Escaping the OR: A Pilot Study of a Jigsaw-Based Workshop to Teach Preoperative Assessment in Internal Medicine Residency

Escaping the OR: A Pilot Study of a Jigsaw-Based Workshop to Teach Preoperative Assessment in Internal Medicine Residency | 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 Escaping the OR: A Pilot Study of a Jigsaw-Based Workshop to Teach Preoperative Assessment in Internal Medicine Residency Ruth Abeles, Laura Eger, Saloni Kumar Maharaj This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7688150/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background: Preoperative assessment is a key but inconsistently taught skill in internal medicine residency, particularly in the ambulatory setting. Many residents report low confidence and limited formal training. Objective: To evaluate the effect of a structured, active learning workshop on resident knowledge and confidence in preoperative assessment. Methods: In 2025, we conducted a quasi-experimental pilot study at the University of California, San Diego. Primary Care Track residents (intervention) completed a 2-hour Jigsaw workshop on cardiovascular risk, medication management, anticoagulation, and special populations. Categorical residents (control) received usual training through consults, conferences, electives, and clinic. Pre- and post-surveys assessed knowledge (multiple-choice) and confidence (Likert scale). Results: A needs assessment of 159 residents (12% response) revealed low confidence in perioperative care; over half reported no structured training. In the control group (n=11 pre, n=10 post), minimal gains occurred (p = NS), with improvement only in anticoagulation (43.8% to 53.3%). In the intervention group (n=11 pre, n=10 post), knowledge rose in special populations (55% to 96%) and cardiovascular risk (43.3% to 66%); however p value was not statically significant. Confidence scores (n=8 pre, n=8 post) improved consistently across all domains (p <0.05), unlike controls (p = NS). Residents valued the interactive, case-based format and the gamified “Escape the OR” activity. Conclusions: A single Jigsaw-based workshop significantly improved resident knowledge and confidence, offering a scalable model to address gaps in perioperative education. Figures Figure 1 Figure 2 Background Preoperative assessment is a core competency for internal medicine residents, especially in ambulatory settings where surgical clearance is frequently requested. Despite its importance, many residency programs lack a structured outpatient preoperative curriculum, resulting in inconsistent trainee exposure and limited confidence in managing such assessments [1,2]. Traditional didactic models may not meet the needs of millennial and Gen Z learners, who benefit from more active, collaborative, and learner-centered approaches to education [3,4]. To better define local learning gaps, we conducted a needs assessment of internal medicine residents at the University of California, San Diego. Among 19 respondents, cardiac risk assessment and anticoagulation emerged as the most desired learning topics (mean interest scores 4.2 and 4.16 out of 5, respectively), while medication management (63%) and anticoagulation (58%) were rated most challenging. Many residents reported limited or no structured training in preoperative care, particularly for inpatient evaluations. These findings underscored both a strong interest and a critical educational gap, supporting the need for a formalized curriculum. The Jigsaw Teaching Method is a cooperative learning strategy in which learners become “experts” on a topic and then teach their peers in small groups [5]. This method has demonstrated effectiveness in promoting engagement, retention, and communication skills across health professions education—including pharmacy [6], dentistry [7], nursing [8], and internal medicine [9–10]. It has also shown promise in teaching complex concepts such as patient safety and women's health in internal medicine residency programs [9,10]. Furthermore, the Jigsaw format has proven adaptable to distance learning during the COVID-19 pandemic [11]. Despite its growing use, the Jigsaw method has not been formally applied to preoperative assessment education in internal medicine nor integrated into a journal club–style format. To address this gap, we developed and piloted a novel workshop using the Jigsaw Teaching Method to teach core domains of outpatient preoperative medicine. As a feasibility pilot, the study was intentionally limited to a small intervention group of primary care residents to evaluate whether the approach was practical and effective in this setting. Methods Study Design and Setting We conducted a quasi-experimental pilot study at the University of California, San Diego (UCSD) Internal Medicine Residency Program between April and May of 2025. The purpose was to evaluate the impact of a structured, interactive workshop using the Jigsaw Teaching Method on resident knowledge and confidence in preoperative assessment. The intervention was delivered within the ambulatory curriculum of the Primary Care Track. Participants and Group Assignment A total of 159 internal medicine residents were eligible to participate in the study. In April 2025, a voluntary needs assessment survey was distributed to all residents. All eight currently active residents in the Primary Care Track were pre-selected to serve as the pilot intervention group based on curriculum timing and ambulatory availability. The remaining respondents formed the control group. The intervention group participated in the Jigsaw-based 3-hour workshop in May of 2025. Control group residents continued with their usual clinical training, which included non-standardized exposure to preoperative care via inpatient consultations, continuity clinic, and elective rotations. These learning opportunities occurred organically and were not delivered as part of a formal curriculum. Data Collection and Measures Participants are invited to a voluntary pre- and post-intervention surveys that included: Multiple-choice knowledge questions Likert-scale confidence ratings across core domains of preoperative care Demographics and self-reported sources of prior training The pre- and post-intervention surveys were developed by the study authors to assess the knowledge and confidence across the four domains (Supplementary File 1). Survey data were collected using Qualtrics. All survey responses were anonymized and analyzed at the group level. Individual responses could not be linked, and no paired analysis was performed. Educational Intervention The educational intervention was a two-hour workshop built around the Jigsaw Teaching Method and active, case-based learning. It focused on four key domains of outpatient preoperative care: Cardiovascular risk assessment Medication management Anticoagulation strategies Special populations (e.g., bariatric surgery, pulmonary/kidney/liver considerations, VTE risk assessments, immunosuppressants) Learners were first assigned to “expert groups” and provided with a guided PowerPoint, a structured worksheet, and selected readings drawn from the most current literature on preoperative management. These readings—focused on cardiovascular risk, medication management, anticoagulation, and special populations—formed the foundation for a journal club–style review within each expert group. After this self-directed preparation, residents joined “home groups” composed of one expert from each domain. Within these groups, learners applied their collective knowledge to collaboratively solve two complex, integrative patient cases simulating real-world preoperative scenarios. Expert Group Materials and Journal Club Format All expert learning materials were developed using the updated perioperative medicine guidelines [1-2, 12-21] as focused “expert slices” designed to be efficiently digestible within a short preparation period. Each domain—cardiovascular risk, medication management, anticoagulation, and special populations—was accompanied by a concise expert packet that included a guided PowerPoint presentation, a structured worksheet, and distilled primary literature or guideline excerpts. These materials functioned as a mini journal club, enabling each learner to gain foundational knowledge and key takeaways within their assigned topic area. The goal was to equip learners with enough clarity and confidence to serve as peer educators during the subsequent home group case-solving session, where they applied their domain knowledge collaboratively to manage complex preoperative scenarios. Debrief and Game Following the case discussions, all participants reconvened for a faculty-led debrief that reinforced key concepts and provided clarification on challenging points. The session concluded with a gamified team activity, “Escape the OR,” in which learners worked in small groups to solve five rounds of clinical puzzles. Each completed round yielded a virtual “key” that unlocked progress toward escaping the operating room—designed to reinforce concepts and promote engagement through playful competition. Data Analysis We evaluated knowledge acquisition across four key domains—cardiovascular risk assessment, medication management, special populations, and anticoagulation—by calculating the mean percentage of correct responses before and after the intervention. For each group (control and intervention), the percentage of correct answers was derived by dividing the number of correct responses by the total number of responses (correct plus incorrect) for each question. Pre- and post-survey responses were analyzed to assess changes in self-reported confidence across seven domains of preoperative assessment. Confidence was rated on a 5-point Likert scale (1 = Not at all confident to 5 = Extremely confident). Because individual-level response data were not available, mean scores were calculated by distributing response frequencies across the total number of respondents for each group (control and intervention). Differences between the two groups were analyzed using a paired t-test.. Ethical Considerations This study was reviewed and approved by the University of California, San Diego Institutional Review Board (Protocol #810740) and was conducted in accordance with the principles of the Declaration of Helsinki. All participants provided written informed consent prior to participation. Results Needs Assessment Findings In April 2025, a voluntary needs assessment was distributed to all 159 internal medicine residents at our institution. A total of 19 residents (12% response rate) responded, with an even distribution across PGY-1 (37%), PGY-2 (37%), and PGY-3 (26%). Most respondents reported only moderate confidence in key areas of preoperative assessment, including cardiac risk stratification (74% moderately confident) and applying ACC/AHA guidelines (47% moderately confident). Confidence was lower in medication management and anticoagulation, with nearly half of respondents identifying as only slightly confident in each domain. Notably, over half (53%) reported receiving no formal education in perioperative medicine during residency. The most frequently cited challenges were medication management (63%), anticoagulation (58%), and optimization of patients with complex comorbidities such as bariatric or transplant candidates (53%). Interest in structured education was high, with average Likert scores ≥ 3.9 across all domains, and highest for cardiac risk assessment (4.21) and anticoagulation management (4.16). Preferred learning formats included interactive workshops (74%), in-person lectures (63%), and case-based discussions (63%). Knowledge Scores: In the control group (n = 11 pre, n = 10 post), notable improvement was observed only in the anticoagulation domain, with knowledge scores increasing from 43.8% to 53.3%. Medication management showed an upward trend (59.1% to 71.7%). Cardiovascular group had no change (45% to 43%), and special population showed a small change from 46.8% to 55%. Overall the results were not statistically significant (p = 0.0567). In the intervention group (n = 11, n = 10 post), the most pronounced gain occurred in the special population domain, with correct responses rising from 55% to 96.0%. A notable ismprovement was also seen in cardiovascular risk (43.3% to 66%). Changes in medication management showed no change (71.6% to 73%) and anticoagulation were minimal (53% to 60%). Similarly to control group, p value was not statically significant (p = 0.0604). Summary of Knowledge Score is presented in Fig. 1. Confidence Scores: In the control group (n = 11 pre, n = 10 post), changes in mean confidence scores were generally small and less consistent. In over half of the categories, post-test confidence scores were lower than pre-test scores (p = 0.39). In the intervention group (n = 8 pre, n = 8 post) mean confidence scores showed consistent gains in confidence across all domains following the educational session (p = 0.0003). Summary of finding is presented in Fig. 2. Training Exposure: Analysis of prior exposure to preoperative training revealed that most residents in both groups had learned from clinical experience rather than structured curricula. When stratified by setting, a larger proportion of intervention group residents reported prior ambulatory exposure, while inpatient training was more commonly cited by the control group. There was no reported training in medical school setting. Learner Feedback and Engagement: Residents in the intervention group reported high levels of engagement with the workshop format. Participants appreciated the case-based learning, peer teaching structure, and real-world applicability of the content. Several noted that the material was dense and suggested allocating more time in future sessions to better absorb the readings and expert group discussions. The final gamified activity, “Escape the OR,” was particularly well received. Residents demonstrated strong enthusiasm and teamwork, describing the game as a fun, high-energy way to apply their knowledge and reinforce key preoperative concepts in a collaborative, competitive format. Discussion This pilot study was intentionally designed to assess the feasibility of implementing a novel, interactive preoperative medicine workshop within a residency curriculum. Our findings demonstrate that the intervention could be successfully delivered in this setting, was well received by participants, and produced encouraging trends in both knowledge acquisition and learner confidence. Although overall knowledge score improvements did not reach statistical significance, the intervention group demonstrated marked gains in clinically nuanced domains such as special populations and cardiovascular risk management. These findings suggest that the Jigsaw-based, case-centered approach may be particularly effective in reinforcing complex topics that are less consistently covered in standard curricula. In contrast, more limited improvement was observed in medication management and anticoagulation, areas where residents may already have higher baseline familiarity or where more detailed reinforcement is needed. The most compelling finding was the significant increase in self-reported confidence across all domains in the intervention group (p = 0.0003), in contrast to inconsistent or declining confidence in the control group. This aligns with prior literature supporting experiential and gamified approaches as strategies to enhance engagement, self-efficacy, and collaborative learning. As a feasibility pilot, the small sample size, single-site implementation, and voluntary participation are acknowledged limitations. However, these parameters were intentional to determine whether such an intervention could be feasibly implemented, integrated into workflow, and generate measurable signals of impact. The trends observed, particularly in learner confidence and domain-specific knowledge, support the potential value of scaling this intervention. Future directions include expanding to larger cohorts across multiple residency sites, evaluating durability of knowledge and confidence gains over time, and exploring downstream outcomes such as clinical decision-making and patient safety. Conclusion This pilot study demonstrates the feasibility of implementing a brief, interactive preoperative medicine workshop for internal medicine residents. While limited by small sample size, the intervention showed promising trends in knowledge gains and produced significant improvements in learner confidence. These findings support the potential for broader implementation and future evaluation in larger, multi-site cohorts. Declarations Human Ethics and Consent to Participate declarations: Not applicable. Consent to Participate: Written informed consent was obtained from all participants involved in this study. Consent for Publication: Written informed consent was obtained from the participant(s) for publication of this study and any accompanying figures or images. Availability of data and materials The datasets generated and/or analyzed during the current study are not publicly available due to institutional privacy policies and the presence of identifiable information within the survey responses. De-identified data may be available from the corresponding author upon reasonable request and with permission from the University of California, San Diego. Competing interests The authors declare that they have no competing interests. Funding Declaration: This study was supported by the University of California, San Diego Sanford Institute Mini-Grant. Authors’ contributions RA conceived and designed the study, developed the educational intervention, facilitated the educational workshop, collected and analyzed the data, and drafted and revised the manuscript. LE performed the data analysis. SKM contributed to educational learning materials and manuscript revision. All authors read and approved the final manuscript. Acknowledgements The authors would like to thank the University of California, San Diego Internal Medicine Residency Program for supporting the implementation of this pilot workshop, and the participating residents for their enthusiastic engagement. The authors also thank the Sanford Institute for Empathy and Compassion for their support through the Mini-Grant program. Clinical Trial Number: Not applicable. References Makaryus AN, et al. Preoperative evaluation: a time for assessment and risk modification. Am J Med . 2010. Qaseem A, et al. Risk assessment for and strategies to reduce perioperative pulmonary complications. Ann Intern Med . 2006. Knowles MS. The Adult Learner: A Neglected Species . Houston: Gulf Publishing; 1984. Graffam B. Active learning in medical education: strategies for beginning implementation. Med Teach . 2007. The Jigsaw Classroom. 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Supplementary Files UCSDDataanalysisKnowledgeandConfidence.xlsx NewPreandPostPreOpdata07172025.xlsx Postintervention.pdf Postcontrol.pdf Precontrol.pdf PreIntervention.pdf PreOpNeedsAssessmentFinal.docx PreSurveyFinalcopy.docx Supplement1.pdf Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 08 Dec, 2025 Reviews received at journal 05 Dec, 2025 Reviews received at journal 24 Nov, 2025 Reviewers agreed at journal 11 Nov, 2025 Reviewers agreed at journal 03 Nov, 2025 Reviewers invited by journal 22 Oct, 2025 Editor assigned by journal 22 Oct, 2025 Editor invited by journal 20 Oct, 2025 Submission checks completed at journal 17 Oct, 2025 First submitted to journal 17 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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01:19:00","extension":"html","order_by":22,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":55003,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7688150/v1/2f4d41e30cccb298caabd4b2.html"},{"id":95063783,"identity":"ff6b2469-ccae-4a84-bf47-45d807007e37","added_by":"auto","created_at":"2025-11-04 01:19:00","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":81956,"visible":true,"origin":"","legend":"\u003cp\u003eIn the control group (n=11 pre, n=10 post), notable improvement was observed only in the anticoagulation domain, with scores increasing from 43.8% to 53.3%. Medication management showed an upward trend (59.1% to 71.7%). Cardiovascular group had no change (45% to 43%), and special population showed a small change from 46.8% to 55%. In the intervention group (n=11, n=10 post), the most pronounced gain occurred in the special population domain, with correct responses rising from 55% to 96.0%. A notable improvement was also seen in cardiovascular risk (43.3% to 66%). Changes in medication management showed no change (71.6% to 73%) and anticoagulation were minimal (53% to 60%).\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7688150/v1/c114c7f1cf18735ea038e5db.jpg"},{"id":95063781,"identity":"bf30eb53-0250-4ad3-929d-4a2ccd3cb5f1","added_by":"auto","created_at":"2025-11-04 01:19:00","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":70952,"visible":true,"origin":"","legend":"\u003cp\u003eIn the control group (n=11 pre, n = 10 post), changes in mean confidence scores were generally small and less consistent. In over half of the categories, post-test confidence scores were lower than pre-test scores. In the intervention group (n=8 pre, n=8 post) mean confidence scores showed consistent gains in confidence across all domains following the educational session.\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7688150/v1/846d4d767981a4e0f67ef2e1.jpg"},{"id":95523962,"identity":"f39cac84-d3bb-4d9d-9def-f7188f529bfb","added_by":"auto","created_at":"2025-11-10 10:01:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":826552,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7688150/v1/75f8ddae-2a27-4149-b89f-960dfc0bd920.pdf"},{"id":95063784,"identity":"4048454a-09ad-4424-998d-e871e4c02d2a","added_by":"auto","created_at":"2025-11-04 01:19:00","extension":"xlsx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":18433,"visible":true,"origin":"","legend":"","description":"","filename":"UCSDDataanalysisKnowledgeandConfidence.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-7688150/v1/d9762d5116f09a04045b3d6d.xlsx"},{"id":95063785,"identity":"9f488595-804c-4c0b-9c7c-2d8532505b80","added_by":"auto","created_at":"2025-11-04 01:19:00","extension":"xlsx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":12620,"visible":true,"origin":"","legend":"","description":"","filename":"NewPreandPostPreOpdata07172025.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-7688150/v1/ae7dee074d48888f216bccc6.xlsx"},{"id":95063789,"identity":"4d314430-73f6-4281-aa32-b09d1c4eea0f","added_by":"auto","created_at":"2025-11-04 01:19:00","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":2562703,"visible":true,"origin":"","legend":"","description":"","filename":"Postintervention.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7688150/v1/26f1d4e727fb71003ba56dfe.pdf"},{"id":95063799,"identity":"957ce211-ad51-41f5-ae92-0f0582813052","added_by":"auto","created_at":"2025-11-04 01:19:00","extension":"pdf","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":2726941,"visible":true,"origin":"","legend":"","description":"","filename":"Postcontrol.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7688150/v1/2e2e6206207d4d604b2b93af.pdf"},{"id":95063795,"identity":"724e66d5-32ef-489e-8584-1ef793d59727","added_by":"auto","created_at":"2025-11-04 01:19:00","extension":"pdf","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":2756027,"visible":true,"origin":"","legend":"","description":"","filename":"Precontrol.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7688150/v1/d487b05675cb3fa3713ad17c.pdf"},{"id":95223673,"identity":"5af18395-c086-4f35-80cd-9b34f46a3022","added_by":"auto","created_at":"2025-11-05 16:22:40","extension":"pdf","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":2689860,"visible":true,"origin":"","legend":"","description":"","filename":"PreIntervention.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7688150/v1/83d7ba9c14394a8a449d3cb9.pdf"},{"id":95223432,"identity":"6cc142f1-105b-425c-bc77-78fbf2cf8262","added_by":"auto","created_at":"2025-11-05 16:22:16","extension":"docx","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":28185,"visible":true,"origin":"","legend":"","description":"","filename":"PreOpNeedsAssessmentFinal.docx","url":"https://assets-eu.researchsquare.com/files/rs-7688150/v1/b0011f8a43895d005a1ac957.docx"},{"id":95063794,"identity":"f0f59bad-fba9-4508-92e9-b7c71754db76","added_by":"auto","created_at":"2025-11-04 01:19:00","extension":"docx","order_by":8,"title":"","display":"","copyAsset":false,"role":"supplement","size":29600,"visible":true,"origin":"","legend":"","description":"","filename":"PreSurveyFinalcopy.docx","url":"https://assets-eu.researchsquare.com/files/rs-7688150/v1/434740fb4e68fd294537d237.docx"},{"id":95222989,"identity":"e82c88a0-0a25-44a6-b9f3-e1c363d4aae7","added_by":"auto","created_at":"2025-11-05 16:21:28","extension":"pdf","order_by":9,"title":"","display":"","copyAsset":false,"role":"supplement","size":68076,"visible":true,"origin":"","legend":"","description":"","filename":"Supplement1.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7688150/v1/656b3ceb64aea4b5c4847c74.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eEscaping the OR: A Pilot Study of a Jigsaw-Based Workshop to Teach Preoperative Assessment in Internal Medicine Residency\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003ePreoperative assessment is a core competency for internal medicine residents, especially in ambulatory settings where surgical clearance is frequently requested. Despite its importance, many residency programs lack a structured outpatient preoperative curriculum, resulting in inconsistent trainee exposure and limited confidence in managing such assessments [1,2]. Traditional didactic models may not meet the needs of millennial and Gen Z learners, who benefit from more active, collaborative, and learner-centered approaches to education [3,4].\u003c/p\u003e\u003cp\u003eTo better define local learning gaps, we conducted a needs assessment of internal medicine residents at the University of California, San Diego. Among 19 respondents, cardiac risk assessment and anticoagulation emerged as the most desired learning topics (mean interest scores 4.2 and 4.16 out of 5, respectively), while medication management (63%) and anticoagulation (58%) were rated most challenging. Many residents reported limited or no structured training in preoperative care, particularly for inpatient evaluations. These findings underscored both a strong interest and a critical educational gap, supporting the need for a formalized curriculum.\u003c/p\u003e\u003cp\u003eThe Jigsaw Teaching Method is a cooperative learning strategy in which learners become \u0026ldquo;experts\u0026rdquo; on a topic and then teach their peers in small groups [5]. This method has demonstrated effectiveness in promoting engagement, retention, and communication skills across health professions education\u0026mdash;including pharmacy [6], dentistry [7], nursing [8], and internal medicine [9\u0026ndash;10]. It has also shown promise in teaching complex concepts such as patient safety and women's health in internal medicine residency programs [9,10]. Furthermore, the Jigsaw format has proven adaptable to distance learning during the COVID-19 pandemic [11].\u003c/p\u003e\u003cp\u003eDespite its growing use, the Jigsaw method has not been formally applied to preoperative assessment education in internal medicine nor integrated into a journal club\u0026ndash;style format. To address this gap, we developed and piloted a novel workshop using the Jigsaw Teaching Method to teach core domains of outpatient preoperative medicine. As a feasibility pilot, the study was intentionally limited to a small intervention group of primary care residents to evaluate whether the approach was practical and effective in this setting.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy Design and Setting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe conducted a quasi-experimental pilot study at the University of California, San Diego (UCSD) Internal Medicine Residency Program between April and May of 2025. The purpose was to evaluate the impact of a structured, interactive workshop using the Jigsaw Teaching Method on resident knowledge and confidence in preoperative assessment. The intervention was delivered within the ambulatory curriculum of the Primary Care Track.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipants and Group Assignment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 159 internal medicine residents were eligible to participate in the study. In April 2025, a voluntary needs assessment survey was distributed to all residents. All eight currently active residents in the Primary Care Track were pre-selected to serve as the pilot intervention group based on curriculum timing and ambulatory availability. The remaining respondents formed the control group.\u003c/p\u003e\n\u003cp\u003eThe intervention group participated in the Jigsaw-based 3-hour workshop in May of 2025. Control group residents continued with their usual clinical training, which included non-standardized exposure to preoperative care via inpatient consultations, continuity clinic, and elective rotations. These learning opportunities occurred organically and were not delivered as part of a formal curriculum.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection and Measures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants are invited to a voluntary pre- and post-intervention surveys that included:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eMultiple-choice knowledge questions\u003c/li\u003e\n \u003cli\u003eLikert-scale confidence ratings across core domains of preoperative care\u003c/li\u003e\n \u003cli\u003eDemographics and self-reported sources of prior training\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe pre- and post-intervention surveys were developed by the study authors to assess the knowledge and confidence across the four domains (Supplementary File 1). Survey data were collected using Qualtrics. All survey responses were anonymized and analyzed at the group level. Individual responses could not be linked, and no paired analysis was performed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEducational Intervention\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe educational intervention was a two-hour workshop built around the Jigsaw Teaching Method and active, case-based learning. It focused on four key domains of outpatient preoperative care:\u003c/p\u003e\n\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003e\u003cstrong\u003eCardiovascular risk assessment\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eMedication management\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eAnticoagulation strategies\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eSpecial populations\u003c/strong\u003e (e.g., bariatric surgery, pulmonary/kidney/liver considerations, VTE risk assessments, immunosuppressants)\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eLearners were first assigned to \u0026ldquo;expert groups\u0026rdquo; and provided with a guided PowerPoint, a structured worksheet, and selected readings drawn from the most current literature on preoperative management. These readings\u0026mdash;focused on cardiovascular risk, medication management, anticoagulation, and special populations\u0026mdash;formed the foundation for a journal club\u0026ndash;style review within each expert group. After this self-directed preparation, residents joined \u0026ldquo;home groups\u0026rdquo; composed of one expert from each domain. Within these groups, learners applied their collective knowledge to collaboratively solve two complex, integrative patient cases simulating real-world preoperative scenarios.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eExpert Group Materials and Journal Club Format\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll expert learning materials were developed using the updated perioperative medicine guidelines [1-2, 12-21] as focused \u0026ldquo;expert slices\u0026rdquo; designed to be efficiently digestible within a short preparation period. Each domain\u0026mdash;cardiovascular risk, medication management, anticoagulation, and special populations\u0026mdash;was accompanied by a concise expert packet that included a guided PowerPoint presentation, a structured worksheet, and distilled primary literature or guideline excerpts. These materials functioned as a mini journal club, enabling each learner to gain foundational knowledge and key takeaways within their assigned topic area. The goal was to equip learners with enough clarity and confidence to serve as peer educators during the subsequent home group case-solving session, where they applied their domain knowledge collaboratively to manage complex preoperative scenarios.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDebrief and Game\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFollowing the case discussions, all participants reconvened for a faculty-led debrief that reinforced key concepts and provided clarification on challenging points. The session concluded with a gamified team activity, \u003cstrong\u003e\u0026ldquo;Escape the OR,\u0026rdquo;\u003c/strong\u003e in which learners worked in small groups to solve five rounds of clinical puzzles. Each completed round yielded a virtual \u0026ldquo;key\u0026rdquo; that unlocked progress toward escaping the operating room\u0026mdash;designed to reinforce concepts and promote engagement through playful competition.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe evaluated knowledge acquisition across four key domains\u0026mdash;cardiovascular risk assessment, medication management, special populations, and anticoagulation\u0026mdash;by calculating the mean percentage of correct responses before and after the intervention. For each group (control and intervention), the percentage of correct answers was derived by dividing the number of correct responses by the total number of responses (correct plus incorrect) for each question.\u003c/p\u003e\n\u003cp\u003ePre- and post-survey responses were analyzed to assess changes in self-reported confidence across seven domains of preoperative assessment. Confidence was rated on a 5-point Likert scale (1 = Not at all confident to 5 = Extremely confident). Because individual-level response data were not available, mean scores were calculated by distributing response frequencies across the total number of respondents for each group (control and intervention). Differences between the two groups were analyzed using a paired t-test..\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was reviewed and approved by the University of California, San Diego Institutional Review Board (Protocol #810740) and was conducted in accordance with the principles of the Declaration of Helsinki. All participants provided written informed consent prior to participation.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eNeeds Assessment Findings\u003c/h2\u003e\u003cp\u003eIn April 2025, a voluntary needs assessment was distributed to all 159 internal medicine residents at our institution. A total of 19 residents (12% response rate) responded, with an even distribution across PGY-1 (37%), PGY-2 (37%), and PGY-3 (26%). Most respondents reported only moderate confidence in key areas of preoperative assessment, including cardiac risk stratification (74% moderately confident) and applying ACC/AHA guidelines (47% moderately confident). Confidence was lower in medication management and anticoagulation, with nearly half of respondents identifying as only slightly confident in each domain. Notably, over half (53%) reported receiving no formal education in perioperative medicine during residency. The most frequently cited challenges were medication management (63%), anticoagulation (58%), and optimization of patients with complex comorbidities such as bariatric or transplant candidates (53%). Interest in structured education was high, with average Likert scores\u0026thinsp;\u0026ge;\u0026thinsp;3.9 across all domains, and highest for cardiac risk assessment (4.21) and anticoagulation management (4.16). Preferred learning formats included interactive workshops (74%), in-person lectures (63%), and case-based discussions (63%).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eKnowledge Scores:\u003c/h2\u003e\u003cp\u003eIn the control group (n\u0026thinsp;=\u0026thinsp;11 pre, n\u0026thinsp;=\u0026thinsp;10 post), notable improvement was observed only in the anticoagulation domain, with knowledge scores increasing from 43.8% to 53.3%. Medication management showed an upward trend (59.1% to 71.7%). Cardiovascular group had no change (45% to 43%), and special population showed a small change from 46.8% to 55%. Overall the results were not statistically significant (p\u0026thinsp;=\u0026thinsp;0.0567). In the intervention group (n\u0026thinsp;=\u0026thinsp;11, n\u0026thinsp;=\u0026thinsp;10 post), the most pronounced gain occurred in the special population domain, with correct responses rising from 55% to 96.0%. A notable ismprovement was also seen in cardiovascular risk (43.3% to 66%). Changes in medication management showed no change (71.6% to 73%) and anticoagulation were minimal (53% to 60%). Similarly to control group, p value was not statically significant (p\u0026thinsp;=\u0026thinsp;0.0604).\u003c/p\u003e\u003cp\u003eSummary of Knowledge Score is presented in Fig.\u0026nbsp;1.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eConfidence Scores:\u003c/h2\u003e\u003cp\u003eIn the control group (n\u0026thinsp;=\u0026thinsp;11 pre, n\u0026thinsp;=\u0026thinsp;10 post), changes in mean confidence scores were generally small and less consistent. In over half of the categories, post-test confidence scores were lower than pre-test scores (p\u0026thinsp;=\u0026thinsp;0.39). In the intervention group (n\u0026thinsp;=\u0026thinsp;8 pre, n\u0026thinsp;=\u0026thinsp;8 post) mean confidence scores showed consistent gains in confidence across all domains following the educational session (p\u0026thinsp;=\u0026thinsp;0.0003).\u003c/p\u003e\u003cp\u003eSummary of finding is presented in Fig.\u0026nbsp;2.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eTraining Exposure:\u003c/h2\u003e\u003cp\u003eAnalysis of prior exposure to preoperative training revealed that most residents in both groups had learned from clinical experience rather than structured curricula. When stratified by setting, a larger proportion of intervention group residents reported prior ambulatory exposure, while inpatient training was more commonly cited by the control group. There was no reported training in medical school setting.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eLearner Feedback and Engagement:\u003c/h2\u003e\u003cp\u003eResidents in the intervention group reported high levels of engagement with the workshop format. Participants appreciated the case-based learning, peer teaching structure, and real-world applicability of the content. Several noted that the material was dense and suggested allocating more time in future sessions to better absorb the readings and expert group discussions. The final gamified activity, \u0026ldquo;Escape the OR,\u0026rdquo; was particularly well received. Residents demonstrated strong enthusiasm and teamwork, describing the game as a fun, high-energy way to apply their knowledge and reinforce key preoperative concepts in a collaborative, competitive format.\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis pilot study was intentionally designed to assess the feasibility of implementing a novel, interactive preoperative medicine workshop within a residency curriculum. Our findings demonstrate that the intervention could be successfully delivered in this setting, was well received by participants, and produced encouraging trends in both knowledge acquisition and learner confidence.\u003c/p\u003e\u003cp\u003eAlthough overall knowledge score improvements did not reach statistical significance, the intervention group demonstrated marked gains in clinically nuanced domains such as special populations and cardiovascular risk management. These findings suggest that the Jigsaw-based, case-centered approach may be particularly effective in reinforcing complex topics that are less consistently covered in standard curricula. In contrast, more limited improvement was observed in medication management and anticoagulation, areas where residents may already have higher baseline familiarity or where more detailed reinforcement is needed.\u003c/p\u003e\u003cp\u003eThe most compelling finding was the significant increase in self-reported confidence across all domains in the intervention group (p\u0026thinsp;=\u0026thinsp;0.0003), in contrast to inconsistent or declining confidence in the control group. This aligns with prior literature supporting experiential and gamified approaches as strategies to enhance engagement, self-efficacy, and collaborative learning.\u003c/p\u003e\u003cp\u003eAs a feasibility pilot, the small sample size, single-site implementation, and voluntary participation are acknowledged limitations. However, these parameters were intentional to determine whether such an intervention could be feasibly implemented, integrated into workflow, and generate measurable signals of impact. The trends observed, particularly in learner confidence and domain-specific knowledge, support the potential value of scaling this intervention.\u003c/p\u003e\u003cp\u003eFuture directions include expanding to larger cohorts across multiple residency sites, evaluating durability of knowledge and confidence gains over time, and exploring downstream outcomes such as clinical decision-making and patient safety.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis pilot study demonstrates the feasibility of implementing a brief, interactive preoperative medicine workshop for internal medicine residents. While limited by small sample size, the intervention showed promising trends in knowledge gains and produced significant improvements in learner confidence. These findings support the potential for broader implementation and future evaluation in larger, multi-site cohorts.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eHuman Ethics and Consent to Participate declarations:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from all participants involved in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the participant(s) for publication of this study and any accompanying figures or images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are not publicly available due to institutional privacy policies and the presence of identifiable information within the survey responses. De-identified data may be available from the corresponding author upon reasonable request and with permission from the University of California, San Diego.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Declaration:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by the \u003cstrong\u003eUniversity of California, San Diego Sanford Institute Mini-Grant.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRA conceived and designed the study, developed the educational intervention, facilitated the educational workshop, collected and analyzed the data, and drafted and revised the manuscript. LE performed the data analysis. SKM contributed to educational learning materials and manuscript revision. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank the University of California, San Diego Internal Medicine Residency Program for supporting the implementation of this pilot workshop, and the participating residents for their enthusiastic engagement. The authors also thank the Sanford Institute for Empathy and Compassion for their support through the Mini-Grant program.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial Number:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMakaryus AN, et al. Preoperative evaluation: a time for assessment and risk modification. \u003cem\u003eAm J Med\u003c/em\u003e. 2010.\u003c/li\u003e\n\u003cli\u003eQaseem A, et al. Risk assessment for and strategies to reduce perioperative pulmonary complications. \u003cem\u003eAnn Intern Med\u003c/em\u003e. 2006.\u003c/li\u003e\n\u003cli\u003eKnowles MS. \u003cem\u003eThe Adult Learner: A Neglected Species\u003c/em\u003e. Houston: Gulf Publishing; 1984.\u003c/li\u003e\n\u003cli\u003eGraffam B. Active learning in medical education: strategies for beginning implementation. \u003cem\u003eMed Teach\u003c/em\u003e. 2007.\u003c/li\u003e\n\u003cli\u003eThe Jigsaw Classroom. Social Psychology Network. https://www.jigsaw.org. Accessed September 4, 2017.\u003c/li\u003e\n\u003cli\u003ePhilips J, Fusco J. Using the jigsaw technique to teach clinical controversy in a clinical skills course. \u003cem\u003eAm J Pharm Educ.\u003c/em\u003e 2015;79(6):90.\u003c/li\u003e\n\u003cli\u003eSagsoz O, et al. Effectiveness of Jigsaw learning in dental education. \u003cem\u003eEur J Dent Educ.\u003c/em\u003e 2017;21(1):28\u0026ndash;32.\u003c/li\u003e\n\u003cli\u003eSanaie N, et al. Comparing the effect of lecture and Jigsaw teaching strategies on nursing students. \u003cem\u003eNurse Educ Today.\u003c/em\u003e 2019;79:35\u0026ndash;40.\u003c/li\u003e\n\u003cli\u003eGoolsarran N, et al. Using the jigsaw technique to teach patient safety. \u003cem\u003eMed Educ Online.\u003c/em\u003e 2020;25(1):1710325.\u003c/li\u003e\n\u003cli\u003eNg P, et al. Using the Jigsaw Teaching Method to Enhance Internal Medicine Residents\u0026apos; Knowledge in Geriatric Women\u0026apos;s Health. \u003cem\u003eMedEdPORTAL.\u003c/em\u003e 2020;16:11003.\u003c/li\u003e\n\u003cli\u003eHaftador AM, et al. Online class or flipped-jigsaw learning during COVID-19? \u003cem\u003eBMC Med Educ.\u003c/em\u003e 2021;21(1):499.\u003c/li\u003e\n\u003cli\u003eThompson A, Fleischmann KE, Smilowitz NR, de Las Fuentes L, Mukherjee D, Aggarwal NR, Ahmad FS, Allen RB, Altin SE, Auerbach A, Berger JS, Chow B, Dakik HA, Eisenstein EL, Gerhard‑Herman M, Ghadimi K, Kachulis B, Leclerc J, Lee CS, Macaulay TE, Mates G, Merli GJ, Parwani P, Poole JE, Rich MW, Ruetzler K, Stain SC, Sweitzer B, Talbot AW, Vallabhajosyula S, Whittle J, Williams KA Sr; Peer Review Committee Members. \u003cem\u003e2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline for perioperative cardiovascular management for noncardiac surgery: a report of the American College of Cardiology/American Heart Association joint committee on clinical practice guidelines\u003c/em\u003e. \u003cem\u003eCirculation\u003c/em\u003e. 2024;150(19):e351‑e442. doi:10.1161/CIR.0000000000001285\u003c/li\u003e\n\u003cli\u003eJ\u0026oslash;rgensen ME, Torp-Pedersen C, Gislason GH, Jensen PF, Berger SM, Christiansen CB, Overgaard C, Schmiegelow MD, Andersson C. Time elapsed after ischemic stroke and risk of adverse cardiovascular events and mortality following elective noncardiac surgery. JAMA. 2014 Jul 16;312(3):269-77. doi: 10.1001/jama.2014.8165. PMID: 25027142.\u003c/li\u003e\n\u003cli\u003eSahai, Sunil K., et al. \u0026quot;Preoperative Management of Cardiovascular Medications: A Society for Perioperative Assessment and Quality Improvement (SPAQI) Consensus Statement.\u0026quot; \u003cem\u003eMayo Clinic Proceedings\u003c/em\u003e, vol. 97, no. 9, 2022, pp. 1734\u0026ndash;1751. Elsevier, https://doi.org/10.1016/j.mayocp.2022.03.039.\u003c/li\u003e\n\u003cli\u003eDoherty, John U., et al. \u0026ldquo;2017 ACC Expert Consensus Decision Pathway for Periprocedural Management of Anticoagulation in Patients with Nonvalvular Atrial Fibrillation: A Report of the American College of Cardiology Clinical Expert Consensus Document Task Force.\u0026rdquo; \u003cem\u003eJournal of the American College of Cardiology\u003c/em\u003e, vol. 69, no. 7, 21 Feb. 2017, pp. 871\u0026ndash;898. \u003cem\u003eJACC\u003c/em\u003e, doi:10.1016/j.jacc.2016.11.024.\u003c/li\u003e\n\u003cli\u003eCronin M, Dengler N, Krauss ES, Segal A, Wei N, Daly M, Mota F, Caprini JA. Completion of the Updated Caprini Risk Assessment Model (2013 Version). Clin Appl Thromb Hemost. 2019 Jan-Dec;25:1076029619838052. doi: 10.1177/1076029619838052. PMID: 30939900; PMCID: PMC6714938.\u003c/li\u003e\n\u003cli\u003eWilson S, Chen X, Cronin M, Dengler N, Enker P, Krauss ES, Laberko L, Lobastov K, Obi AT, Powell CA, Schastlivtsev I, Segal A, Simonson B, Siracuse J, Wakefield TW, McAneny D, Caprini JA. Thrombosis prophylaxis in surgical patients using the Caprini Risk Score. Curr Probl Surg. 2022 Nov;59(11):101221. doi: 10.1016/j.cpsurg.2022.101221. Epub 2022 Sep 24. PMID: 36372452.\u003c/li\u003e\n\u003cli\u003eGolemi I, Salazar Adum JP, Tafur A, Caprini J. Venous thromboembolism prophylaxis using the Caprini score. Dis Mon. 2019 Aug;65(8):249-298. doi: 10.1016/j.disamonth.2018.12.005. Epub 2019 Jan 9. PMID: 30638566.\u003c/li\u003e\n\u003cli\u003eModha K, Whinney C. Preoperative Evaluation for Noncardiac Surgery. Ann Intern Med. 2022 Nov;175(11):ITC161-ITC176. doi: 10.7326/AITC202211150. Epub 2022 Nov 8. Erratum in: Ann Intern Med. 2025 Apr;178(4):607-608. doi: 10.7326/ANNALS-25-00731. PMID: 36343344.\u003c/li\u003e\n\u003cli\u003ePfeifer KJ, Selzer A, Mendez CE, Whinney CM, Rogers B, Simha V, Regan D, Urman RD, Mauck K. Preoperative Management of Endocrine, Hormonal, and Urologic Medications: Society for Perioperative Assessment and Quality Improvement (SPAQI) Consensus Statement. Mayo Clin Proc. 2021 Jun;96(6):1655-1669. doi:10.1016/j.mayocp.2020.10.002. Epub 2021 Mar 10. PMID: 33714600.\u003c/li\u003e\n\u003cli\u003eDoherty JU et al. \u0026ldquo;2017 ACC Expert Consensus Decision Pathway for Periprocedural Management of Anticoagulation in Patients with Nonvalvular Atrial Fibrillation: A Report of the American College of Cardiology Clinical Expert Consensus Document Task Force.\u0026rdquo; JACC. 2017; 69 (7): 871-98.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7688150/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7688150/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003cbr\u003e\nPreoperative assessment is a key but inconsistently taught skill in internal medicine residency, particularly in the ambulatory setting. Many residents report low confidence and limited formal training.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003e\u003cbr\u003e\nTo evaluate the effect of a structured, active learning workshop on resident knowledge and confidence in preoperative assessment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003cbr\u003e\nIn 2025, we conducted a quasi-experimental pilot study at the University of California, San Diego. Primary Care Track residents (intervention) completed a 2-hour Jigsaw workshop on cardiovascular risk, medication management, anticoagulation, and special populations. Categorical residents (control) received usual training through consults, conferences, electives, and clinic. Pre- and post-surveys assessed knowledge (multiple-choice) and confidence (Likert scale).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003cbr\u003e\nA needs assessment of 159 residents (12% response) revealed low confidence in perioperative care; over half reported no structured training. In the control group (n=11 pre, n=10 post), minimal gains occurred (p = NS), with improvement only in anticoagulation (43.8% to 53.3%). In the intervention group (n=11 pre, n=10 post), knowledge rose in special populations (55% to 96%) and cardiovascular risk (43.3% to 66%); however p value was not statically significant. Confidence scores (n=8 pre, n=8 post) improved consistently across all domains (p \u0026lt;0.05), unlike controls (p = NS). Residents valued the interactive, case-based format and the gamified “Escape the OR” activity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e\u003cbr\u003e\nA single Jigsaw-based workshop significantly improved resident knowledge and confidence, offering a scalable model to address gaps in perioperative education.\u003c/p\u003e","manuscriptTitle":"Escaping the OR: A Pilot Study of a Jigsaw-Based Workshop to Teach Preoperative Assessment in Internal Medicine Residency","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-04 01:18:55","doi":"10.21203/rs.3.rs-7688150/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-08T11:07:30+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-05T15:14:58+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-24T20:39:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"302637197143744549149527987258510410459","date":"2025-11-12T00:06:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"174977516797985651237421548229260379472","date":"2025-11-03T15:57:39+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-22T07:22:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-22T06:45:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-10-20T06:39:25+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-17T15:13:46+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2025-10-17T15:10:52+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c267608d-6bd1-44e5-b5e1-4ec6285fd564","owner":[],"postedDate":"November 4th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-07T15:25:57+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-04 01:18:55","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7688150","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7688150","identity":"rs-7688150","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}