Effectiveness of a Portable Multifaceted Feedback Mechanism for Formative Assessment in Standardized Training of Surgical Residents: A Randomized Controlled Trial

Effectiveness of a Portable Multifaceted Feedback Mechanism for Formative Assessment in Standardized Training of Surgical Residents: A Randomized Controlled Trial | 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 Effectiveness of a Portable Multifaceted Feedback Mechanism for Formative Assessment in Standardized Training of Surgical Residents: A Randomized Controlled Trial YingMing Song, JiaHui Wu, Chao Han, YanJun Xu, HaoDong Zhang, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7262949/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract This study investigates the effectiveness of a Portable multifaceted Feedback Mechanism in standardized training for surgical residents. Sixty-eight resident physicians undergoing training at the Peace Hospital Affiliated to Changzhi Medical College from August 2022 to August 2024 were selected as subjects and divided into experimental and control groups. DaThe experimental group utilized a formative evaluation system with a Portable Multifaceted Feedback Mechanism, while the control group employed summative evaluation.t analysis involved comparing scores across all items in the Portable Multifaceted Feedback Mechanism scoring scale and general assessment tools, evaluating teacher and student satisfaction levels, and analyzing peer physician feedback through t-tests. Results showed statistically significant differences (P<0.05) between experimental and control groups in both individual items of the scoring scale and general assessment tools. Significant variations were also observed across different training phases within the experimental group. Teacher and student satisfaction scores revealed no significant differences between the experimental and control groups, but significant differences existed between the control group and experimental groups 2 and 3, as well as between groups 2 and 3 (P<0.05). Peer physician feedback analysis demonstrated gradual improvement in evaluations toward the experimental group (B=4.061, P<0.05). These findings indicate that the Portable Multifaceted Feedback Mechanism proves effective in standardized training for surgical residents, representing a replicable approach worthy of wider adoption. teaching resident physicians surgery Portable Multifaceted Feedback Mechanism Background Educational evaluation originated in the 1930s. Currently, it can be categorized into summative assessment, diagnostic assessment, and formative assessment. Formative assessment refers to teaching methods where students receive timely feedback during activities (training) and can improve their performance through self-correction. The Operational Skills Direct Observation Method (Portable Multifaceted Feedback Mechanism) is a crucial form of formative assessment. The implementation of evaluation itself may drive learning behaviors, thereby becoming part of the instructional design process. Through the use of tools, providing timely feedback when incorporated into curricula can guide better teaching practices [ 1 ][ 2 ][ 15 ] . International studies have successively indicated that portable multifaceted feedback mechanism scoring has shown significant positive effects in improving skill proficiency during training for urology, gastroenterology endoscopy, otolaryngology, and general practitioner programs [ 3 ][ 4 ] . However, there are currently few studies on the application of portable multifaceted feedback mechanism scoring in surgical residency training [ 25 ] . Recognizing peer residents as valuable sources of feedback [ 5 ] , and guided by Chinese and international surgical training standards (e.g., “Content and Standards for Standardized Training of Resident Physicians”), this randomized controlled trial (RCT) aims to evaluate the effectiveness of formative assessment using the PMFS(Portable Multimodal Feedback System) within the standardized surgical residency program. The standardized residency training program (hereinafter referred to as "Resident Training") is a systematic and standardized program for medical students with bachelor's degrees or higher who undergo training as resident physicians after completing five years of medical school education. [ 6 ][ 9 ] As a crucial component of post-graduate education, it plays a vital role in cultivating high-caliber clinicians and improving healthcare quality. It also serves as an essential requirement for advancing medical reforms and building a people-oriented healthcare system [ 7 ][ 8 ][ 9 ] . Surgery, as a comprehensive medical discipline, presents significant challenges to Resident Training due to its broad service scope, extensive coverage, high patient expectations, and stringent requirements for surgical precision [ 10 ] . Method This study enrolled 68 resident physicians undergoing surgical training at our hospital from August 2022 to August 2024, comprising 56 males and 12 females. Sixty participants held master's degrees while 8 had bachelor's degrees. Comparative analysis of baseline data between groups showed no statistically significant differences (P > 0.05), confirming comparability. See Table 1 . Following a fully randomized design, residents were randomly assigned to experimental and control groups. All participants received standardized surgical training across relevant departments. Evaluation panels, consisting of 1–2 experienced senior attending physicians or higher-level instructors, conducted direct observations of residents' procedures for scoring. Prior to the study, we incorporated best practices from mini-CEX and Direct Observation of Surgical Skills (DOPS) in formative assessment. To ensure reliability, evaluators received training in Portable Multimodal Feedback Systems prior to assessments, establishing standardized protocols and mitigating inter-rater bias for objectivity [ 10 ][ 12 ] . The experimental group underwent formative evaluations through these systems during departmental training. Post-training assessments were conducted using the Portable Multimodal Feedback System (PMFS) scoring scale at 2 weeks (Group 1),4 weeks (Group 2), and 1 week before graduation (Group 3). During the evaluation period, our hospital's standardized clinical practice skills assessment scale (commonly referred to as the "General Scale") was used for scoring. The control group underwent summative evaluations, including a General Scale assessment and a Portable Multifaceted Feedback Mechanism (PMFM) evaluation one week before graduation. Peer evaluations among resident physicians were enhanced through simultaneous assessments with the PMFM, with specific procedures: A physician provided a unified evaluation of their peers' overall performance to better monitor residents 'progress and research outcomes. The operational items and subjects included: 1) Tracheal intubation; 2) Cardiopulmonary resuscitation (CPR); 3) Wound debridement; 4) Abscess incision and drainage; 5) Thoracentesis; 6) Lumbar puncture; 7) Abdominal puncture; 8) Sterile drapes; 9) Catheterization; 10) Surgical hand disinfection; 11) Spinal injury transportation; 12) Limb fracture fixation techniques; 13) Surgical wound dressing and suture removal; 14) Basic surgical procedures (incision, exposure, suturing, ligating, hemostasis). Except for CPR, all other patients served as operational subjects with their guardians' consent and signed informed consent forms. The PMFM evaluation criteria primarily covered 11 aspects: 1) Understanding and executing skill instructions; 2) Informed consent communication; 3) Preoperative preparation; 4) Appropriate anesthesia safety; 5) Skill proficiency; 6) Aseptic technique adherence; 7) Seeking assistance when needed; 8) Postoperative care; 9) Communication skills; 10) Professional competence and empathy; 11) Overall performance. Each evaluation item in the aforementioned assessment framework is scored on a 9-point scale, where 1–3 points indicate non-compliance, 4–6 points meet requirements, and 7–9 points demonstrate excellence. Based on teacher evaluations and feedback, both students and evaluators rate satisfaction using a 9-point scale (1 being the lowest and 9 the highest). The general scale utilizes each project's skill assessment criteria established by the research institute and employs a percentage system. Peer evaluations among resident physicians categorize grades as: Excellent, Good, Qualified, Basically Qualified, and Unqualified. This comprehensive evaluation system assesses residents' overall competencies according to the latest "Resident Standardized Training Content and Standards (2022 Edition)", which outlines six core competencies: professional ethics, clinical competence, patient management, communication and collaboration, teaching ability, and continuous learning. Scores from the portable multi-feedback scale and general scale were compared between the experimental group and control group. Additionally, satisfaction levels among students and teachers, as well as peer evaluations, were analyzed across both groups. Data analysis was conducted using SPSS 27.0 software. For data lacking normal distribution or homogeneity of variance, rank sum tests were employed; other data were compared through t-tests or ANOVA. Linear regression analysis was also conducted to verify trend patterns in relevant data. Result When comparing item scores across the Portable Multimodal Feedback System rating scales in each group, the experimental group demonstrated statistically significant superiority over the control group (P < 0.05). Significant differences were observed between Experimental Groups 1, 2, and 3 in the evaluation of the Portable Multimodal Feedback System (P < 0.05), as detailed in Table 2 . Analysis of all items on the general scale across groups revealed that the experimental group significantly outperformed the control group (P < 0.05), with notable disparities among Groups 1, 2, and 3, as shown in Table 3 . When comparing teacher and student satisfaction scores across groups, no significant differences were found between the experimental Group 1 and the control Group regarding teacher satisfaction, while significant differences emerged between Groups 2 and 3, as presented in Table 4 . When comparing peer evaluation forms among resident physicians in the experimental group, we found that peer satisfaction with each other's evaluation showed a positive trend, as shown in Table 5 . Table 1 Comparison of general data group number of people Sex (male/female, name) Age (years, x ± s) record of formal schooling Bachelor degree Master's degree experimental group 38 30/8 24.44 ± 2.02 3 35 control group 30 26/4 24.45 ± 2.52 5 25 χ 2 / t 0.821 0.254 1.108 P 0.415 0.801 0.272 Table 2 Comparison of scores of items in the portable multi-feedback mechanism scale project control group Experimental group 1 Experimental group 2 Experimental group 3 F/H P catheter 79.87 ± 9.446 73.74 ± 10.396a 83.75 ± 6.863b 88.90 ± 4.759abc 23.593 < 0.001 Abdominal puncture 70.54 ± 7.450 75.02 ± 5.572a 82.29 ± 4.951ab 86.41 ± 4.398abc 55.874 < 0.001 Treatment of spinal cord injury 78.54 ± 3.975 76.04 ± 4.190a 86.65 ± 2.560ab 92.87 ± 1.310abc 216.496 < 0.001 Close the chest 66.61 ± 11.299 37.88 ± 4.262a 62.57 ± 7.706ab 74.68 ± 6.992abc 157.855 < 0.001 Open the chest 64.91 ± 7.365 42.97 ± 7.609a 66.24 ± 7.902b 81.65 ± 6.855abc 173.440 < 0.001 Abscess incision 73.72 ± 6.929 57.23 ± 5.569a 73.71 ± 3.965b 84.42 ± 3.280abc 190.302 < 0.001 trachea cannula 69.48 ± 10.243 48.85 ± 6.790a 70.47 ± 5.988ab 84.94 ± 4.181abc 174.354 < 0.001 debride 67.96 ± 9.605 56.80 ± 5.784a 73.47 ± 6.342ab 83.61 ± 6.537abc 94.872 < 0.001 Basic surgery 64.07 ± 3.232 54.65 ± 4.189a 67.75 ± 4.428ab 79.29 ± 4.110abc 238.854 < 0.001 Fractured limb 73.78 ± 7.992 58.87 ± 4.364a 72.77 ± 9.358b 83.48 ± 3.913abc 85.658 < 0.001 Surgical dressing and removal 79.34 ± 3.655 66.56 ± 7.678a 80.77 ± 4.276b 91.20 ± 3.266abc 148.971 < 0.001 Hands are disinfected during surgery 70.56 ± 5.367 66.20 ± 6.008a 78.81 ± 6.769ab 91.09 ± 3.563abc 143.550 < 0.001 Disinfectant towels 67.68 ± 15.224 65.43 ± 10.738 78.28 ± 6.713ab 80.42 ± 17.420ab 12.059 < 0.001 cardio-pulmonary resuscitation 72.49 ± 9.936 56.45 ± 10.337a 73.82 ± 6.676b 89.44 ± 5.984abc 98.729 < 0.001 paracentesis of chest 76.38 ± 9.452 59.02 ± 10.772a 76.33 ± 8.022b 90.35 ± 5.510abc 84.206 < 0.001 Corning's puncture 74.16 ± 6.029 64.32 ± 8.771a 80.30 ± 8.464ab 89.35 ± 4.695abc 79.575 < 0.001 Table 3 Comparison of scores of items in the general scale for each group project control group Experimental group 1 Experimental group 2 Experimental group 3 F/P P catheter 85.11 ± 7.506 75.10 ± 10.017a 87.87 ± 5.582b 93.08 ± 3.704ab 43.370 < 0.001 Abdominal puncture 74.81 ± 5.854 66.91 ± 5.667a 81.38 ± 4.192ab 90.69 ± 3.899abc 156.900 < 0.001 Treatment of spinal cord injury 85.91 ± 4.211 80.21 ± 4.059 91.92 ± 1.974ab 96.18 ± 1.218abc 193.698 < 0.001 Close the chest 72.86 ± 5.344 57.97 ± 5.029a 75.71 ± 7.664ab 87.34 ± 4.746abc 214.998 < 0.001 Open the chest 72.86 ± 5.334 57.97 ± 5.029a 75.71 ± 7.664b 87.34 ± 4.746abc 162.766 < 0.001 Abscess incision 78.06 ± 7.426 64.36 ± 5.379a 78.67 ± 3.736b 86.14 ± 3.654abc 118.913 < 0.001 trachea cannula 80.92 ± 5.709 61.03 ± 5.535a 79.57 ± 3.927b 89.71 ± 3.770abc 242.398 < 0.001 debride 74.46 ± 2.758 57.60 ± 7.760a 76.96 ± 3.469b 85.99 ± 4.265abc 90.176 < 0.001 Basic surgery 74.46 ± 2.758 57.60 ± 7.760a 76.96 ± 3.469ab 85.99 ± 4.265abc 209.566 < 0.001 Fractured limb 80.48 ± 7.444 63.98 ± 8.341a 81.52 ± 7.157b 90.19 ± 4.150abc 94.786 < 0.001 Surgical dressing and removal 88.75 ± 3.031 75.88 ± 7.269a 89.03 ± 3.976b 96.01 ± 1.620abc 128.882 < 0.001 Hands are disinfected during surgery 76.75 ± 5.618 70.99 ± 4.846a 84.21 ± 5.076ab 95.01 ± 2.689abc 187.153 < 0.001 Disinfectant towels 78.96 ± 9.665 72.16 ± 6.689a 86.81 ± 6.023ab 94.87 ± 2.844abc 84.161 < 0.001 cardio-pulmonary resuscitation 82.97 ± 8.074 71.40 ± 7.583a 84.24 ± 3.352b 94.79 ± 1.685abc 107.282 < 0.001 paracentesis of chest 84.28 ± 5.751 66.01 ± 6.842a 81.27 ± 6.194b 90.72 ± 3.131abc 129.339 < 0.001 Corning's puncture 82.51 ± 5.558 69.40 ± 9.358a 85.93 ± 7.051ab 92.96 ± 4.806abc 75.965 < 0.001 Table 4 Comparison of satisfaction scores between teachers and resident physicians group control group Experimental group 1 Experimental group 2 Experimental group 3 H P teacher 6(4,7) 3(2,4)a 6(5,7)b 8(7,9)abc 63.496 < 0.001 student 6(5,7) 3(2,5)a 6(5,7)ab 8(8,9)abc 68.891 < 0.001 Z 0.405 0.16 0.69 1.752 P 0.685 0.987 0.945 0.080 Table 5 Comparison of peer evaluations among resident physicians divide into groups Peer resident physician evaluation level B and P outstanding good qualified Basically qualified unqualified Experimental group 1 0 6(15.8%) 10(26.3%) 20(52.6%) 2(5.3%) B = 4.061 P < 0.05 Experimental group 2 4(10.5%) 5(13.2%) 18(47.4%) 10(26.3%) 1(3.6%) Experimental group 3 9(23.7%) 13(34.2%) 10(26.3%) 6(15.8%) 0 Discussion In most cases, we focus more on training in fundamental skills such as clinical thinking, medical record writing, and bedside management, as well as the pass rate training for the "dual certification" exam (Physician Practice Certificate and Hospital Training Completion Certificate). However, we often neglect the training of surgical skills, with many residents lacking opportunities to perform or independently operate. [ 11 ][ 12 ] A reasonable teaching mechanism and evaluation system are particularly crucial, facilitating comprehensive improvement in residents 'clinical practice abilities and their problem-solving capabilities [ 15 ] . The portable multi-dimensional feedback mechanism serves as an important formative assessment method. It embodies the three elements of formative evaluation (FED: feedback-encouragement-guidance), providing immediate feedback through direct observation of students' operational processes [ 13 ][ 14 ] . This innovative clinical assessment tool emphasizes teaching processes, future development, and student growth, thereby enhancing the quality of educational activities [ 25 ] .Our randomized controlled trial demonstrates that the PMFS, as a structured formative assessment tool, significantly enhances surgical residents' procedural competencies compared to traditional summative evaluation. These findings align with international evidence on Direct Observation of Procedural Skills (DOPS) efficacy in specialties like endoscopy and urology, yet extend its validation to comprehensive surgical training—a domain previously underexplored. Mechanisms of PMFS Effectiveness In our practice, we employ this method to assess each teaching module and conduct three evaluations for residents. Results show that the portable multi-dimensional feedback mechanism yields better outcomes compared to summative evaluations. Through analysis, we concluded that in clinical practice, using summative evaluation methods—where instructors only provide clinical guidance during residency rotations and expect trainees to repeatedly practice independently—fails to help students develop practical competencies. The instructor's casual teaching style makes it difficult to comprehensively observe trainees' actual operational processes. To enable trainees to evaluate their skills and identify areas for improvement, implementing a portable multi-dimensional feedback mechanism provides 2–3 opportunities for repeated practice, feedback, correction, and assessment. Results showed that the experimental group scored higher on both the general scale and the portable multi-dimensional feedback scoring scale in their second evaluation than the control group. This demonstrates that formative evaluation through the portable multi-dimensional feedback mechanism can significantly enhance residency physicians 'clinical skills in a shorter timeframe compared to single summative assessment methods. In clinical practice, trainees frequently perform procedures like catheterization, dressing changes, and suture removal daily. However, data from both groups revealed that general scale scores remained notably lower than those from the portable multi-dimensional feedback mechanism. The primary reason lies in trainees' lack of proactive instructor observation during these procedures—such as surgical drapes disinfection. Typically, instructors only arrive in the operating room after trainees complete these tasks. Some instructors with strong teaching philosophies may proactively observe procedures beforehand and discuss their strengths and weaknesses with trainees. Teachers with weaker pedagogical skills tend to avoid proactively observing and identifying issues, often leaving problems for final evaluations [ 16 ] . In the Portable Multimodal Feedback System assessment, resident physicians spend 10–15 minutes demonstrating sterile towel placement techniques. Instructors evaluate using this method, followed by 5–10 minute discussion sessions lasting no more than half an hour. This approach minimizes workload while enabling physicians to promptly identify and correct errors through repeated practice, observation, guidance, and refinement—a virtuous cycle that ensures mastery of surgical skills [ 17 ] . National health authorities mandate in surgical training that residents master complex procedures such as independent thoracic surgery, general abdominal appendectomy, high ligation of inguinal hernia, and circumcision. However, in today's increasingly risky healthcare landscape, residents rarely perform these surgeries independently. Even when given opportunities, many abandon attempts due to lack of confidence, particularly in independent thoracotomy and closure procedures [ 18 ][ 19 ] . Our team underwent rigorous training using the portable multi-feedback system. The open-chest group included 38 students (experimental) versus 30 (control), while the closed-chest group had 38 students (experimental) versus 30 (control). The comparative results demonstrate that the experimental group achieved significantly higher proficiency in thoracotomy and closure techniques compared to the control group. Through three rounds of real-time assessment via a Portable Multimodal Feedback System, resident physicians 'confidence was progressively strengthened, motivating them to actively learn and improve their skills. This led to a gradual upward spiral in evaluation outcomes across both assessment scales. Therefore, implementing standardized Portable Multimodal Feedback Systems in clinical practice not only enhances residents' mastery of advanced techniques—aligning with national training objectives—but also boosts their self-confidence and professional identity. The American College of Graduate Medical Education (ACGME) outlines six core competencies for residency training: patient care, medical knowledge, systems-based practice, practice-based learning and improvement, professional ethics, and communication. China's healthcare institutions have similarly established three core competencies: theoretical knowledge, clinical skills, and humanistic values. The 16-item assessment framework of the Portable Multimodal Feedback System covers not only medical knowledge and clinical skills but also interpersonal communication, professional ethics, and patient care—essential elements of medical humanities. In practice, not all procedures (e.g., dressing changes or intubation) require anesthesia, making them unsuitable for the standardized evaluation system. Consequently, we organized expert discussions with surgical residency training specialists to develop customized assessment tools for each procedure [ 20 ][ 23 ] . For example, in the cardiopulmonary resuscitation test item, "to judge consciousness and call for help" was changed to "informed consent notification and communication"; "safe and appropriate anesthesia" was replaced by "appropriate and safe environment assessment"; and "sterile concept" was changed to "accuracy of pressure and ventilation". During the evaluation process, we focused on the following key components: "Technical Proficiency" to develop students 'ability to manage sudden cardiac arrest; "Compression Force and Depth" to assess CPR effectiveness; and "Follow-up Care" to enhance their capacity for advanced life support after effective CPR. Regarding dressing changes and catheterization, the evaluation criteria shifted from "safe and appropriate anesthesia" to "humanistic and safe anesthesia," with enhanced medical safeguards including maintaining warmth, ensuring patient privacy, and avoiding verbal stimulation. This personalized portable multi-dimensional feedback mechanism corrected inappropriate elements in the assessment framework, emphasized critical steps requiring mastery, aligned closely with clinical practice, and significantly improved residency physicians' practical experience and core competencies. Satisfaction and Peer Feedback Dynamics In our research, we observed that both student and teacher satisfaction in the experimental group showed upward trends through implementing a formative evaluation system with Portable Multimodal Feedback Systems. We believe this improvement primarily stems from the strict adherence to feedback principles during the formative evaluation process: conducting 5–10 minute post-operation discussions after each task, and requiring evaluators to follow these guidelines: 1) Descriptive: Use descriptive language to specifically point out strengths and weaknesses during operations; 2) Timeliness: Provide immediate feedback post-operation while continuing observation and supervision during teaching; 3) Constructive: Offer corrective, non-critical feedback along with corresponding suggestions for improvement and follow-up plans; 4) Interactivity: Teachers listen to students 'perspectives, check comprehension of feedback content, and allow students to identify areas for instructional improvement. Feedback stands as the most significant distinction and characteristic of the Portable Multimodal Feedback System compared to traditional operational assessments, representing a crucial feature of formative evaluation. We require teachers to implement the "sandwich" feedback rule—first acknowledging the commendable aspects of trainee doctors' operations, then pointing out areas needing improvement. This feedback approach demands not only solid theoretical foundations, rich practical experience, and meticulous instructional design from teachers, but also the ability to effectively manage and adapt to situations. This approach has motivated students to take the initiative in learning, become proficient in practical operations, and balance theoretical knowledge with hands-on experience [ 21 ][ 22 ] . It has enhanced their problem-solving capabilities, communication skills, and interpersonal competencies, particularly in developing practical skills and humanistic awareness. Consequently, both teacher satisfaction and evaluation outcomes have shown positive trends since the implementation of this assessment system [ 24 ] . However, maintaining consistent scoring across different instructors remains challenging due to the lack of standardized formats for feedback formats, content, and duration, which grants teachers significant autonomy. Therefore, teacher training is crucial for ensuring evaluation consistency. We established a skills-training evaluation team to conduct research and discussions. During teacher training programs, we emphasize continuous feedback and improvement to help educators fully grasp the essence of the portable multi-dimensional feedback mechanism, thereby enhancing their observation, evaluation, and feedback skills. This helps reduce subjective biases among teachers, standardize evaluation criteria, and improve the reliability and effectiveness of assessments. Additionally, our surveys revealed increasing satisfaction among peer residents during mutual evaluations, further validating the role of peer assessment in formative evaluation processes. Conclusion In conclusion, the evaluation of portable multi-dimensional feedback mechanisms in standardized training for surgical residents effectively enhances their mastery of clinical skills, significantly improves core competencies and overall professional qualities. Furthermore, this approach facilitates teaching-learning interactions through mutual feedback between instructors and residents. This resident training model represents a replicable and scalable methodology worthy of widespread adoption. Abbreviations PMFS Portable Multimodal Feedback System Resident Training The standardized residency training program DOPS Direct Observation of Procedural Skills PMFM Portable Multifaceted Feedback Mechanism CPR Cardiopulmonary resuscitation FED feedback-encouragement-guidance ACGME The American College of Graduate Medical Education Declarations Clinical trial number: not applicable. Ethics approval and consent to participate : The Ethics Committee of Peace Hospital Affiliated to Changzhi Medical College formally reviewed this practical teaching project and granted an exemption from ethical review.All procedures performed in this study were in accordance with the ethical principles of the Declaration of Helsinki.Informed consent was obtained from all participants. Consent for publication : Not applicable. Availability of data and materials : The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests : The authors declare no competing interests. Funding : Institute-level projects（HPYJ202203）院级课题（HPYJ202203）基于便携式多元反馈机制的外科住院医师规范化培训中混合式教学的管理研究 Authors' contributions Song YingMing: conceived and designed the experiment, conducted the research, collected data, analyzed and interpreted the data, and drafted the article; reviewed and supported the content of the article. Wu JiaHui: drafted the article, collected data, analyzed and interpreted the data, performed statistical analysis, and reviewed the content of the article. Han Chao: collected and analyzed data, and reviewed the content of the article. Xu YanJun: collected and analyzed data, and reviewed the content of the article. Zhang HaoDong: collected and analyzed data, and reviewed the content of the article. Li KeYan:collected and analyzed data, and reviewed the content of the article. Corresponding author Correspondence to YingMing Song,Email: [email protected] Acknowledgements : We sincerely thank all the students and their teachers who participated in this study and provided insights into the standardized training of resident physicians。 Authors' information : Yingming Song : Department of Gastrointestinal Surgery, Peace Hospital Affiliated to Changzhi Medical College, Changzhi,China Jiahui Wu : The First Clinical College of Changzhi Medical College, Changzhi,China Chao Han :Department of Gastrointestinal Surgery, Peace Hospital Affiliated to Changzhi Medical College, Changzhi,China Yanjun Xu :Department of Gastrointestinal Surgery, Peace Hospital Affiliated to Changzhi Medical College, Changzhi,China Haodong Zhang :Department of Gastrointestinal Surgery, Peace Hospital Affiliated to Changzhi Medical College, Changzhi,China Keyan Li :Department of Gastrointestinal Surgery, Peace Hospital Affiliated to Changzhi Medical College, Changzhi,China References Elzubeir M, Rizk D. 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Tools for the direct observation and assessment of psychomotor skills in medical trainees: a systematic review. Med Educ. 2013 Jul;47(7):650-73. doi: 10.1111/medu.12220. Castro MABE, de Almeida RLM, Lucchetti ALG, Tibiriçá SHC, da Silva Ezequiel O, Lucchetti G. The Use of Feedback in Improving the Knowledge, Attitudes and Skills of Medical Students: a Systematic Review and Meta-analysis of Randomized Controlled Trials. Med Sci Educ. 2021 Oct 18;31(6):2093-2104. doi: 10.1007/s40670-021-01443-3. Skinner C, Valentin K, Davin L, Leahy T, Berlach L. Shaping minds and hearts in medical education: Embedding and implementing a personal and professional development curriculum. Med Teach. 2024 Dec;46(12):1544-1552. doi: 10.1080/0142159X.2024.2409283. Hennel EK, Trachsel A, Subotic U, Lörwald AC, Harendza S, Huwendiek S. How does multisource feedback influence residency training? A qualitative case study. Med Educ. 2022 Jun;56(6):660-669. doi: 10.1111/medu.14798. 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Song","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9ElEQVRIie3QMWvCQBTA8RcOLsvFc7yj0HyFVwLRIfhZLIGbpFS6dGsg0C6Ca/0Wjo5pH+oidO3gkFBwTjcHKaZdW3J2c7j//H7cvQfgcp1jTFbV5+HrQTKfyhqTgZ34gkU6K4b6SZir51uT2okUvBs0BN8AL0T96mU2EebBCvRie6NzGEYJFgx8Ws7bCFLHlOPN7k4yr/gY4bYDwpj3VsKgh4ozb/b9ygh3DJSIW0mYQ6xEQ+bU7NJH8jIbARKxCh7p+ofAKQSJp5HamEjnzZEnaFJu2yWc0ktV3yeXUq6p3B+SgfRp1f6xX/H/jbtcLpfrr44EnErSvNYrFQAAAABJRU5ErkJggg==","orcid":"","institution":"Peace Hospital Affiliated to Changzhi Medical College","correspondingAuthor":true,"prefix":"","firstName":"YingMing","middleName":"","lastName":"Song","suffix":""},{"id":522597830,"identity":"dd15acaa-ee28-4f77-afd4-096e59cf5b75","order_by":1,"name":"JiaHui Wu","email":"","orcid":"","institution":"The First Clinical College of Changzhi Medical College","correspondingAuthor":false,"prefix":"","firstName":"JiaHui","middleName":"","lastName":"Wu","suffix":""},{"id":522597831,"identity":"289a5bcb-a512-4e68-af4b-50d109444d5d","order_by":2,"name":"Chao Han","email":"","orcid":"","institution":"Peace Hospital Affiliated to Changzhi Medical College","correspondingAuthor":false,"prefix":"","firstName":"Chao","middleName":"","lastName":"Han","suffix":""},{"id":522597832,"identity":"a4f74aae-4fb5-4259-aecc-db01c39381a7","order_by":3,"name":"YanJun Xu","email":"","orcid":"","institution":"Peace Hospital Affiliated to Changzhi Medical College","correspondingAuthor":false,"prefix":"","firstName":"YanJun","middleName":"","lastName":"Xu","suffix":""},{"id":522597833,"identity":"b190dd5f-b6f6-447a-97ce-711a9aa7c7bc","order_by":4,"name":"HaoDong Zhang","email":"","orcid":"","institution":"Peace Hospital Affiliated to Changzhi Medical 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14:21:32","extension":"html","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":114061,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7262949/v1/fb03d039b69ac4e59a52d0fa.html"},{"id":93576351,"identity":"0467c831-676a-4b60-be2c-2b81ee38fe50","added_by":"auto","created_at":"2025-10-15 09:32:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":797938,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7262949/v1/5754b01d-cfe1-4c52-9621-e0ecc0355dbe.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effectiveness of a Portable Multifaceted Feedback Mechanism for Formative Assessment in Standardized Training of Surgical Residents: A Randomized Controlled Trial","fulltext":[{"header":"Background","content":"\u003cp\u003eEducational evaluation originated in the 1930s. Currently, it can be categorized into summative assessment, diagnostic assessment, and formative assessment. Formative assessment refers to teaching methods where students receive timely feedback during activities (training) and can improve their performance through self-correction. The Operational Skills Direct Observation Method (Portable Multifaceted Feedback Mechanism) is a crucial form of formative assessment. The implementation of evaluation itself may drive learning behaviors, thereby becoming part of the instructional design process. Through the use of tools, providing timely feedback when incorporated into curricula can guide better teaching practices\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e][\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e][\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. International studies have successively indicated that portable multifaceted feedback mechanism scoring has shown significant positive effects in improving skill proficiency during training for urology, gastroenterology endoscopy, otolaryngology, and general practitioner programs\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e][\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. However, there are currently few studies on the application of portable multifaceted feedback mechanism scoring in surgical residency training\u003csup\u003e[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/sup\u003e. Recognizing peer residents as valuable sources of feedback\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e, and guided by Chinese and international surgical training standards (e.g., \u0026ldquo;Content and Standards for Standardized Training of Resident Physicians\u0026rdquo;), this randomized controlled trial (RCT) aims to evaluate the effectiveness of formative assessment using the PMFS(Portable Multimodal Feedback System) within the standardized surgical residency program.\u003c/p\u003e\u003cp\u003eThe standardized residency training program (hereinafter referred to as \"Resident Training\") is a systematic and standardized program for medical students with bachelor's degrees or higher who undergo training as resident physicians after completing five years of medical school education.\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e][\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e As a crucial component of post-graduate education, it plays a vital role in cultivating high-caliber clinicians and improving healthcare quality. It also serves as an essential requirement for advancing medical reforms and building a people-oriented healthcare system\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e][\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e][\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e. Surgery, as a comprehensive medical discipline, presents significant challenges to Resident Training due to its broad service scope, extensive coverage, high patient expectations, and stringent requirements for surgical precision\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e"},{"header":"Method","content":"\u003cp\u003eThis study enrolled 68 resident physicians undergoing surgical training at our hospital from August 2022 to August 2024, comprising 56 males and 12 females. Sixty participants held master\u0026apos;s degrees while 8 had bachelor\u0026apos;s degrees. Comparative analysis of baseline data between groups showed no statistically significant differences (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05), confirming comparability. See Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. Following a fully randomized design, residents were randomly assigned to experimental and control groups. All participants received standardized surgical training across relevant departments. Evaluation panels, consisting of 1\u0026ndash;2 experienced senior attending physicians or higher-level instructors, conducted direct observations of residents\u0026apos; procedures for scoring. Prior to the study, we incorporated best practices from mini-CEX and Direct Observation of Surgical Skills (DOPS) in formative assessment. To ensure reliability, evaluators received training in Portable Multimodal Feedback Systems prior to assessments, establishing standardized protocols and mitigating inter-rater bias for objectivity\u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e][\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. The experimental group underwent formative evaluations through these systems during departmental training. Post-training assessments were conducted using the Portable Multimodal Feedback System (PMFS) scoring scale at 2 weeks (Group 1),4 weeks (Group 2), and 1 week before graduation (Group 3). During the evaluation period, our hospital\u0026apos;s standardized clinical practice skills assessment scale (commonly referred to as the \u0026quot;General Scale\u0026quot;) was used for scoring. The control group underwent summative evaluations, including a General Scale assessment and a Portable Multifaceted Feedback Mechanism (PMFM) evaluation one week before graduation. Peer evaluations among resident physicians were enhanced through simultaneous assessments with the PMFM, with specific procedures: A physician provided a unified evaluation of their peers\u0026apos; overall performance to better monitor residents \u0026apos;progress and research outcomes. The operational items and subjects included: 1) Tracheal intubation; 2) Cardiopulmonary resuscitation (CPR); 3) Wound debridement; 4) Abscess incision and drainage; 5) Thoracentesis; 6) Lumbar puncture; 7) Abdominal puncture; 8) Sterile drapes; 9) Catheterization; 10) Surgical hand disinfection; 11) Spinal injury transportation; 12) Limb fracture fixation techniques; 13) Surgical wound dressing and suture removal; 14) Basic surgical procedures (incision, exposure, suturing, ligating, hemostasis). Except for CPR, all other patients served as operational subjects with their guardians\u0026apos; consent and signed informed consent forms. The PMFM evaluation criteria primarily covered 11 aspects: 1) Understanding and executing skill instructions; 2) Informed consent communication; 3) Preoperative preparation; 4) Appropriate anesthesia safety; 5) Skill proficiency; 6) Aseptic technique adherence; 7) Seeking assistance when needed; 8) Postoperative care; 9) Communication skills; 10) Professional competence and empathy; 11) Overall performance. Each evaluation item in the aforementioned assessment framework is scored on a 9-point scale, where 1\u0026ndash;3 points indicate non-compliance, 4\u0026ndash;6 points meet requirements, and 7\u0026ndash;9 points demonstrate excellence. Based on teacher evaluations and feedback, both students and evaluators rate satisfaction using a 9-point scale (1 being the lowest and 9 the highest). The general scale utilizes each project\u0026apos;s skill assessment criteria established by the research institute and employs a percentage system. Peer evaluations among resident physicians categorize grades as: Excellent, Good, Qualified, Basically Qualified, and Unqualified. This comprehensive evaluation system assesses residents\u0026apos; overall competencies according to the latest \u0026quot;Resident Standardized Training Content and Standards (2022 Edition)\u0026quot;, which outlines six core competencies: professional ethics, clinical competence, patient management, communication and collaboration, teaching ability, and continuous learning. Scores from the portable multi-feedback scale and general scale were compared between the experimental group and control group. Additionally, satisfaction levels among students and teachers, as well as peer evaluations, were analyzed across both groups. Data analysis was conducted using SPSS 27.0 software. For data lacking normal distribution or homogeneity of variance, rank sum tests were employed; other data were compared through t-tests or ANOVA. Linear regression analysis was also conducted to verify trend patterns in relevant data.\u003c/p\u003e"},{"header":"Result","content":"\u003cp\u003eWhen comparing item scores across the Portable Multimodal Feedback System rating scales in each group, the experimental group demonstrated statistically significant superiority over the control group (P \u0026lt; 0.05). Significant differences were observed between Experimental Groups 1, 2, and 3 in the evaluation of the Portable Multimodal Feedback System (P \u0026lt; 0.05), as detailed in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Analysis of all items on the general scale across groups revealed that the experimental group significantly outperformed the control group (P \u0026lt; 0.05), with notable disparities among Groups 1, 2, and 3, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. When comparing teacher and student satisfaction scores across groups, no significant differences were found between the experimental Group 1 and the control Group regarding teacher satisfaction, while significant differences emerged between Groups 2 and 3, as presented in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. When comparing peer evaluation forms among resident physicians in the experimental group, we found that peer satisfaction with each other's evaluation showed a positive trend, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e\u003cdiv class=\"gridtable\"\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\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\u003eComparison of general data\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003egroup\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003enumber of people\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSex (male/female, name)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eAge (years, x ± s)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003erecord of formal schooling\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eBachelor degree\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eMaster's degree\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eexperimental group\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30/8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e24.44 ± 2.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e35\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003econtrol group\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26/4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e24.45 ± 2.52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eχ\u003csup\u003e2\u003c/sup\u003e/ t\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.821\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.254\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e1.108\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.415\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.801\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e0.272\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cdiv class=\"gridtable\"\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\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\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\u003eComparison of scores of items in the portable multi-feedback mechanism scale\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eproject\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003econtrol group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eExperimental group 1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eExperimental group 2\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eExperimental group 3\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eF/H\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eP\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ecatheter\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e79.87 ± 9.446\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e73.74 ± 10.396a\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e83.75 ± 6.863b\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e88.90 ± 4.759abc\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e23.593\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAbdominal puncture\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e70.54 ± 7.450\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e75.02 ± 5.572a\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e82.29 ± 4.951ab\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e86.41 ± 4.398abc\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e55.874\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTreatment of spinal cord injury\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e78.54 ± 3.975\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e76.04 ± 4.190a\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e86.65 ± 2.560ab\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e92.87 ± 1.310abc\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e216.496\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eClose the chest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e66.61 ± 11.299\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e37.88 ± 4.262a\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e62.57 ± 7.706ab\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e74.68 ± 6.992abc\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e157.855\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOpen the chest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e64.91 ± 7.365\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e42.97 ± 7.609a\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e66.24 ± 7.902b\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e81.65 ± 6.855abc\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e173.440\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAbscess incision\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e73.72 ± 6.929\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e57.23 ± 5.569a\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e73.71 ± 3.965b\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e84.42 ± 3.280abc\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e190.302\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003etrachea cannula\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e69.48 ± 10.243\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e48.85 ± 6.790a\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e70.47 ± 5.988ab\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e84.94 ± 4.181abc\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e174.354\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003edebride\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e67.96 ± 9.605\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e56.80 ± 5.784a\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e73.47 ± 6.342ab\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e83.61 ± 6.537abc\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e94.872\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBasic surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e64.07 ± 3.232\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e54.65 ± 4.189a\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e67.75 ± 4.428ab\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e79.29 ± 4.110abc\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e238.854\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFractured limb\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e73.78 ± 7.992\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e58.87 ± 4.364a\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e72.77 ± 9.358b\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e83.48 ± 3.913abc\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e85.658\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSurgical dressing and removal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e79.34 ± 3.655\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e66.56 ± 7.678a\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e80.77 ± 4.276b\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e91.20 ± 3.266abc\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e148.971\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHands are disinfected during surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e70.56 ± 5.367\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e66.20 ± 6.008a\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e78.81 ± 6.769ab\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e91.09 ± 3.563abc\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e143.550\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDisinfectant towels\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e67.68 ± 15.224\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e65.43 ± 10.738\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e78.28 ± 6.713ab\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e80.42 ± 17.420ab\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e12.059\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ecardio-pulmonary resuscitation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e72.49 ± 9.936\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e56.45 ± 10.337a\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e73.82 ± 6.676b\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e89.44 ± 5.984abc\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e98.729\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eparacentesis of chest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e76.38 ± 9.452\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e59.02 ± 10.772a\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e76.33 ± 8.022b\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e90.35 ± 5.510abc\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e84.206\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCorning's puncture\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e74.16 ± 6.029\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e64.32 ± 8.771a\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e80.30 ± 8.464ab\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e89.35 ± 4.695abc\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e79.575\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cdiv class=\"gridtable\"\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\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of scores of items in the general scale for each group\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eproject\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003econtrol group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eExperimental group 1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eExperimental group 2\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eExperimental group 3\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eF/P\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eP\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ecatheter\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e85.11 ± 7.506\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e75.10 ± 10.017a\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e87.87 ± 5.582b\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e93.08 ± 3.704ab\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e43.370\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAbdominal puncture\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e74.81 ± 5.854\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e66.91 ± 5.667a\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e81.38 ± 4.192ab\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e90.69 ± 3.899abc\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e156.900\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTreatment of spinal cord injury\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e85.91 ± 4.211\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e80.21 ± 4.059\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e91.92 ± 1.974ab\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e96.18 ± 1.218abc\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e193.698\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eClose the chest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e72.86 ± 5.344\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e57.97 ± 5.029a\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e75.71 ± 7.664ab\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e87.34 ± 4.746abc\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e214.998\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOpen the chest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e72.86 ± 5.334\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e57.97 ± 5.029a\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e75.71 ± 7.664b\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e87.34 ± 4.746abc\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e162.766\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAbscess incision\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e78.06 ± 7.426\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e64.36 ± 5.379a\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e78.67 ± 3.736b\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e86.14 ± 3.654abc\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e118.913\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003etrachea cannula\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e80.92 ± 5.709\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e61.03 ± 5.535a\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e79.57 ± 3.927b\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e89.71 ± 3.770abc\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e242.398\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003edebride\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e74.46 ± 2.758\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e57.60 ± 7.760a\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e76.96 ± 3.469b\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e85.99 ± 4.265abc\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e90.176\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBasic surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e74.46 ± 2.758\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e57.60 ± 7.760a\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e76.96 ± 3.469ab\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e85.99 ± 4.265abc\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e209.566\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFractured limb\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e80.48 ± 7.444\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e63.98 ± 8.341a\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e81.52 ± 7.157b\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e90.19 ± 4.150abc\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e94.786\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSurgical dressing and removal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e88.75 ± 3.031\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e75.88 ± 7.269a\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e89.03 ± 3.976b\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e96.01 ± 1.620abc\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e128.882\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHands are disinfected during surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e76.75 ± 5.618\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e70.99 ± 4.846a\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e84.21 ± 5.076ab\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e95.01 ± 2.689abc\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e187.153\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDisinfectant towels\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e78.96 ± 9.665\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e72.16 ± 6.689a\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e86.81 ± 6.023ab\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e94.87 ± 2.844abc\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e84.161\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ecardio-pulmonary resuscitation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e82.97 ± 8.074\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e71.40 ± 7.583a\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e84.24 ± 3.352b\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e94.79 ± 1.685abc\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e107.282\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eparacentesis of chest\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e84.28 ± 5.751\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e66.01 ± 6.842a\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e81.27 ± 6.194b\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e90.72 ± 3.131abc\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e129.339\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCorning's puncture\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e82.51 ± 5.558\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e69.40 ± 9.358a\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e85.93 ± 7.051ab\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e92.96 ± 4.806abc\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e75.965\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cdiv class=\"gridtable\"\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\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of satisfaction scores between teachers and resident physicians\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003egroup\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003econtrol group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eExperimental group 1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eExperimental group 2\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eExperimental group 3\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eH\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eP\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eteacher\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6(4,7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3(2,4)a\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6(5,7)b\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8(7,9)abc\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e63.496\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003estudent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6(5,7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3(2,5)a\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6(5,7)ab\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8(8,9)abc\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e68.891\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eZ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.405\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.752\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.685\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.987\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.945\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.080\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cdiv class=\"gridtable\"\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\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of peer evaluations among resident physicians\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003c/colgroup\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003edivide into groups\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e\u003cp\u003ePeer resident physician evaluation level\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eB and P\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eoutstanding\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003egood\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003equalified\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eBasically qualified\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eunqualified\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eExperimental group 1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6(15.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10(26.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e20(52.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2(5.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eB = 4.061\u003c/p\u003e\u003cp\u003eP \u0026lt; 0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eExperimental group 2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4(10.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5(13.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18(47.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e10(26.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1(3.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eExperimental group 3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9(23.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13(34.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10(26.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6(15.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn most cases, we focus more on training in fundamental skills such as clinical thinking, medical record writing, and bedside management, as well as the pass rate training for the \"dual certification\" exam (Physician Practice Certificate and Hospital Training Completion Certificate). However, we often neglect the training of surgical skills, with many residents lacking opportunities to perform or independently operate.\u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e][\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e A reasonable teaching mechanism and evaluation system are particularly crucial, facilitating comprehensive improvement in residents 'clinical practice abilities and their problem-solving capabilities\u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. The portable multi-dimensional feedback mechanism serves as an important formative assessment method. It embodies the three elements of formative evaluation (FED: feedback-encouragement-guidance), providing immediate feedback through direct observation of students' operational processes\u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e][\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e. This innovative clinical assessment tool emphasizes teaching processes, future development, and student growth, thereby enhancing the quality of educational activities\u003csup\u003e[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/sup\u003e.Our randomized controlled trial demonstrates that the PMFS, as a structured formative assessment tool, significantly enhances surgical residents' procedural competencies compared to traditional summative evaluation. These findings align with international evidence on Direct Observation of Procedural Skills (DOPS) efficacy in specialties like endoscopy and urology, yet extend its validation to comprehensive surgical training\u0026mdash;a domain previously underexplored.\u003c/p\u003e\u003cp\u003eMechanisms of PMFS Effectiveness\u003c/p\u003e\u003cp\u003eIn our practice, we employ this method to assess each teaching module and conduct three evaluations for residents. Results show that the portable multi-dimensional feedback mechanism yields better outcomes compared to summative evaluations. Through analysis, we concluded that in clinical practice, using summative evaluation methods\u0026mdash;where instructors only provide clinical guidance during residency rotations and expect trainees to repeatedly practice independently\u0026mdash;fails to help students develop practical competencies. The instructor's casual teaching style makes it difficult to comprehensively observe trainees' actual operational processes. To enable trainees to evaluate their skills and identify areas for improvement, implementing a portable multi-dimensional feedback mechanism provides 2\u0026ndash;3 opportunities for repeated practice, feedback, correction, and assessment. Results showed that the experimental group scored higher on both the general scale and the portable multi-dimensional feedback scoring scale in their second evaluation than the control group. This demonstrates that formative evaluation through the portable multi-dimensional feedback mechanism can significantly enhance residency physicians 'clinical skills in a shorter timeframe compared to single summative assessment methods. In clinical practice, trainees frequently perform procedures like catheterization, dressing changes, and suture removal daily. However, data from both groups revealed that general scale scores remained notably lower than those from the portable multi-dimensional feedback mechanism. The primary reason lies in trainees' lack of proactive instructor observation during these procedures\u0026mdash;such as surgical drapes disinfection. Typically, instructors only arrive in the operating room after trainees complete these tasks. Some instructors with strong teaching philosophies may proactively observe procedures beforehand and discuss their strengths and weaknesses with trainees. Teachers with weaker pedagogical skills tend to avoid proactively observing and identifying issues, often leaving problems for final evaluations\u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e. In the Portable Multimodal Feedback System assessment, resident physicians spend 10\u0026ndash;15 minutes demonstrating sterile towel placement techniques. Instructors evaluate using this method, followed by 5\u0026ndash;10 minute discussion sessions lasting no more than half an hour. This approach minimizes workload while enabling physicians to promptly identify and correct errors through repeated practice, observation, guidance, and refinement\u0026mdash;a virtuous cycle that ensures mastery of surgical skills\u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e. National health authorities mandate in surgical training that residents master complex procedures such as independent thoracic surgery, general abdominal appendectomy, high ligation of inguinal hernia, and circumcision. However, in today's increasingly risky healthcare landscape, residents rarely perform these surgeries independently. Even when given opportunities, many abandon attempts due to lack of confidence, particularly in independent thoracotomy and closure procedures\u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e][\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e. Our team underwent rigorous training using the portable multi-feedback system. The open-chest group included 38 students (experimental) versus 30 (control), while the closed-chest group had 38 students (experimental) versus 30 (control). The comparative results demonstrate that the experimental group achieved significantly higher proficiency in thoracotomy and closure techniques compared to the control group. Through three rounds of real-time assessment via a Portable Multimodal Feedback System, resident physicians 'confidence was progressively strengthened, motivating them to actively learn and improve their skills. This led to a gradual upward spiral in evaluation outcomes across both assessment scales. Therefore, implementing standardized Portable Multimodal Feedback Systems in clinical practice not only enhances residents' mastery of advanced techniques\u0026mdash;aligning with national training objectives\u0026mdash;but also boosts their self-confidence and professional identity. The American College of Graduate Medical Education (ACGME) outlines six core competencies for residency training: patient care, medical knowledge, systems-based practice, practice-based learning and improvement, professional ethics, and communication. China's healthcare institutions have similarly established three core competencies: theoretical knowledge, clinical skills, and humanistic values. The 16-item assessment framework of the Portable Multimodal Feedback System covers not only medical knowledge and clinical skills but also interpersonal communication, professional ethics, and patient care\u0026mdash;essential elements of medical humanities. In practice, not all procedures (e.g., dressing changes or intubation) require anesthesia, making them unsuitable for the standardized evaluation system. Consequently, we organized expert discussions with surgical residency training specialists to develop customized assessment tools for each procedure\u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e][\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e. For example, in the cardiopulmonary resuscitation test item, \"to judge consciousness and call for help\" was changed to \"informed consent notification and communication\"; \"safe and appropriate anesthesia\" was replaced by \"appropriate and safe environment assessment\"; and \"sterile concept\" was changed to \"accuracy of pressure and ventilation\". During the evaluation process, we focused on the following key components: \"Technical Proficiency\" to develop students 'ability to manage sudden cardiac arrest; \"Compression Force and Depth\" to assess CPR effectiveness; and \"Follow-up Care\" to enhance their capacity for advanced life support after effective CPR. Regarding dressing changes and catheterization, the evaluation criteria shifted from \"safe and appropriate anesthesia\" to \"humanistic and safe anesthesia,\" with enhanced medical safeguards including maintaining warmth, ensuring patient privacy, and avoiding verbal stimulation. This personalized portable multi-dimensional feedback mechanism corrected inappropriate elements in the assessment framework, emphasized critical steps requiring mastery, aligned closely with clinical practice, and significantly improved residency physicians' practical experience and core competencies.\u003c/p\u003e\u003cp\u003eSatisfaction and Peer Feedback Dynamics\u003c/p\u003e\u003cp\u003eIn our research, we observed that both student and teacher satisfaction in the experimental group showed upward trends through implementing a formative evaluation system with Portable Multimodal Feedback Systems. We believe this improvement primarily stems from the strict adherence to feedback principles during the formative evaluation process: conducting 5\u0026ndash;10 minute post-operation discussions after each task, and requiring evaluators to follow these guidelines: 1) Descriptive: Use descriptive language to specifically point out strengths and weaknesses during operations; 2) Timeliness: Provide immediate feedback post-operation while continuing observation and supervision during teaching; 3) Constructive: Offer corrective, non-critical feedback along with corresponding suggestions for improvement and follow-up plans; 4) Interactivity: Teachers listen to students 'perspectives, check comprehension of feedback content, and allow students to identify areas for instructional improvement. Feedback stands as the most significant distinction and characteristic of the Portable Multimodal Feedback System compared to traditional operational assessments, representing a crucial feature of formative evaluation. We require teachers to implement the \"sandwich\" feedback rule\u0026mdash;first acknowledging the commendable aspects of trainee doctors' operations, then pointing out areas needing improvement. This feedback approach demands not only solid theoretical foundations, rich practical experience, and meticulous instructional design from teachers, but also the ability to effectively manage and adapt to situations. This approach has motivated students to take the initiative in learning, become proficient in practical operations, and balance theoretical knowledge with hands-on experience\u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e][\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e. It has enhanced their problem-solving capabilities, communication skills, and interpersonal competencies, particularly in developing practical skills and humanistic awareness. Consequently, both teacher satisfaction and evaluation outcomes have shown positive trends since the implementation of this assessment system\u003csup\u003e[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e. However, maintaining consistent scoring across different instructors remains challenging due to the lack of standardized formats for feedback formats, content, and duration, which grants teachers significant autonomy. Therefore, teacher training is crucial for ensuring evaluation consistency. We established a skills-training evaluation team to conduct research and discussions. During teacher training programs, we emphasize continuous feedback and improvement to help educators fully grasp the essence of the portable multi-dimensional feedback mechanism, thereby enhancing their observation, evaluation, and feedback skills. This helps reduce subjective biases among teachers, standardize evaluation criteria, and improve the reliability and effectiveness of assessments. Additionally, our surveys revealed increasing satisfaction among peer residents during mutual evaluations, further validating the role of peer assessment in formative evaluation processes.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, the evaluation of portable multi-dimensional feedback mechanisms in standardized training for surgical residents effectively enhances their mastery of clinical skills, significantly improves core competencies and overall professional qualities. Furthermore, this approach facilitates teaching-learning interactions through mutual feedback between instructors and residents. This resident training model represents a replicable and scalable methodology worthy of widespread adoption.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePMFS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePortable Multimodal Feedback System\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eResident Training\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eThe standardized residency training program\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eDOPS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eDirect Observation of Procedural Skills\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePMFM\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePortable Multifaceted Feedback Mechanism\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCPR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCardiopulmonary resuscitation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eFED\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003efeedback-encouragement-guidance\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eACGME\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eThe American College of Graduate Medical Education\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eClinical trial number:\u003c/strong\u003enot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cstrong\u003e :\u003c/strong\u003eThe Ethics Committee of Peace Hospital Affiliated to Changzhi Medical College formally reviewed this practical teaching project and granted an exemption from ethical review.All procedures performed in this study were in accordance with the ethical principles of the Declaration of Helsinki.Informed consent was obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cstrong\u003e :\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003cstrong\u003e :\u003c/strong\u003e The authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003eInstitute-level projects（HPYJ202203）院级课题（HPYJ202203）基于便携式多元反馈机制的外科住院医师规范化培训中混合式教学的管理研究\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSong YingMing: conceived and designed the experiment, conducted the research, collected data, analyzed and interpreted the data, and drafted the article; reviewed and supported the content of the article.\u003c/p\u003e\n\u003cp\u003eWu JiaHui: drafted the article, collected data, analyzed and interpreted the data, performed statistical analysis, and reviewed the content of the article.\u003c/p\u003e\n\u003cp\u003eHan Chao: collected and analyzed data, and reviewed the content of the article.\u003c/p\u003e\n\u003cp\u003eXu YanJun: collected and analyzed data, and reviewed the content of the article.\u003c/p\u003e\n\u003cp\u003eZhang HaoDong: collected and analyzed data, and reviewed the content of the article.\u003c/p\u003e\n\u003cp\u003eLi KeYan:collected and analyzed data, and reviewed the content of the article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCorresponding author\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCorrespondence to YingMing Song,Email:[email protected]\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAcknowledgements :\u003c/strong\u003eWe sincerely thank all the students and their teachers who participated in this study and provided insights into the standardized training of resident physicians。\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; information \u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYingming Song : Department of Gastrointestinal Surgery, Peace Hospital Affiliated to Changzhi Medical College, Changzhi,China\u003c/p\u003e\n\u003cp\u003eJiahui Wu : The First Clinical College of Changzhi Medical College, Changzhi,China\u003c/p\u003e\n\u003cp\u003eChao Han :Department of Gastrointestinal Surgery, Peace Hospital Affiliated to Changzhi Medical College, Changzhi,China\u003c/p\u003e\n\u003cp\u003eYanjun Xu :Department of Gastrointestinal Surgery, Peace Hospital Affiliated to Changzhi Medical College, Changzhi,China\u003c/p\u003e\n\u003cp\u003eHaodong Zhang :Department of Gastrointestinal Surgery, Peace Hospital Affiliated to Changzhi Medical College, Changzhi,China\u003c/p\u003e\n\u003cp\u003eKeyan Li :Department of Gastrointestinal Surgery, Peace Hospital Affiliated to Changzhi Medical College, Changzhi,China\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eElzubeir M, Rizk D. 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Medical education challenges in Mainland China: An analysis of the application of problem-based learning. Med Teach. 2025 Apr;47(4):713-728. doi: 10.1080/0142159X.2024.2369238.\u003c/li\u003e\n \u003cli\u003eLeBlanc C, Sonnenberg LK, King S, Busari J. Medical education leadership: from diversity to inclusivity. GMS J Med Educ. 2020 Mar 16;37(2):Doc18. doi: 10.3205/zma001311.\u003c/li\u003e\n \u003cli\u003eDavey P, Thakore S, Tully V. How to embed quality improvement into medical training. BMJ. 2022 Feb 24;376:e055084. doi: 10.1136/bmj-2020-055084.\u003c/li\u003e\n \u003cli\u003eJohnson CE, Keating JL, Leech M, Congdon P, Kent F, Farlie MK, Molloy EK. Development of the Feedback Quality Instrument: a guide for health professional educators in fostering learner-centred discussions. BMC Med Educ. 2021 Jul 12;21(1):382. doi: 10.1186/s12909-021-02722-8.\u003c/li\u003e\n \u003cli\u003eTian J, Hui Z, Lei H. 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The development and validation of a questionnaire to explore medical students\u0026apos; learning in a blended learning environment. BMC Med Educ. 2022 Jan 3;22(1):4. doi: 10.1186/s12909-021-03045-4\u003c/li\u003e\n \u003cli\u003eMaqsood Z, Sajjad M, Yasmin R. Effect of feedback-integrated reflection, on deep learning of undergraduate medical students in a clinical setting. BMC Med Educ. 2025 Jan 14;25(1):66. doi: 10.1186/s12909-025-06648-3.\u003c/li\u003e\n \u003cli\u003eCardoso SA, Suyambu J, Iqbal J, Cortes Jaimes DC, Amin A, Sikto JT, Valderrama M, Aulakh SS, Ramana V, Shaukat B, Patel T. Exploring the Role of Simulation Training in Improving Surgical Skills Among Residents: A Narrative Review. Cureus. 2023 Sep 4;15(9):e44654. doi: 10.7759/cureus.44654.\u003c/li\u003e\n \u003cli\u003eJelovsek JE, Kow N, Diwadkar GB. Tools for the direct observation and assessment of psychomotor skills in medical trainees: a systematic review. Med Educ. 2013 Jul;47(7):650-73. doi: 10.1111/medu.12220.\u003c/li\u003e\n \u003cli\u003eCastro MABE, de Almeida RLM, Lucchetti ALG, Tibiri\u0026ccedil;\u0026aacute; SHC, da Silva Ezequiel O, Lucchetti G. The Use of Feedback in Improving the Knowledge, Attitudes and Skills of Medical Students: a Systematic Review and Meta-analysis of Randomized Controlled Trials. Med Sci Educ. 2021 Oct 18;31(6):2093-2104. doi: 10.1007/s40670-021-01443-3.\u003c/li\u003e\n \u003cli\u003eSkinner C, Valentin K, Davin L, Leahy T, Berlach L. Shaping minds and hearts in medical education: Embedding and implementing a personal and professional development curriculum. Med Teach. 2024 Dec;46(12):1544-1552. doi: 10.1080/0142159X.2024.2409283.\u003c/li\u003e\n \u003cli\u003eHennel EK, Trachsel A, Subotic U, L\u0026ouml;rwald AC, Harendza S, Huwendiek S. How does multisource feedback influence residency training? A qualitative case study. Med Educ. 2022 Jun;56(6):660-669. doi: 10.1111/medu.14798.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"teaching, resident physicians, surgery, Portable Multifaceted Feedback Mechanism","lastPublishedDoi":"10.21203/rs.3.rs-7262949/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7262949/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThis study investigates the effectiveness of a Portable multifaceted Feedback Mechanism in standardized training for surgical residents. Sixty-eight resident physicians undergoing training at the Peace Hospital Affiliated to Changzhi Medical College from August 2022 to August 2024 were selected as subjects and divided into experimental and control groups. DaThe experimental group utilized a formative evaluation system with a Portable Multifaceted Feedback Mechanism, while the control group employed summative evaluation.t analysis involved comparing scores across all items in the Portable Multifaceted Feedback Mechanism scoring scale and general assessment tools, evaluating teacher and student satisfaction levels, and analyzing peer physician feedback through t-tests. Results showed statistically significant differences (P\u0026lt;0.05) between experimental and control groups in both individual items of the scoring scale and general assessment tools. Significant variations were also observed across different training phases within the experimental group. Teacher and student satisfaction scores revealed no significant differences between the experimental and control groups, but significant differences existed between the control group and experimental groups 2 and 3, as well as between groups 2 and 3 (P\u0026lt;0.05). Peer physician feedback analysis demonstrated gradual improvement in evaluations toward the experimental group (B=4.061, P\u0026lt;0.05). These findings indicate that the Portable Multifaceted Feedback Mechanism proves effective in standardized training for surgical residents, representing a replicable approach worthy of wider adoption.\u003c/p\u003e","manuscriptTitle":"Effectiveness of a Portable Multifaceted Feedback Mechanism for Formative Assessment in Standardized Training of Surgical Residents: A Randomized Controlled Trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-01 05:07:26","doi":"10.21203/rs.3.rs-7262949/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c37c02a2-2378-4d96-a76a-846009bf3c84","owner":[],"postedDate":"October 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-10-15T09:23:53+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-01 05:07:26","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7262949","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7262949","identity":"rs-7262949","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}