some studies often included other geography/population in their study, they were only included if the majority of studies were relevant. One urology paper was not excluded, as the procedure tested was equally performed by GS trainees. A vascular paper was not excluded as GS and vascular training paths only separated in 2022(\\u003cspan citationid=\\\"CR64\\\" class=\\\"CitationRef\\\"\\u003e64\\u003c/span\\u003e). One scoping review was removed, yet the decision was made to keep one systematic review as it matched this paper\\u0026rsquo;s methodology perfectly, capturing all Kirpatrick\\u0026rsquo;s levels. This left 31 final studies for the scoping review.\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003cp\\u003eStudy design and setting\\u003c/p\\u003e \\u003cp\\u003eThe included studies fell into five broad methodological categories: self-report measures, objective or performance-based assessments, descriptive analyses, and multi-methods. Thirteen used self-reported data, three through interviews, seven via questionnaires, two with focus groups and one via polling. Seven studies employed objective assessments: five assessed technical performance, while others used tools such as S-QAT (a self-assessment tool appraising training quality), OSATS (evaluating surgical technical skills), STAI (measuring state and trait anxiety), debrief scores, and NOTSS (assessing non-technical surgical skills). Eight were descriptive in design, including six studies analysing ISCP and/or eLogbook data and two based on training reports. One paper was a systematic review.\\u003c/p\\u003e \\u003cp\\u003eDistribution by Kirkpatrick level\\u003c/p\\u003e \\u003cp\\u003eThe papers were then categorised according to Kirkpatrick's Four Levels of Training Evaluation (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e); many papers assessment incorporated multiple levels. They were distributed most commonly in level 1 with eight papers, then eight in level 3 and seven were under a combination of levels 3 and 4. Three papers were categorized as level 2. Two fell into level2/3 and then one paper in each of the following categories: level1/2, level 1/2/3/4, level 4(Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig4\\\" class=\\\"InternalRef\\\"\\u003e4\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003cp\\u003eLevel 1[Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e]\\u003c/p\\u003e \\u003cp\\u003eEight studies [Figure \\u003cspan refid=\\\"Fig4\\\" class=\\\"InternalRef\\\"\\u003e4\\u003c/span\\u003e] assessed trainee reactions to simulation or formative assessment interventions, focusing on perceptions, confidence, and engagement rather than measurable outcomes. Data were largely qualitative, drawn from interviews and questionnaires. Trainees often reported increased motivation and confidence, particularly following simulation-based teaching such as bootcamps and skills camps. There was strong support for structured, modular, and mental rehearsal-based approaches (\\u003cspan citationid=\\\"CR40\\\" class=\\\"CitationRef\\\"\\u003e40\\u003c/span\\u003e), though barriers to engagement included service demands, trainer resistance, and a tick-box WBA culture (e.g.33\\u0026ndash;35).\\u003c/p\\u003e \\u003cp\\u003eLevel 2[Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e]\\u0026ndash; Learning\\u003c/p\\u003e \\u003cp\\u003eThree studies [Figure \\u003cspan refid=\\\"Fig4\\\" class=\\\"InternalRef\\\"\\u003e4\\u003c/span\\u003e] measured evaluation of learning through knowledge e.g., impact of 3D diagnostic skills(\\u003cspan citationid=\\\"CR43\\\" class=\\\"CitationRef\\\"\\u003e43\\u003c/span\\u003e) and visual aids(\\u003cspan citationid=\\\"CR44\\\" class=\\\"CitationRef\\\"\\u003e44\\u003c/span\\u003e). Outcomes were demonstrated with objective metrics like post-test scores, NOTTS, S-QAT and OSATS. Improvements were seen especially if combined with mental rehearsal (\\u003cspan citationid=\\\"CR44\\\" class=\\\"CitationRef\\\"\\u003e44\\u003c/span\\u003e) structured debrief (\\u003cspan citationid=\\\"CR46\\\" class=\\\"CitationRef\\\"\\u003e46\\u003c/span\\u003e). Multimedia, 3D visual aids, and mental imagery enhanced performance, confidence, and reduced errors(\\u003cspan citationid=\\\"CR44\\\" class=\\\"CitationRef\\\"\\u003e44\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eLevel 3[Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e]\\u0026ndash; Behaviour\\u003c/p\\u003e \\u003cp\\u003eEight studies assessed evaluation of skills [Figure \\u003cspan refid=\\\"Fig4\\\" class=\\\"InternalRef\\\"\\u003e4\\u003c/span\\u003e]. Evidence was largely anecdotal or inferred, based on questionnaires or post-training interviews. A consensus was pro-simulation training. Reported changes included improved operative confidence and patient safety in simulations (\\u003cspan citationid=\\\"CR45\\\" class=\\\"CitationRef\\\"\\u003e45\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR46\\\" class=\\\"CitationRef\\\"\\u003e46\\u003c/span\\u003e, \\u003cspan additionalcitationids=\\\"CR50 CR51 CR52 CR53\\\" citationid=\\\"CR49\\\" class=\\\"CitationRef\\\"\\u003e49\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR54\\\" class=\\\"CitationRef\\\"\\u003e54\\u003c/span\\u003e). Improvements in independence were enhanced further by increased fidelity of model (\\u003cspan citationid=\\\"CR50\\\" class=\\\"CitationRef\\\"\\u003e50\\u003c/span\\u003e), dedicated training program.s (\\u003cspan citationid=\\\"CR51\\\" class=\\\"CitationRef\\\"\\u003e51\\u003c/span\\u003e) and deliberate practice (\\u003cspan citationid=\\\"CR54\\\" class=\\\"CitationRef\\\"\\u003e54\\u003c/span\\u003e). However, cost and limited trainer and training time were common barriers (\\u003cspan citationid=\\\"CR47\\\" class=\\\"CitationRef\\\"\\u003e47\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR48\\\" class=\\\"CitationRef\\\"\\u003e48\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR53\\\" class=\\\"CitationRef\\\"\\u003e53\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eMixed levels[Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e]\\u003c/p\\u003e \\u003cp\\u003eEleven papers used multi-methods to assess learning on multiple evaluation levels simultaneously allowing in-depth multimodal assessment of learning. Level3/4, being the most common combination, offered the opportunity to evaluate new skills in the clinical field, often via formative assessment PBAs. Competence progression across training years was shown with a gradual decrease in supervision, especially for less complex procedures (\\u003cspan additionalcitationids=\\\"CR56 CR57 CR58 CR59\\\" citationid=\\\"CR55\\\" class=\\\"CitationRef\\\"\\u003e55\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR60\\\" class=\\\"CitationRef\\\"\\u003e60\\u003c/span\\u003e). Learner\\u0026rsquo;s increased level of autonomy could infer positive clinical outcome, but not guarantee it, hence the level3/4 grade as opposed to level4. Level2/3 tested NOTSS skills and tested these via objective post sim methods, coaching improved real-time decision-making and teamwork (\\u003cspan citationid=\\\"CR45\\\" class=\\\"CitationRef\\\"\\u003e45\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR46\\\" class=\\\"CitationRef\\\"\\u003e46\\u003c/span\\u003e). A training module was able to evaluate independent skill progression through questionnaires and test clinical outcome metrics objectively(\\u003cspan citationid=\\\"CR61\\\" class=\\\"CitationRef\\\"\\u003e61\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eOne cadaveric review also reviewed the Kirkpatrick levels and therefore (\\u003cspan citationid=\\\"CR62\\\" class=\\\"CitationRef\\\"\\u003e62\\u003c/span\\u003e) provided: strong trainee approval, knowledge gains, procedural improvement and modest real-world outcome effects, to address all four levels of the training experience(Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eLevel 4[Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e] \\u0026ndash; Results\\u003c/p\\u003e \\u003cp\\u003eOnly one study [Figure \\u003cspan refid=\\\"Fig4\\\" class=\\\"InternalRef\\\"\\u003e4\\u003c/span\\u003e] evaluated solely the clinical impact (\\u003cspan citationid=\\\"CR63\\\" class=\\\"CitationRef\\\"\\u003e63\\u003c/span\\u003e), this study examined the impact of a national training programme and noted improved in-training competency and improved real-time patient outcomes. The remaining studies were tested in conjunction with level 4.\\u003c/p\\u003e \\u003cp\\u003eStrength of Evidence of each Kirkpatrick Level\\u003c/p\\u003e \\u003cp\\u003eIn this scoping review, the strength of evidence for each Kirkpatrick Level was assessed using a combination of methodological accuracy, data type, and the depth of outcome measurement reported in included studies and which type of levels and teaching opportunities would be best to improve surgical skill acquisition[Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e]. Eight papers were rated low and were in Level 1 as it relied on subjective trainee perceptions(\\u003cspan additionalcitationids=\\\"CR34 CR35 CR36 CR37 CR38 CR39\\\" citationid=\\\"CR33\\\" class=\\\"CitationRef\\\"\\u003e33\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR40\\\" class=\\\"CitationRef\\\"\\u003e40\\u003c/span\\u003e). Level 2 papers involvin were categorized as moderate, if studies included objective, quantifiable outcomes (\\u003cspan additionalcitationids=\\\"CR42 CR43 CR44 CR45\\\" citationid=\\\"CR41\\\" class=\\\"CitationRef\\\"\\u003e41\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR46\\\" class=\\\"CitationRef\\\"\\u003e46\\u003c/span\\u003e). Papers in level 3 with self-rated outcomes through questionnaires were graded moderate due to their clinical relevance (\\u003cspan additionalcitationids=\\\"CR50 CR51 CR52\\\" citationid=\\\"CR49\\\" class=\\\"CitationRef\\\"\\u003e49\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR53\\\" class=\\\"CitationRef\\\"\\u003e53\\u003c/span\\u003e). However, papers scored high when clinical outcomes were measured directly which only one paper qualified for (\\u003cspan citationid=\\\"CR62\\\" class=\\\"CitationRef\\\"\\u003e62\\u003c/span\\u003e) and was categorized as level 4.\\u003c/p\\u003e \\u003cp\\u003eStudies spanning multiple levels were assessed contextually, with the highest level of rigorously collected and validated outcome data informing their overall strength. Papers in level 3/4 were rated moderate-high and contained eight papers that relied on large-scale datasets such as national trainee progression records. PBAs ratings of independence could indirectly support good clinical outcome (\\u003cspan additionalcitationids=\\\"CR56 CR57 CR58 CR59\\\" citationid=\\\"CR55\\\" class=\\\"CitationRef\\\"\\u003e55\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR60\\\" class=\\\"CitationRef\\\"\\u003e60\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eThis evaluative strategy aligns with well-known best-practice frameworks for educational evidence synthesis and therefore could relate to effective skill acquisition and potential for further research.\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab2\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 2\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eKirkpatrick framework summary for surgical training evaluation\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"6\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c6\\\" colnum=\\\"6\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eKirkpatrick Level\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eFocus\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eOutcome Type\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eData Sources\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eStrength of Evidence\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eLimitations\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eLevel 1: Reaction\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eTrainee satisfaction, perception of value\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eSubjective (opinions, confidence)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eSurveys,\\u003c/p\\u003e \\u003cp\\u003efocus groups,\\u003c/p\\u003e \\u003cp\\u003einterviews,\\u003c/p\\u003e \\u003cp\\u003eLikert scales\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eLow\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e● No direct measure of learning or competence\\u003c/p\\u003e \\u003cp\\u003e● Highly variable- Susceptible to social desirability bias\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eLevel 2: Learning\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eCognitive or psychomotor gains\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eObjective (task scores, post-tests, NOTSS)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eSimulators,\\u003c/p\\u003e \\u003cp\\u003etechnical task analysis,\\u003c/p\\u003e \\u003cp\\u003epre/post MCQs,\\u003c/p\\u003e \\u003cp\\u003evideo scoring\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eModerate\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e● May not translate to behavior\\u003c/p\\u003e \\u003cp\\u003e● Studies often lack long-term follow-up\\u003c/p\\u003e \\u003cp\\u003e● Mixed fidelity of simulation methods\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eLevel 3: Behavior\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eTransfer to real-world practice\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eObservational/self-report, performance logs\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eSimulation follow-up,\\u003c/p\\u003e \\u003cp\\u003epost-course self-assessments\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eModerate to high\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e● Self-reporting bias\\u003c/p\\u003e \\u003cp\\u003e● Hard to isolate effect of training alone\\u003c/p\\u003e \\u003cp\\u003e● Confidence\\u0026thinsp;\\u0026ne;\\u0026thinsp;competence\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eLevel 4: Results\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eInstitutional/patient outcomes, system change\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eClinical outcomes, operative independence, progression data\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eE-logbook data,\\u003c/p\\u003e \\u003cp\\u003enational audits,\\u003c/p\\u003e \\u003cp\\u003ePBA records,\\u003c/p\\u003e \\u003cp\\u003ecompletion rates\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eHigh\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e● Resource intensive\\u003c/p\\u003e \\u003cp\\u003e● Rarely performed\\u003c/p\\u003e \\u003cp\\u003e● Hard to attribute causality\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMixed Levels\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eMulti-domain outcomes\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eSubjective\\u0026thinsp;+\\u0026thinsp;objective\\u0026thinsp;+\\u0026thinsp;behavioral\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eLiterature reviews,\\u003c/p\\u003e \\u003cp\\u003emulti-level studies (e.g., cadaveric sims).\\u003c/p\\u003e \\u003cp\\u003eISCP portfolios.\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eVaries by level\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e● Methodological inconsistency- Attribution across levels can be imprecise\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eThis scoping review aimed to identify which teaching methods used by GS in simulation and formative assessment contribute most effectively to surgical skill acquisition in UK trainees and which gaps remain in the current limited research surrounding this topic. The Kirkpatrick model(\\u003cspan citationid=\\\"CR32\\\" class=\\\"CitationRef\\\"\\u003e32\\u003c/span\\u003e) and Miller\\u0026rsquo;s Pyramid(\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e) provided a valuable conceptual scaffold to interpret the nature and depth of learning outcomes revealed in this scoping review, while the Kirkpatrick Model enabled categorisation of educational interventions based on their evaluative impact, Miller\\u0026rsquo;s framework clarifies the type of competence being developed at each stage. By using Kirkpatrick\\u0026rsquo;s model to interpret the outcomes, an uneven distribution of evidence strength and a dominance of lower-level evaluation was identified. By using Miller\\u0026rsquo;s pyramid it was still possible to highlight the progression from \\\"knows\\\" and \\\"knows how\\\", through cognitive gains and improved procedural understanding and \\\"shows how\\\" via simulation or structured assessment(\\u003cspan additionalcitationids=\\\"CR66\\\" citationid=\\\"CR65\\\" class=\\\"CitationRef\\\"\\u003e65\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR67\\\" class=\\\"CitationRef\\\"\\u003e67\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003e \\u003cspan type=\\\"BoldUnderline\\\" class=\\\"BoldUnderline\\\" name=\\\"Emphasis\\\"\\u003eLevel 1\\u003c/span\\u003e(\\u003cspan additionalcitationids=\\\"CR34 CR35 CR36 CR37 CR38 CR39\\\" citationid=\\\"CR33\\\" class=\\\"CitationRef\\\"\\u003e33\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR40\\\" class=\\\"CitationRef\\\"\\u003e40\\u003c/span\\u003e) outcomes were the most frequently reported, capturing trainee perceptions, satisfaction, and confidence e.g., via Likert scales or interviews. Trainees often reported increased motivation and confidence, particularly following simulation-based teaching such as bootcamps and skills camps. While many trainees valued simulation such as teaching camps for building confidence, some questioned its realism and educational value(\\u003cspan citationid=\\\"CR39\\\" class=\\\"CitationRef\\\"\\u003e39\\u003c/span\\u003e). There was strong support for structured, modular, and MR approaches (\\u003cspan citationid=\\\"CR40\\\" class=\\\"CitationRef\\\"\\u003e40\\u003c/span\\u003e), though barriers to engagement included service demands, trainer resistance, and a tick-box WBA culture (\\u003cspan citationid=\\\"CR35\\\" class=\\\"CitationRef\\\"\\u003e35\\u003c/span\\u003e). MR was regarded as valuable across all levels(\\u003cspan citationid=\\\"CR40\\\" class=\\\"CitationRef\\\"\\u003e40\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eLevel 1 outcomes, although high in quantity, most were single-centre, underpowered and were reliant on subjective tools to determine outcome. As a result of the subjective nature of their outcome they were classified as a weaker form of evidence. Their generalisability was limited and they failed to assess actual knowledge attainment or long-term clinical relevance\\u003c/p\\u003e \\u003cp\\u003eThe deliberate proactive engagement suggested in Kolb\\u0026rsquo;s cycle of reflection leads to the transfer of cognitive knowledge to clinical knowledge(\\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e), one could argue that this was executed through self-reporting outcomes. Insights into attitude could indicate confidence, motivation and readiness(Kirkpatrick level1) but offered little measurable indication of learning, hence unable to confirm knowledge acquisition was achieved (Miller\\u0026rsquo;s base).\\u003c/p\\u003e \\u003cp\\u003e \\u003cspan type=\\\"BoldUnderline\\\" class=\\\"BoldUnderline\\\" name=\\\"Emphasis\\\"\\u003eLevel 2\\u003c/span\\u003e(\\u003cspan additionalcitationids=\\\"CR42 CR43 CR44 CR45\\\" citationid=\\\"CR41\\\" class=\\\"CitationRef\\\"\\u003e41\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR46\\\" class=\\\"CitationRef\\\"\\u003e46\\u003c/span\\u003e) studies demonstrated more objective improvements across the cognitive domain, particularly with moderate-fidelity simulation and blended training models. Objective learning outcomes were assessed via post-intervention knowledge tests, diagnostic skill assessments, NOTTS, S-QAT and OSATS. They offered a means to demonstrate statistically significant improvements in post-intervention test scores. This level of evaluation provided stronger evidence for the acquisition of knowledge. Significant gains were seen with support of coaching(\\u003cspan citationid=\\\"CR45\\\" class=\\\"CitationRef\\\"\\u003e45\\u003c/span\\u003e), 3D visual aids and mental imagery to enhance performance, confidence, and reduced errors(\\u003cspan citationid=\\\"CR44\\\" class=\\\"CitationRef\\\"\\u003e44\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eThe strength was rated moderate, when using objective tools, to assess technical and cognitive acquisition. Limitations of its effectiveness in teaching included lack of long-term follow-up and over-reliance on surrogate endpoints like confidence or task completion and lack of skills assessment in the clinical field limited mixed simulation fidelity constrained broader application.\\u003c/p\\u003e \\u003cp\\u003eLevel 2 tools evaluated knowledge gains and skill acquisition and mapped with Miller\\u0026rsquo;s \\\"Knows\\u0026rdquo; when testing knowledge(\\u003cspan additionalcitationids=\\\"CR42 CR43\\\" citationid=\\\"CR41\\\" class=\\\"CitationRef\\\"\\u003e41\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR44\\\" class=\\\"CitationRef\\\"\\u003e44\\u003c/span\\u003e) and the \\u0026ldquo;Knows How\\\" stage, when testing knowledge through clinical problem solving(\\u003cspan citationid=\\\"CR45\\\" class=\\\"CitationRef\\\"\\u003e45\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR46\\\" class=\\\"CitationRef\\\"\\u003e46\\u003c/span\\u003e). Level 2 teaching methods can be considered more effective due to their reliance on objective testing to assess knowledge retention yet are still flawed due to their lack of direct skill assessment.\\u003c/p\\u003e \\u003cp\\u003e \\u003cspan type=\\\"BoldUnderline\\\" class=\\\"BoldUnderline\\\" name=\\\"Emphasis\\\"\\u003eLevel 3\\u003c/span\\u003e(\\u003cspan additionalcitationids=\\\"CR48 CR49 CR50 CR51 CR52 CR53\\\" citationid=\\\"CR47\\\" class=\\\"CitationRef\\\"\\u003e47\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR54\\\" class=\\\"CitationRef\\\"\\u003e54\\u003c/span\\u003e) appraised skill attainment and predominantly explored behaviour change in the workplace, often self-reported through post-course feedback engagement. These studies linked simulation training to improved workplace preparedness, particularly in procedural confidence and clinical decision-making(\\u003cspan citationid=\\\"CR51\\\" class=\\\"CitationRef\\\"\\u003e51\\u003c/span\\u003e). Objective assessment tools such as post-test scores, simulation metrics and timed laparoscopic tasks were occasionally employed to measure time, accuracy and error rates e.g., laparoscopic exercises(\\u003cspan citationid=\\\"CR54\\\" class=\\\"CitationRef\\\"\\u003e54\\u003c/span\\u003e). However, most relied on self-reported post-course questionnaires to demonstrate improved skill improvement, confidence(\\u003cspan citationid=\\\"CR49\\\" class=\\\"CitationRef\\\"\\u003e49\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR51\\\" class=\\\"CitationRef\\\"\\u003e51\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR52\\\" class=\\\"CitationRef\\\"\\u003e52\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR53\\\" class=\\\"CitationRef\\\"\\u003e53\\u003c/span\\u003e) and teamwork dynamics(\\u003cspan citationid=\\\"CR46\\\" class=\\\"CitationRef\\\"\\u003e46\\u003c/span\\u003e). Simulation courses led to increased confidence and perceived readiness for registrar-level tasks(\\u003cspan citationid=\\\"CR49\\\" class=\\\"CitationRef\\\"\\u003e49\\u003c/span\\u003e). Simulation was identified as a driver of workplace behavioural change when structured feedback and debrief were included(\\u003cspan citationid=\\\"CR46\\\" class=\\\"CitationRef\\\"\\u003e46\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eThe evidence was graded moderate as outcomes were mostly deducted from self-reported growth without observational objective verification. In addition, fidelity of a simulation could affect the transferability of skill. Furthermore, minimal long-term follow-ups undermined the reliability of these paper\\u0026rsquo;s findings.\\u003c/p\\u003e \\u003cp\\u003eInterventions involving high-fidelity simulation, mental rehearsal, and modular training allowed trainees not only to understand a procedure but to demonstrate it in controlled environments. When learners demonstrate skills in a simulated or structured setting, they \\u0026ldquo;show how\\u0026rdquo; (Miller\\u0026rsquo;s) behaviour could change (Kirkpatrick\\u0026rsquo;s level3). One may interpret the potential for good learning progression to the intermediate levels by demonstrating some behaviour changes indicative of competence and skill development.\\u003c/p\\u003e \\u003cp\\u003e \\u003cspan type=\\\"BoldUnderline\\\" class=\\\"BoldUnderline\\\" name=\\\"Emphasis\\\"\\u003eLevel 4\\u003c/span\\u003e was demonstrated, in isolation, only by one paper(\\u003cspan citationid=\\\"CR63\\\" class=\\\"CitationRef\\\"\\u003e63\\u003c/span\\u003e) and evaluated clinical impact. It highlighted the benefits of a dedicated training programme in laparoscopic colorectal cancer surgery through demonstrating both the clinical benefits through mortality and morbidity reduction; as well clinical performance through assessment tools(\\u003cspan citationid=\\\"CR63\\\" class=\\\"CitationRef\\\"\\u003e63\\u003c/span\\u003e). This extended on previous papers where trainees call for such dedicated programs and structures(36,46,48,51,52,61) and should be incorporated into further curriculum work. Trainees, almost unanimously, called for dedicated teaching time, trainers, and incorporation into the training programs(\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR36\\\" class=\\\"CitationRef\\\"\\u003e36\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR46\\\" class=\\\"CitationRef\\\"\\u003e46\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR48\\\" class=\\\"CitationRef\\\"\\u003e48\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR51\\\" class=\\\"CitationRef\\\"\\u003e51\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR52\\\" class=\\\"CitationRef\\\"\\u003e52\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR61\\\" class=\\\"CitationRef\\\"\\u003e61\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eDespite the low quantity of papers, the sole paper(\\u003cspan citationid=\\\"CR63\\\" class=\\\"CitationRef\\\"\\u003e63\\u003c/span\\u003e) was considered a higher grade in strength due to high fidelity and thus skill transferability. Measuring clinical patient outcomes is arguably the most reliable way of testing skill outcomes. Reliability was high due to the three years follow up to monitor trainee\\u0026rsquo;s competency.\\u003c/p\\u003e \\u003cp\\u003eLevel 4 of Kirpatrick model matched with the maximum competence (\\u0026ldquo;Does\\u0026rdquo;) stage of Miller pyramid by demonstrating patient outcomes. It could be assumed to be the most rigorous form of assessment of skill attainment. One can infer the rarity of such papers to be secondary to logistical, ethical and financial challenges in measuring patient outcomes. Overall, level 4 papers were underrepresented, reinforcing the need for more longitudinal, mixed-method studies; with the capability of delineating impact of simulation and formative assessments from training environments to real-world clinical practice.\\u003c/p\\u003e \\u003cp\\u003e \\u003cspan type=\\\"BoldUnderline\\\" class=\\\"BoldUnderline\\\" name=\\\"Emphasis\\\"\\u003eMajority of papers used multiple methods\\u003c/span\\u003e to address multiple levels of learning categories, which allowed insights across multiple levels. For example, level2/3(\\u003cspan citationid=\\\"CR45\\\" class=\\\"CitationRef\\\"\\u003e45\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR46\\\" class=\\\"CitationRef\\\"\\u003e46\\u003c/span\\u003e) deducted objective skill acquisition assessment and measured the broader impact of training outcome. The most common form was level3/4, which used large-scale national datasets from ISCP and eLogbook platforms to demonstrate index operative experience and achievement of a third level 4 competence that leads to CCT(\\u003cspan additionalcitationids=\\\"CR57 CR58 CR59\\\" citationid=\\\"CR56\\\" class=\\\"CitationRef\\\"\\u003e56\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR60\\\" class=\\\"CitationRef\\\"\\u003e60\\u003c/span\\u003e). Being based on real patient operations one can assume, indirectly, that increased level of independent operating (behaviour) is related to better patient outcome. Their long-term follow-up was associated with increased reliability. Interestingly, many trainees failed to obtain WBAs indicative of independence in their index procedures, suggesting that indicative numbers alone could fail to confirm true competence thereby questioning the validity of CCT by using WBAs(\\u003cspan citationid=\\\"CR57\\\" class=\\\"CitationRef\\\"\\u003e57\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR58\\\" class=\\\"CitationRef\\\"\\u003e58\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR59\\\" class=\\\"CitationRef\\\"\\u003e59\\u003c/span\\u003e). Furthermore, WBAs were often pre-filled by the trainees and inconsistently validated by their trainers(\\u003cspan citationid=\\\"CR38\\\" class=\\\"CitationRef\\\"\\u003e38\\u003c/span\\u003e). A recurring concern was the perceived ineffectiveness of WBAs/PBAs, with trainees reporting these often being used as \\u0026lsquo;tick-box\\u0026rsquo; assessments(\\u003cspan citationid=\\\"CR35\\\" class=\\\"CitationRef\\\"\\u003e35\\u003c/span\\u003e), countering their educational intent.\\u003c/p\\u003e \\u003cp\\u003eMixed levels studies evidence strength depended on the type of outcomes measured. Level 4 outcomes, alone or with level 3, provided rigorous generalisable data and insight into long-term impact on learning due to their large data, duration and reliability. In contrast, these were often associated with subjective or inconsistent validation means thereby lowering their evidence strength. If behavioural change through clinical application in real-world settings was demonstrated, then the \\\"Does\\\" level of Miller\\u0026rsquo;s Pyramid was reached. However, post-certification(CCT) performance was poorly tracked therefore, making it difficult to assess competency, at the ultimate phase of integration into practice. Arguably, mixing the forms of assessments may yield valuable data, which is less ethically challenging than pure level 4 studies. Interest persists in creating more higher level competence-based assignments and to revise current WBAs given the current collated negative feedback.\\u003c/p\\u003e \\u003cp\\u003eThis review has several limitations, firstly, the inclusion of heterogeneous study designs, populations (e.g., CTs, STs, SAS), and simulation modalities complicated direct comparison. Secondly, many included studies were observational, underpowered, or single-institution, limiting the external validity of findings. Thirdly, the nature of a scoping review precludes formal quality appraisal or meta-analysis. Fourthly, data focused solely on UK-based data, which, while relevant to the research question, may omit valuable international insights. Finally, reporting bias may exist, as negative or inconclusive studies are less likely to be published.\\u003c/p\\u003e \\u003cp\\u003eBy linking Kirkpatrick\\u0026rsquo;s levels with Miller\\u0026rsquo;s ascending hierarchy of competence, the review supports that true surgical skill acquisition is multidimensional, requiring not just improved learner satisfaction or knowledge gain, but demonstrable procedural capability and transfer into practice. Integrating both models in curriculum and teaching design enables a more comprehensive evaluation of medical education from trainee satisfaction to patient outcome. Pursuing research into level 3 and 4(/\\u0026ldquo;Shows How\\u0026rdquo; and \\u0026ldquo;Does\\u0026rdquo;) is likely to be the most effective means to identify solutions to improving surgical skill acquisition.\\u003c/p\\u003e\"},{\"header\":\"Conclusion\",\"content\":\"\\u003cp\\u003eThis scoping review maps the current landscape of simulation and formative assessment in UK general surgery training, using the Kirkpatrick model to evaluate effectiveness of educational interventions whilst also describing the progression of knowledge to performance with Miller\\u0026rsquo;s Pyramid of competency. Linking Kirkpatrick\\u0026rsquo;s model with Miller\\u0026rsquo;s pyramid underscores the need for educational strategies that move beyond early-stage gains to demonstrate actual competence in clinical settings. While simulation and formative assessment improve trainee confidence and technical ability (Levels 1\\u0026ndash;2, \\u0026ldquo;Knows\\u0026rdquo;/\\u0026ldquo;Knows How\\u0026rdquo;), fewer studies assess behavioural change or real-world performance (Levels 3\\u0026ndash;4, \\u0026ldquo;Shows How\\u0026rdquo;/\\u0026ldquo;Does\\u0026rdquo;). Future research should prioritise prospective, longitudinal designs capable of tracking performance into independent practice and thereby focusing on Levels 3\\u0026ndash;4, \\u0026ldquo;Shows How\\u0026rdquo;/\\u0026ldquo;Does\\u0026rdquo;, criteria as it demonstrates more ingrained learning for surgical skill acquisition. This form is already part of curriculum in form of WBAs, yet they need further research to improve given plentiful complaints raised. Embedding effective, evidence-based strategies into cohesive, competency-based teaching methods, may ultimately support a more accountable framework for developing safe and more consistent GS training across the UK.\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e \\u003ch2\\u003eCompeting Interest\\u003c/h2\\u003e \\u003cp\\u003eI declare there are no financial or non-financial competing interests.\\u003c/p\\u003e \\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003eRodriguez-Paz JM, Kennedy M, Salas E, Wu AW, Sexton JB, Hunt EA, Pronovost PJ. Beyond see one, do one, teach one: toward a different training paradigm. Postgrad Med J. 2009;85(1003):244\\u0026ndash;9.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eWelchman SA. Royal College of Surgeons of England. Improving surgical training. 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Gastroenterology. 2015;148:S\\u0026ndash;202.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eElsey EJ, Griffiths G, West J, Humes DJ. Changing autonomy in operative experience: a UK cohort study. Ann Surg. 2019;269(3):399\\u0026ndash;406.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAbdel-Dayem M, Thippeswamy KM, Haray P. Structured modular approach for laparoscopic colorectal surgery. Surg Innov. 2021;28(4):479\\u0026ndash;84.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eJames HK, Chapman AW, Pattison GTR, Griffin DR, Fisher JD. Cadaveric simulation in surgical training: a systematic review. Br J Surg. 2019;106(13):1726\\u0026ndash;34.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eHanna GB, Mackenzie H, Miskovic D, Ni M, Wyles S, et al. Laparoscopic Colorectal Surgery Outcomes Improved After National Training Program (LAPCO) for Specialists in England. Ann Surg. 2022;275(6):1149\\u0026ndash;55.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003e2022 ST3 Vascular Surgery Supplementary Applicant Handbook. Summary of changes for 2022 recruitment. London: NHS England; 2022.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eHalligan M, Murphy MP, Friedman M. Learning outcomes. In: Certified Healthcare Simulation Educator (CHSE\\u0026reg;) Review: Comprehensive Review, PLUS More Than 350 Questions Based on the Latest Exam Blueprint. 2023.p.19:311.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eToy S. Evaluation paradigms. Scholarship in Healthcare: The Health Scholar\\u0026rsquo;s Toolbox. Cham: Springer International Publishing; 2023. pp. 81\\u0026ndash;101.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eTangpaisarn T, Phrampus PE, O\\u0026rsquo;Donnell JM. Learning theory in healthcare simulation. Navigating Healthcare Simulation: A Practical Guide for Effective Teaching. Cham: Springer Nature Switzerland.; 2025. pp. 9\\u0026ndash;16.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eArora S, et al. Mental practice enhances surgical technical skills: a randomized controlled study. Ann Surg. 2012;255(6):1181\\u0026ndash;7.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAppendix. 1- List definitions.\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":true,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"global-surgical-education-journal-of-the-association-for-surgical-education\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"GSED\",\"sideBox\":\"Learn more about [Global Surgical Education - Journal of the Association for Surgical Education](https://link.springer.com/journal/44186)\",\"snPcode\":\"44186\",\"submissionUrl\":\"https://www.editorialmanager.com/gsed/default1.aspx\",\"title\":\"Global Surgical Education - Journal of the Association for Surgical Education\",\"twitterHandle\":\"\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"Springer Hybrid\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":false},\"keywords\":\"General surgery, simulation, formative assessment, surgical education, scoping review, UK training\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-8310571/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-8310571/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003e\\u003cb\\u003eBackground:\\u003c/b\\u003e\\u003c/p\\u003e \\u003cp\\u003eThe UK general surgery (GS) training faces challenges despite curriculum reforms, this includes varied teaching quality, limited simulation teaching, reduced training opportunities and curriculum flaws. Recent national surveys highlight discrepancies between GS trainees\\u0026rsquo; dissatisfaction in comparison to other specialities. The aim is to identify teaching methods in simulation or formative assessment leading to improved surgical skill acquisition in GS.\\u003c/p\\u003e\\u003cp\\u003e\\u003cb\\u003eMethods:\\u003c/b\\u003e\\u003c/p\\u003e \\u003cp\\u003eA scoping review, following the PRISMA-ScR guidelines, identified studies from the last decade using Pubmed/Medline, EMBASE, ERIC and Web of Science. Data was extracted into tables and reviewed using basic numerical analysis. The charted data was analysed using narrative synthesis and categorized using the Kirkpatrick model, with alignment to Miller\\u0026rsquo;s Pyramid, to assess effectiveness of competency.\\u003c/p\\u003e\\u003cp\\u003e\\u003cb\\u003eResults:\\u003c/b\\u003e\\u003c/p\\u003e \\u003cp\\u003e31 studies highlighted a range of simulation and assessment strategies. 26% were categorized into the lowest form of competency, Kirkpatrick Levels 1(Miller\\u0026rsquo;s \\u0026ldquo;Knows\\u0026rdquo;) and showed enhanced trainee confidence. 3% were graded as level 4 (Miller\\u0026rsquo;s \\u0026ldquo;Does\\u0026rdquo;) and demonstrated competency through clinical outcomes. 35% were a mix of methods to assess learning on multiple levels simultaneously allowing in-depth multimodal assessment of learning.\\u003c/p\\u003e\\u003cp\\u003e\\u003cb\\u003eConclusion:\\u003c/b\\u003e\\u003c/p\\u003e \\u003cp\\u003eThis paper suggests that an imbalance exists between the quantity of research versus the quality of research that formally assesses surgical skills acquisition at higher levels of competency. Thereby suggesting a demand for higher and reliable research to bridge the current gap in research and develop a more competency-based curriculum embedded with validated tools aligning with the higher levels of competency and supporting surgical autonomy and patient safety.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Teaching methods used by general surgeons in simulation or formative assessment leading to improved surgical skill acquisition in UK surgical trainees: a scoping review\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2025-12-22 09:35:17\",\"doi\":\"10.21203/rs.3.rs-8310571/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"reviewerAgreed\",\"content\":\"\",\"date\":\"2025-12-22T01:47:46+00:00\",\"index\":0,\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2025-12-15T14:52:07+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvited\",\"content\":\"Global Surgical Education - Journal of the Association for Surgical Education\",\"date\":\"2025-12-14T19:04:07+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2025-12-13T08:37:07+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"Global Surgical Education - Journal of the Association for Surgical Education\",\"date\":\"2025-12-08T14:05:52+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"global-surgical-education-journal-of-the-association-for-surgical-education\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"GSED\",\"sideBox\":\"Learn more about [Global Surgical Education - Journal of the Association for Surgical Education](https://link.springer.com/journal/44186)\",\"snPcode\":\"44186\",\"submissionUrl\":\"https://www.editorialmanager.com/gsed/default1.aspx\",\"title\":\"Global Surgical Education - Journal of the Association for Surgical Education\",\"twitterHandle\":\"\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"Springer Hybrid\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":false}}],\"origin\":\"\",\"ownerIdentity\":\"37c7f0b7-1b51-4982-9889-cdf9ae7baca6\",\"owner\":[],\"postedDate\":\"December 22nd, 2025\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"under-review\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2026-05-19T19:40:36+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2025-12-22 09:35:17\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-8310571\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-8310571\",\"identity\":\"rs-8310571\",\"version\":[\"v1\"]},\"buildId\":\"8U1c8b4HqxoKbykW_rLl7\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}