Surgical education – online or on-site? A single-center survey of German medical students

Surgical education – online or on-site? A single-center survey of German medical students | 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 Surgical education – online or on-site? A single-center survey of German medical students Laura Isabel Hanke, Tilman Borchardt, Florentine Huettl, Hauke Lang, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6557289/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Introduction Education as a whole has undergone a remarkable amount of change in the last 100 years. The age of digitalization had a considerable influence on education, providing new media and new techniques to convey content. Not only technical changes have had an impact on education but also scientific findings about how we learn effectively. Surgical education is no exception here and it should be considered that our teachers learned in a different way than medical students and junior residents do today. The international COVID-19 pandemic has boosted the use of digital media due to necessary social distancing measures. After reintroduction of teaching on-site opinions on the necessity of the digital teaching contents appeared to diverge between students and teachers. This representative survey aimed to highlight the “needs” and “wants” of German medical students and to analyze the use of digital teaching media in our institute. Material and Method We performed a survey using Lime Survey including students of human medicine of the Johannes Gutenberg-University Mainz, Germany. Students were asked about their use of online materials provided to them and what kind of courses they preferred for different aspects of surgical education and why. They were also asked what aspects of teaching they missed most during social distancing. Furthermore, we analyzed the use of online content created by our institute over three semesters (summer semester 2023 – summer semester 2024). Results 481 students answered the survey the majority of which were female (n = 345, 71.7%) and were in the clinical part of their studies (n = 300, 62.4%). Students by a vast majority preferred practical courses as on-site teaching, i.e. studying surgical sutures (n(completely prefer and mostly prefer on-site) = 342, 71.1%) and lectures as online classes (n(completely prefer and mostly prefer online) = 363, 75.5%). Responses were mixed regarding seminars (n(completely prefer online) = 98, 20.4%, n(completely prefer on-site) = 158, 32.9%). While attendance in the facultative lecture was comparatively low (0 to 10 students per lecture), use of online lectures was satisfactory with a median of 53 views per semester (SD 32.355, n(min) = 10, n(max) = 169). Discussion A combination of teaching in person and using digital media facilitates efficient learning for students as well as sustainable use of time for teachers. While theoretical classes like lectures lend themselves to online teaching, practical classes should be taught in person. The use of online and on-site teaching should be evaluated for every course and a mindful balance should be the overall goal. Surgical Education digital education e-learning sustainability medical education Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Education and beliefs about education in general and medical education in particular have evolved greatly over time especially in the last century [ 1 ]. While frontal lectures and observation were the teaching standard for an extended time period, more active participation of students has found its way into most subjects. The age of digitalization has further impacted education methods and media. Medical education and especially surgical education hold the added difficulty of teaching not only theoretical knowledge but also practical skills, which have to be examined in a practical manner i.e. as objective standardized clinical examination (OSCE) [ 2 ]. The broadening of the physicians job away from just treating patients to an interprofessional healthcare manager has further complicated the educational needs for future generations [ 3 ]. These circumstances come with several predicaments: teaching practical skills and use of newer teaching methods require small groups of students. While lectures can be held just as well no matter if the auditorium consists of 20 or 200 students, practical skills courses suffer in quality the larger the group. This is more time consuming and requires a greater amount of educational human resources [ 4 ]. At the same time, cost efficiency is a key objective for most healthcare systems and hospitals, making time and personnel a precious resource. Student teachers and peer teaching is a helpful way to attenuate this problem but not the overall solution [ 5 ]. Furthermore, consistency of a lecture held for the whole semester is much higher than teaching 20 or more small groups by different teachers. This means curricula have to be more concise and objectives have to be clear for all participants, teachers and students alike [ 4 ]. To optimize this, teaching the teachers is an established method in order to facilitate high quality, consistent education [ 6 ]. However, these concepts are also time-consuming and demand a high amount of motivation from teachers. The international COVID-19 pandemic challenged teachers of all subjects and all ages. Classes, which were conceptualized to be held in presence, had to be switched to e-learnings or online seminars almost overnight [ 7 , 8 ]. All aspects of medical education suffered due to the restricted contact with patients [ 9 ]. Surgical education in particular was impeded because practical skills courses were restricted, visits in the operating room were prohibited and elective surgery was postponed. Doctor-patient-interactions and practical skills are especially difficult to instruct virtually and researchers agreed that these should be taught in attendance and cannot be replaced entirely by e-learnings [ 10 , 11 ]. While some teachers had a hard time adjusting to the use of digital media during the COVID-19 pandemic, most students were well versed in the matter already. There is a wide range of supplemental information in different media, which are consumed and combined by students according to personal preference and need. Whereas most of today’s professors have studied with lectures and books, today’s students supplement this with podcast, apps and video content [ 12 ]. These media enable flexible time schedules, repetition as needed and the efficient use of time i.e. listening to a podcast while commuting or completing household chores. The concept of younger generations being more acquainted with digital technologies is also known as “digital natives” hence they grew up using these media from a very young age. While older generations (“physical natives” or “digital immigrants”) have to make a conscious effort to implement these technologies, younger generations appear to use them more effortlessly [ 13 ]. The use of e-learning starts as young as schoolchildren and is widely used across subjects. At the same time the amount of online graduate and post-graduate degree programs of all fields has rapidly increased in the last few years. Elaborate tools for at home test-taking and different study tools are commonly used by now [ 14 ]. When social distancing rules were lifted new teaching concepts which had been implemented using online tools were questioned. In personal conversations as well as student evaluation it became clear that opinions about the future of surgical education diverged between students and teachers as well as between generations. This survey aimed to identify the “wants” and “needs” of German medical students and find common ground for fruitful and effective surgical education in the future. Material and Methods Online Survey The student survey consisted of 16 questions regarding demographic information, use of online available material and preferences of online or on-site teaching for practical courses, lectures, seminars and overall. They were also asked if they missed contact to peers, teachers and patients during social distancing measures and if they attended lectures regularly before the COVID-19 pandemic. Preferences and use of online materials were assessed using 7-point Likert scales (1 = not at all, 7 = very much). In addition, there was the possibility to comment in free-text. The survey was custom-build and has not been used in prior publications. Student survey was dispersed via the student body of the faculty and during lectures and classes starting May 2023 and ending August 2023. Eligible for participation were students of human medicine of the University Medical Center at the Johannes Gutenberg-University Mainz of all semesters. We deliberately chose to exclude other universities and other medical professions (i.e. dentistry) since educational concepts differ considerably between faculties. Analysis of asynchronous lectures Of all 76 provided asynchronous online lectures 25 lectures by 10 teachers were randomly selected and their use in call-ups per semester was analyzed for summer semester 2023 (SS23), winter semester 2023/2024 (WS23/24) and summer semester 2024 (SS24). The lectures were chosen, because there had not been any changes to the lecturer or to the lectures’ structure during this time in order to minimize fluctuation in views due to change in teaching personnel or style. The time period was picked because it was well after the end of social distancing measures and on-site and online teaching were allowed without restrictions. The lectures were evenly distributed between the fields of benign diseases (n = 14), malignancies (n = 6), operative technique (n = 2) and transplant surgery (n = 3) to minimize selection bias. All topics were relevant for the written exam at the end of the 9th semester. The survey was conducted via Lime Survey (LimeSurvey GmbH, Lime Survey: an open source survey tool) from June to August 2023. Statistical analysis was performed using SPSS (IBM SPSS Statistics, V 29.0, Chicago, USA) and Excel (Microsoft Office 2016, Microsoft, Washington, USA). Descriptive statistics and dependent sample t-test were employed. All online content was provided using LMS Moodle (Moodle.de, Berlin, Germany), video lectures were recorded using Panopto (Panopto©, Panopto EMEA Limited, London United Kingdom). Results 481 students of human medicine participated in the survey of which the majority was female (n(female) = 345, 71.7%, n(male) = 133, 27.7%, n(diverse/other) = 3, 0.6%) and in the clinical part of their studies (n(preclinical) = 181, 37.8%, n(clinical) = 300, 62.4%). Median age of participants was 25 years (minimum 18, maximum 38, SD 3.7). Distribution of students over the semesters is shown in Fig. 1 . Almost 20% of participants stated, that they regularly visited in person lectures before the COVID-19 pandemic, while almost 40% never or almost never attended in person lectures. Details are shown in Fig. 2 . Asked about what they missed most in their studies during COVID-19 social distancing measures, almost half of the participants missed contact to their peers and more than half contact to patients, while contact to teachers was not as regarded as important. Details are shown in Fig. 3 . There was a significant difference in how much students missed contact to their peers (p < .001) and to patients (p < .001) compared to how much they missed contact to their teachers. There was no significant difference between how much they missed contact to their peers compared to contact to patients (p = 0.519) Majority of students stated that they regularly used asynchronous online lectures and used those for preparation and reworking of on-site classes as well as for preparation for exams and even used some online content multiple times. Table 1 depicts detailed results of the survey. Overall, more than half of participants used provided content very often and almost 80% used it often or very often. Table 1 depicts the answers to three survey questions on a 7-point Likert scale. Overall more than half of participants used provided online materials very often. never 2 3 4 5 6 very often Did you use provided online lectures? (n) 4 (0.8%) 9 (1.9%) 19 (3.9%) 20 (4.1%) 50 (10.4%) 100 (20.7%) 275 (57.1%) Did you use provided online content for preparation and reworking of on-site classes? (n) 4 (0.8%) 7 (1.5%) 12 (2.5%) 25 (5.2%) 65 (13.5%) 100 (20.7%) 264 (54.8%) Did you use provided online content more than once? (n) 12 (2.5%) 21 (4.4%) 20 (4.1%) 25 (5.2%) 68 (14.1%) 76 (15.8%) 256 (53.1%) Asked if they would prefer to study medicine online, on-site or as a mixture of both the majority preferred a mixture of online and on-site teaching (n(completely online) = 26, 5.4%, n(2) = 62, 12.9%, n(3) = 65, 13.5%, n(mixture) = 196, 40.7%, n(5) = 93, 19.3%, n(6) = 31, 6.4%, n(completely on-site) = 6, 1.2%). Figure 4 depicts participants’ preferences for lectures, seminars and practical courses. Analysis of the use of online lectures showed a median call up over all lectures of 53 per semester (SD 32.355, n(min) = 10, n(max) = 169). Detailed call-ups for all lectures are shown in Fig. 5 . Attendance of the weekly on-site lecture was low with 0 to 10 students. Discussion Changes in educational concepts and beliefs over the last decades have been impactful for students and teachers alike. While learning used to be evolve around the teachers and their preferences, learners have taken on a more active role in shaping courses [ 1 ]. Even though the international COVID-19 pandemic forced the majority of learning and teaching to be online, it also demonstrated new possibilities for the effective use of time and sustainable use of resources [ 15 ]. Our survey shows that medical students prefer a balance of online and on-site classes, with an emphasis on practical skills and bedside teaching in on-site classes. This is congruent with recommendations made by prior studies, which highlight the impact of feedback on acquiring practical skills [ 16 ]. Over half of participating students missed contact to patients during COVID-19 induced social distancing measures, fitting the importance of patient interactions that has been described in earlier publications [ 17 ]. Participants answered in free text that they appreciated contact to patients and their peers in on-site classes but also the rigid time frame, which forced them to focus on the class, while online classes are easily paused and restarted. They highlighted the importance of discussion with peers and the lower threshold to ask questions than in online classes. Some students also stated that they feel more confident in recalling information after experiencing patient contact, which can be attributed to the benefits of case-based learning [ 18 ]. An earlier survey conducted by Sawant et al. during the COVID-19 pandemic in India in undergraduate medical students painted a similar picture, in that students appreciated that they could study in their own time and pace and highlighted the resource saving aspect of online classes. However, overall students were dissatisfied with online classes only, because they felt lonely and unconfident in patient interaction and had a hard time to motivate themselves [ 11 ]. A different survey during the COVID-19 pandemic by Stoehr et al. found similar benefits and limitations of online education during the pandemic but saw an important chance for change for the future. Their survey results suggested a preference for a mix of on-site and online learning [ 15 ]. The key difference between these earlier publications and our study is the setting in time. While Sawant et al. and Stoehr et al. performed their survey in the midst of the pandemic, during which frustration and loneliness were big impacting factors [ 11 ] our survey took place well after all social distancing measures were lifted. Our participants were able to participate in online and on-site classes alike and go about their part-time jobs and hobbies. The wish for balance of online and on-site education of our participants matches the reasons, why participants of Sawant et al.’s study participants were unhappy and appears to prevail even long after the need for social distancing. The importance of interaction with peers for mental health has been underlined by prior surveys as perception of loneliness and dread were increased during social distancing measures [ 19 ]. Sharma et al. recommended a mentoring and mental health support network to go beyond the confinements of the pandemic [ 20 ]. Kortemeyer et al. conducted a survey about preferences towards the mode of lecture attendance at a technical university [ 21 ]. While similar in topic the survey we present concentrates on medical and surgical education in particular and we chose not to ask for performance markers. However, the authors agree with Kortemeyer et al. in that social interactions between students of the same and of different majors are an important but overlooked part of university life and academia appropriately described as the “hidden curriculum” [ 21 ]. The use of online lectures has been shown to be a sustainable use of time for teachers and increases repeatability for students [ 7 , 22 ]. Survey participants valued the flexibility they gained due to online lectures, because it reduced commute and enabled them to watch lectures on demand while completing other tasks. They highlighted the option to increase or reduce speed and repeat sections or entire lectures if needed. Flexibility was especially underlined by students with children and/or jobs, which have been increasing in number over the last years [ 23 , 24 ]. While many teachers suspect, that online materials are not used, our numbers speak a different language. In fact, flexibility is also an important pro for teachers, who can record their lectures on their own time and do not have to leave busy hospital work or the operating room for a lecture. However, the direct contact to teachers is an important part of conveying the ethos and the passion for a subject, which is limited via online classes. Our chances to enthuse the future generation to become leaders in surgery are thus limited. The wide range of numbers of lecture use (n(min) = 10, n(max) = 169) in our data may have multiple reasons: students may estimate certain topics to be more high-yielding for future exams (i.e. n(rectal carcinoma SS24) = 169, n(diverticulitis SS23) = 104, n (pancreatic carcinoma SS24) = 122) or may be more interested in certain topics than others (i.e. n(liver transplant SS23) = 114, n(pancreas and kidney transplant SS23) = 148). This high variance is consistent with our experience from all-on-site teaching, where certain lectures drew more interest than others. While number in online call-ups vary, online lectures currently enable us to reach around a quarter of the semester (median = 53) with far higher numbers in oncologic surgery and common diseases like diverticulitis while on-site lectures range around 5% of the semester. Our survey is able to give some insights into students’ “wants” and “needs” but comes with some limitations. For once, a survey is never able to depict all details of all opinions but rather highlights the majorities. Furthermore, one’s preference how to learn may not be the most efficient and effective way, thus preference does not speak to quality of a course. However, even the least efficient way of studying is more beneficial, than not studying at all. Randomized controlled studies about the efficiency of online and on-site classes like presented in the study protocol by Raffing et al. will be able to give important insights in the future [ 25 ]. Overall, medical students wish for a balanced mixture of online and on-site teaching. We advise to evaluate for each class how much on-site and how much online teaching is feasible and necessary to optimize time for students and teachers alike. In our department as an example we decided to give a repetition in basic anatomy and physiology as an online lecture before on-site lectures (i.e. online: surgical anatomy of the pancreas, on-site: pancreatic carcinoma). This enables us to start into the on-site lecture with a strong knowledge base so the valuable time together can be spent for case discussions and patient interactions. We agree with our students that online resources are a valuable supplement for medical and surgical education but practical skills should be taught on-site with direct feedback. Abbreviations OSCE Objective Structured Clinical Examination COVID-19 Coronavirus Disease 2019 SS23 summer semester 2023 WS 23/24 winter semester 2023/2024 SS24 summer semester 2024 Declarations Human Ethics and Consent to Participate: not applicable. Participation was anonymous and voluntary. Voluntary surveys are exempt by the local Ethics Committee of the Regional Medical Association of Rhineland Palatinate (Ethikkommission der Landesärztekammer Rheinland-Pfalz) from Ethics approval and from written consent.. Consent for publication: Not applicable. Data Availability: data is available upon reasonable request with the corresponding author in anonymized fashion. Competing Interests: There are no competing interests of the authors. Funding Declaration: no funding received. Authors’ contribution: LIH and TH conceptualized the survey, TB programmed the survey, LIH, TB and FH distributed the survey, LIH wrote the manuscript, FH, HL and TH corrected the mansucript, TH and HL oversaw and coordinated the study, all authors reviewed the manuscript Acknowledgements: none References Baum, K.D. and S. Axtell, Trends in North American medical education. Keio J Med, 2005. 54 (1): p. 22-8. Biggs, J., C. Tang, and G. Kennedy, Teaching for quality learning at university 5e . 2022: McGraw-hill education (UK). Bai, H., Modernizing Medical Education through Leadership Development. Yale J Biol Med, 2020. 93 (3): p. 433-439. Jones, R.W., Learning and teaching in small groups: characteristics, benefits, problems and approaches. Anaesth Intensive Care, 2007. 35 (4): p. 587-92. Zhang, H., et al., Effectiveness of peer teaching in health professions education: A systematic review and meta-analysis. Nurse Educ Today, 2022. 118 : p. 105499. D'Eon, M.F. and D. AuYeung, Follow-up in train-the-trainer continuing medical education events. J Contin Educ Health Prof, 2001. 21 (1): p. 33-9. Riedel, M., et al., Experiences with alternative online lectures in medical education in obstetrics and gynecology during the COVID-19 pandemic-possible efficient and student-orientated models for the future? Arch Gynecol Obstet, 2022. 305 (4): p. 1041-1053. Hanke, L.I., et al., [Surgical Education of Medical Students in Times of COVID-19 - Necessary Adjustments are Chances for the Future]. Zentralbl Chir, 2021. 146 (6): p. 586-596. Rose, S., Medical Student Education in the Time of COVID-19. Jama, 2020. 323 (21): p. 2131-2132. Ding, A., Medical education-collateral damage of COVID-19? Postgrad Med J, 2021. 97 (1148): p. 404-405. Sawant, N.S., et al., Online teaching, learning, and health outcomes: Impact on medical undergraduate students. Ind Psychiatry J, 2023. 32 (1): p. 59-64. Guze, P.A., Using Technology to Meet the Challenges of Medical Education. Trans Am Clin Climatol Assoc, 2015. 126 : p. 260-70. Ball, C., et al., The Physical-Digital Divide: Exploring the Social Gap Between Digital Natives and Physical Natives. J Appl Gerontol, 2019. 38 (8): p. 1167-1184. Statista. Digitalisierung an Schulen - Daten & Fakten . 2025 [cited 2025 08.04.2025]; Available from: https://de.statista.com/themen/6104/digitale-bildung-in-der-schule/#topicOverview. Stoehr, F., et al., How COVID-19 kick-started online learning in medical education-The DigiMed study. PLoS One, 2021. 16 (9): p. e0257394. Enoch, L.C., R.M. Abraham, and V.S. Singaram, A comparative analysis of the impact of online, blended, and face-to-face learning on medical students' clinical competency in the affective, cognitive, and psychomotor domains. BMC Med Educ, 2022. 22 (1): p. 753. Peters, M. and O. Ten Cate, Bedside teaching in medical education: a literature review. Perspect Med Educ, 2014. 3 (2): p. 76-88. Das, S., et al., Case-based learning: A 'Case' for restructuring anatomy education in Indian nursing curriculum. J Educ Health Promot, 2022. 11 : p. 258. Herchenröder, M.V., Edgar, Studierendenumfrage zur Corronakrise: Deutlicher Einschnitt. Deutsches Ärzteblatt, Medizin studieren, 2020. WS 2020/21 (10): p. 10-11. Sharma, D. and S. Bhaskar, Addressing the Covid-19 Burden on Medical Education and Training: The Role of Telemedicine and Tele-Education During and Beyond the Pandemic. Front Public Health, 2020. 8 : p. 589669. Kortemeyer, G., et al., Attending lectures in person, hybrid or online-how do students choose, and what about the outcome? Int J Educ Technol High Educ, 2023. 20 (1): p. 19. Seymour-Walsh, A.E., A. Weber, and A. Bell, Pedagogical foundations to online lectures in health professions education. Rural Remote Health, 2020. 20 (2): p. 6038. Forschung, B.f.B.u. Die wirtschaftliche und soziale Lage der Studierenden in der Bundesreupublik Deutschland 2003 - 17. Sozialerhebung des Deutschen Studentenwerks . 2003 [cited 2025 08.04.2025]; Available from: extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.sozialpolitik-aktuell.de/files/sozialpolitik-aktuell/_Politikfelder/Einkommen-Armut/Dokumente/Hauptbericht_soz_117.SozialerhebungStudenten.pdf. Forschung, B.f.B.u. Die Studierendenbefragung in Deutschland: 22. Sozialerhebung - Die wirtschaftliche und soziale Lage der Studierenden in Deutschland 2021 . 2021 [cited 2025 08.04.2025]; Available from: extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.bmbf.de/SharedDocs/Publikationen/DE/4/31790_22_Sozialerhebung_2021.pdf?__blob=publicationFile&v=9. Raffing, R., L. Konge, and H. Tønnesen, Learning effect of online versus onsite education in health and medical scholarship - protocol for a cluster randomized trial. BMC Med Educ, 2024. 24 (1): p. 927. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6557289","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":471874832,"identity":"71ba627b-f9fb-4fd0-87f3-32c0f8b8c8eb","order_by":0,"name":"Laura Isabel Hanke","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABP0lEQVRIie3RPUvDQBjA8ecIpMulWSMIfoWUg+rgywfpkiNQl2QqFEGQSOG6RFzbQf0KJy51MnDQ6WxXoQ4GoVOFuIiCUC/tUnoddHO4/5BwD/lxxwXAZPqHVZevDAADegHw1IImEJRDq3zYGrFXiOX/mdjechFs+GB1UpH14hOed3axGJ46g72GWwk7RT6Ahtt1RAHtfY3giPRTmNbuL1hz4kgv7qd54lMJcU9UAx9GTf1gEVFnEoiPcX3iMC/mTzQJKJvHicB+gJjQiDsj6BvEER+7H62SPCiSUQbxjSIZYnONeBGx1C6UP6a2tdjFo+dJSbjAtQSxTCfTlrXti5DLIdm6UqQn8w6U5FZgAsEoXCeuG96h2Yk44DLMizd2Fl92j1/fvxS5HktSFO1D7ZYX+ZvHsPaPTCaTyfTbfgD11nBOnfQPfAAAAABJRU5ErkJggg==","orcid":"","institution":"University Medical Center of the Johannes Gutenberg University Mainz","correspondingAuthor":true,"prefix":"","firstName":"Laura","middleName":"Isabel","lastName":"Hanke","suffix":""},{"id":471874833,"identity":"3661ce16-d5ef-4f13-9db2-20bc6e5cdbc0","order_by":1,"name":"Tilman Borchardt","email":"","orcid":"","institution":"University Medical Center of the Johannes Gutenberg University Mainz","correspondingAuthor":false,"prefix":"","firstName":"Tilman","middleName":"","lastName":"Borchardt","suffix":""},{"id":471874834,"identity":"4e3d59cd-9a96-4e2c-9b30-c34e4e336aee","order_by":2,"name":"Florentine Huettl","email":"","orcid":"","institution":"University Medical Center of the Johannes Gutenberg University Mainz","correspondingAuthor":false,"prefix":"","firstName":"Florentine","middleName":"","lastName":"Huettl","suffix":""},{"id":471874835,"identity":"d71a797c-7d25-4103-9741-be3fda6abdce","order_by":3,"name":"Hauke Lang","email":"","orcid":"","institution":"University Medical Center of the Johannes Gutenberg University Mainz","correspondingAuthor":false,"prefix":"","firstName":"Hauke","middleName":"","lastName":"Lang","suffix":""},{"id":471874836,"identity":"03c60247-8ecd-4929-a12d-66f586b2af09","order_by":4,"name":"Tobias Huber","email":"","orcid":"","institution":"University Medical Center of the Johannes Gutenberg University Mainz","correspondingAuthor":false,"prefix":"","firstName":"Tobias","middleName":"","lastName":"Huber","suffix":""}],"badges":[],"createdAt":"2025-04-29 14:08:26","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6557289/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6557289/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":84920972,"identity":"1b72fdda-0792-471e-a4cc-25244e2d47a6","added_by":"auto","created_at":"2025-06-18 19:41:22","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":16123,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of participants over the semesters.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6557289/v1/005d311392c6182de1363bd3.png"},{"id":84919312,"identity":"fdcf7b0a-7f4f-4bf4-a58f-1478e96a5cd2","added_by":"auto","created_at":"2025-06-18 19:33:22","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":40309,"visible":true,"origin":"","legend":"\u003cp\u003eDepiction of use of lectures prior to the COVID-19 pandemic. Around 20% of students visited lectures daily or almost daily, while more than 40% attended lectures never or almost never.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6557289/v1/f615767dc741a584a480a29f.png"},{"id":84919311,"identity":"bfb0bd5e-69eb-4b66-8967-3f695d8a8162","added_by":"auto","created_at":"2025-06-18 19:33:22","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":17480,"visible":true,"origin":"","legend":"\u003cp\u003eParticipants were asked, if and how much they missed contact to peers, teachers and patients. While the majority missed contact to peers and patients, contact to teachers appeared to be less important.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6557289/v1/a6ee125e6b50838bc608e4f6.png"},{"id":84920973,"identity":"8a15156a-a240-45a8-9d9c-01a32df6cec4","added_by":"auto","created_at":"2025-06-18 19:41:22","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":9397,"visible":true,"origin":"","legend":"\u003cp\u003eParticipants’ preferences for online vs. onsite teaching for lectures, seminars and practical courses on a 7-point Likert scale. Lectures were preferred as online classes by the majority (71%) and practical courses onsite (57.5%). Opinions regarding seminars were split\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-6557289/v1/5c09977381d1c7c42ba2d167.png"},{"id":84919318,"identity":"8ad09197-56e3-42b8-99df-b72c0f75185b","added_by":"auto","created_at":"2025-06-18 19:33:22","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":12114,"visible":true,"origin":"","legend":"\u003cp\u003eEach cluster depicts the total number of call-ups for one lecture over three semesters, which are differentiated by shades of blue.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-6557289/v1/bb3632c9a724340310e46dfe.png"},{"id":84920976,"identity":"a438fae9-bed0-4d21-bdae-ebe612e8c9fd","added_by":"auto","created_at":"2025-06-18 19:41:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":492679,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6557289/v1/ebc4c4b4-60ca-4b4a-952e-1c152cd4fb4b.pdf"},{"id":84919313,"identity":"08b4063b-4feb-4fa8-b101-5f2e70bf954c","added_by":"auto","created_at":"2025-06-18 19:33:22","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":586970,"visible":true,"origin":"","legend":"","description":"","filename":"QuestionnairEnglish.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6557289/v1/877af535e40564caa91e8c00.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Surgical education – online or on-site? A single-center survey of German medical students","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEducation and beliefs about education in general and medical education in particular have evolved greatly over time especially in the last century [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. While frontal lectures and observation were the teaching standard for an extended time period, more active participation of students has found its way into most subjects. The age of digitalization has further impacted education methods and media. Medical education and especially surgical education hold the added difficulty of teaching not only theoretical knowledge but also practical skills, which have to be examined in a practical manner i.e. as objective standardized clinical examination (OSCE) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The broadening of the physicians job away from just treating patients to an interprofessional healthcare manager has further complicated the educational needs for future generations [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. These circumstances come with several predicaments: teaching practical skills and use of newer teaching methods require small groups of students. While lectures can be held just as well no matter if the auditorium consists of 20 or 200 students, practical skills courses suffer in quality the larger the group. This is more time consuming and requires a greater amount of educational human resources [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. At the same time, cost efficiency is a key objective for most healthcare systems and hospitals, making time and personnel a precious resource. Student teachers and peer teaching is a helpful way to attenuate this problem but not the overall solution [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Furthermore, consistency of a lecture held for the whole semester is much higher than teaching 20 or more small groups by different teachers. This means curricula have to be more concise and objectives have to be clear for all participants, teachers and students alike [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. To optimize this, teaching the teachers is an established method in order to facilitate high quality, consistent education [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. However, these concepts are also time-consuming and demand a high amount of motivation from teachers.\u003c/p\u003e \u003cp\u003eThe international COVID-19 pandemic challenged teachers of all subjects and all ages. Classes, which were conceptualized to be held in presence, had to be switched to e-learnings or online seminars almost overnight [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. All aspects of medical education suffered due to the restricted contact with patients [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Surgical education in particular was impeded because practical skills courses were restricted, visits in the operating room were prohibited and elective surgery was postponed. Doctor-patient-interactions and practical skills are especially difficult to instruct virtually and researchers agreed that these should be taught in attendance and cannot be replaced entirely by e-learnings [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile some teachers had a hard time adjusting to the use of digital media during the COVID-19 pandemic, most students were well versed in the matter already. There is a wide range of supplemental information in different media, which are consumed and combined by students according to personal preference and need. Whereas most of today\u0026rsquo;s professors have studied with lectures and books, today\u0026rsquo;s students supplement this with podcast, apps and video content [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. These media enable flexible time schedules, repetition as needed and the efficient use of time i.e. listening to a podcast while commuting or completing household chores. The concept of younger generations being more acquainted with digital technologies is also known as \u0026ldquo;digital natives\u0026rdquo; hence they grew up using these media from a very young age. While older generations (\u0026ldquo;physical natives\u0026rdquo; or \u0026ldquo;digital immigrants\u0026rdquo;) have to make a conscious effort to implement these technologies, younger generations appear to use them more effortlessly [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The use of e-learning starts as young as schoolchildren and is widely used across subjects. At the same time the amount of online graduate and post-graduate degree programs of all fields has rapidly increased in the last few years. Elaborate tools for at home test-taking and different study tools are commonly used by now [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhen social distancing rules were lifted new teaching concepts which had been implemented using online tools were questioned. In personal conversations as well as student evaluation it became clear that opinions about the future of surgical education diverged between students and teachers as well as between generations. This survey aimed to identify the \u0026ldquo;wants\u0026rdquo; and \u0026ldquo;needs\u0026rdquo; of German medical students and find common ground for fruitful and effective surgical education in the future.\u003c/p\u003e"},{"header":"Material and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eOnline Survey\u003c/h2\u003e \u003cp\u003eThe student survey consisted of 16 questions regarding demographic information, use of online available material and preferences of online or on-site teaching for practical courses, lectures, seminars and overall. They were also asked if they missed contact to peers, teachers and patients during social distancing measures and if they attended lectures regularly before the COVID-19 pandemic. Preferences and use of online materials were assessed using 7-point Likert scales (1\u0026thinsp;=\u0026thinsp;not at all, 7\u0026thinsp;=\u0026thinsp;very much). In addition, there was the possibility to comment in free-text. The survey was custom-build and has not been used in prior publications. Student survey was dispersed via the student body of the faculty and during lectures and classes starting May 2023 and ending August 2023. Eligible for participation were students of human medicine of the University Medical Center at the Johannes Gutenberg-University Mainz of all semesters. We deliberately chose to exclude other universities and other medical professions (i.e. dentistry) since educational concepts differ considerably between faculties.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eAnalysis of asynchronous lectures\u003c/h3\u003e\n\u003cp\u003eOf all 76 provided asynchronous online lectures 25 lectures by 10 teachers were randomly selected and their use in call-ups per semester was analyzed for summer semester 2023 (SS23), winter semester 2023/2024 (WS23/24) and summer semester 2024 (SS24). The lectures were chosen, because there had not been any changes to the lecturer or to the lectures\u0026rsquo; structure during this time in order to minimize fluctuation in views due to change in teaching personnel or style. The time period was picked because it was well after the end of social distancing measures and on-site and online teaching were allowed without restrictions. The lectures were evenly distributed between the fields of benign diseases (n\u0026thinsp;=\u0026thinsp;14), malignancies (n\u0026thinsp;=\u0026thinsp;6), operative technique (n\u0026thinsp;=\u0026thinsp;2) and transplant surgery (n\u0026thinsp;=\u0026thinsp;3) to minimize selection bias. All topics were relevant for the written exam at the end of the 9th semester.\u003c/p\u003e \u003cp\u003eThe survey was conducted via Lime Survey (LimeSurvey GmbH, Lime Survey: an open source survey tool) from June to August 2023. Statistical analysis was performed using SPSS (IBM SPSS Statistics, V 29.0, Chicago, USA) and Excel (Microsoft Office 2016, Microsoft, Washington, USA). Descriptive statistics and dependent sample t-test were employed. All online content was provided using LMS Moodle (Moodle.de, Berlin, Germany), video lectures were recorded using Panopto (Panopto\u0026copy;, Panopto EMEA Limited, London United Kingdom).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e481 students of human medicine participated in the survey of which the majority was female (n(female)\u0026thinsp;=\u0026thinsp;345, 71.7%, n(male)\u0026thinsp;=\u0026thinsp;133, 27.7%, n(diverse/other)\u0026thinsp;=\u0026thinsp;3, 0.6%) and in the clinical part of their studies (n(preclinical)\u0026thinsp;=\u0026thinsp;181, 37.8%, n(clinical)\u0026thinsp;=\u0026thinsp;300, 62.4%). Median age of participants was 25 years (minimum 18, maximum 38, SD 3.7). Distribution of students over the semesters is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAlmost 20% of participants stated, that they regularly visited in person lectures before the COVID-19 pandemic, while almost 40% never or almost never attended in person lectures. Details are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e Asked about what they missed most in their studies during COVID-19 social distancing measures, almost half of the participants missed contact to their peers and more than half contact to patients, while contact to teachers was not as regarded as important. Details are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. There was a significant difference in how much students missed contact to their peers (p\u0026thinsp;\u0026lt;\u0026thinsp;.001) and to patients (p\u0026thinsp;\u0026lt;\u0026thinsp;.001) compared to how much they missed contact to their teachers. There was no significant difference between how much they missed contact to their peers compared to contact to patients (p\u0026thinsp;=\u0026thinsp;0.519)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eMajority of students stated that they regularly used asynchronous online lectures and used those for preparation and reworking of on-site classes as well as for preparation for exams and even used some online content multiple times. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e depicts detailed results of the survey. Overall, more than half of participants used provided content very often and almost 80% used it often or very often.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003edepicts the answers to three survey questions on a 7-point Likert scale. Overall more than half of participants used provided online materials very often.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003enever\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003every often\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDid you use provided online lectures? (n)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4 (0.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9 (1.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e19 (3.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e20 (4.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e50 (10.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e100 (20.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e275 (57.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDid you use provided online content for preparation and reworking of on-site classes? (n)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4 (0.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7 (1.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12 (2.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e25 (5.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e65 (13.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e100 (20.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e264 (54.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDid you use provided online content more than once? (n)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12 (2.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21 (4.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20 (4.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e25 (5.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e68 (14.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e76 (15.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e256 (53.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAsked if they would prefer to study medicine online, on-site or as a mixture of both the majority preferred a mixture of online and on-site teaching (n(completely online)\u0026thinsp;=\u0026thinsp;26, 5.4%, n(2)\u0026thinsp;=\u0026thinsp;62, 12.9%, n(3)\u0026thinsp;=\u0026thinsp;65, 13.5%, n(mixture)\u0026thinsp;=\u0026thinsp;196, 40.7%, n(5)\u0026thinsp;=\u0026thinsp;93, 19.3%, n(6)\u0026thinsp;=\u0026thinsp;31, 6.4%, n(completely on-site)\u0026thinsp;=\u0026thinsp;6, 1.2%). Figure\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e depicts participants\u0026rsquo; preferences for lectures, seminars and practical courses.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAnalysis of the use of online lectures showed a median call up over all lectures of 53 per semester (SD 32.355, n(min)\u0026thinsp;=\u0026thinsp;10, n(max)\u0026thinsp;=\u0026thinsp;169). Detailed call-ups for all lectures are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e. Attendance of the weekly on-site lecture was low with 0 to 10 students.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eChanges in educational concepts and beliefs over the last decades have been impactful for students and teachers alike. While learning used to be evolve around the teachers and their preferences, learners have taken on a more active role in shaping courses [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Even though the international COVID-19 pandemic forced the majority of learning and teaching to be online, it also demonstrated new possibilities for the effective use of time and sustainable use of resources [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur survey shows that medical students prefer a balance of online and on-site classes, with an emphasis on practical skills and bedside teaching in on-site classes. This is congruent with recommendations made by prior studies, which highlight the impact of feedback on acquiring practical skills [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Over half of participating students missed contact to patients during COVID-19 induced social distancing measures, fitting the importance of patient interactions that has been described in earlier publications [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Participants answered in free text that they appreciated contact to patients and their peers in on-site classes but also the rigid time frame, which forced them to focus on the class, while online classes are easily paused and restarted. They highlighted the importance of discussion with peers and the lower threshold to ask questions than in online classes. Some students also stated that they feel more confident in recalling information after experiencing patient contact, which can be attributed to the benefits of case-based learning [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAn earlier survey conducted by Sawant et al. during the COVID-19 pandemic in India in undergraduate medical students painted a similar picture, in that students appreciated that they could study in their own time and pace and highlighted the resource saving aspect of online classes. However, overall students were dissatisfied with online classes only, because they felt lonely and unconfident in patient interaction and had a hard time to motivate themselves [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. A different survey during the COVID-19 pandemic by Stoehr et al. found similar benefits and limitations of online education during the pandemic but saw an important chance for change for the future. Their survey results suggested a preference for a mix of on-site and online learning [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The key difference between these earlier publications and our study is the setting in time. While Sawant et al. and Stoehr et al. performed their survey in the midst of the pandemic, during which frustration and loneliness were big impacting factors [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] our survey took place well after all social distancing measures were lifted. Our participants were able to participate in online and on-site classes alike and go about their part-time jobs and hobbies. The wish for balance of online and on-site education of our participants matches the reasons, why participants of Sawant et al.\u0026rsquo;s study participants were unhappy and appears to prevail even long after the need for social distancing.\u003c/p\u003e \u003cp\u003eThe importance of interaction with peers for mental health has been underlined by prior surveys as perception of loneliness and dread were increased during social distancing measures [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Sharma et al. recommended a mentoring and mental health support network to go beyond the confinements of the pandemic [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eKortemeyer et al. conducted a survey about preferences towards the mode of lecture attendance at a technical university [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. While similar in topic the survey we present concentrates on medical and surgical education in particular and we chose not to ask for performance markers. However, the authors agree with Kortemeyer et al. in that social interactions between students of the same and of different majors are an important but overlooked part of university life and academia appropriately described as the \u0026ldquo;hidden curriculum\u0026rdquo; [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe use of online lectures has been shown to be a sustainable use of time for teachers and increases repeatability for students [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Survey participants valued the flexibility they gained due to online lectures, because it reduced commute and enabled them to watch lectures on demand while completing other tasks. They highlighted the option to increase or reduce speed and repeat sections or entire lectures if needed. Flexibility was especially underlined by students with children and/or jobs, which have been increasing in number over the last years [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. While many teachers suspect, that online materials are not used, our numbers speak a different language. In fact, flexibility is also an important pro for teachers, who can record their lectures on their own time and do not have to leave busy hospital work or the operating room for a lecture. However, the direct contact to teachers is an important part of conveying the ethos and the passion for a subject, which is limited via online classes. Our chances to enthuse the future generation to become leaders in surgery are thus limited. The wide range of numbers of lecture use (n(min)\u0026thinsp;=\u0026thinsp;10, n(max)\u0026thinsp;=\u0026thinsp;169) in our data may have multiple reasons: students may estimate certain topics to be more high-yielding for future exams (i.e. n(rectal carcinoma SS24)\u0026thinsp;=\u0026thinsp;169, n(diverticulitis SS23)\u0026thinsp;=\u0026thinsp;104, n (pancreatic carcinoma SS24)\u0026thinsp;=\u0026thinsp;122) or may be more interested in certain topics than others (i.e. n(liver transplant SS23)\u0026thinsp;=\u0026thinsp;114, n(pancreas and kidney transplant SS23)\u0026thinsp;=\u0026thinsp;148). This high variance is consistent with our experience from all-on-site teaching, where certain lectures drew more interest than others. While number in online call-ups vary, online lectures currently enable us to reach around a quarter of the semester (median\u0026thinsp;=\u0026thinsp;53) with far higher numbers in oncologic surgery and common diseases like diverticulitis while on-site lectures range around 5% of the semester.\u003c/p\u003e \u003cp\u003eOur survey is able to give some insights into students\u0026rsquo; \u0026ldquo;wants\u0026rdquo; and \u0026ldquo;needs\u0026rdquo; but comes with some limitations. For once, a survey is never able to depict all details of all opinions but rather highlights the majorities. Furthermore, one\u0026rsquo;s preference how to learn may not be the most efficient and effective way, thus preference does not speak to quality of a course. However, even the least efficient way of studying is more beneficial, than not studying at all. Randomized controlled studies about the efficiency of online and on-site classes like presented in the study protocol by Raffing et al. will be able to give important insights in the future [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOverall, medical students wish for a balanced mixture of online and on-site teaching. We advise to evaluate for each class how much on-site and how much online teaching is feasible and necessary to optimize time for students and teachers alike. In our department as an example we decided to give a repetition in basic anatomy and physiology as an online lecture before on-site lectures (i.e. online: surgical anatomy of the pancreas, on-site: pancreatic carcinoma). This enables us to start into the on-site lecture with a strong knowledge base so the valuable time together can be spent for case discussions and patient interactions. We agree with our students that online resources are a valuable supplement for medical and surgical education but practical skills should be taught on-site with direct feedback.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eOSCE\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Objective Structured Clinical Examination\u003c/p\u003e\n\u003cp\u003eCOVID-19 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Coronavirus Disease 2019\u003c/p\u003e\n\u003cp\u003eSS23\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;summer semester 2023\u003c/p\u003e\n\u003cp\u003eWS 23/24\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;winter semester 2023/2024\u003c/p\u003e\n\u003cp\u003eSS24 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;summer semester 2024\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eHuman Ethics and Consent to Participate:\u003c/em\u003e not applicable. Participation was anonymous and voluntary. Voluntary surveys are exempt by the local Ethics Committee of the Regional Medical Association of Rhineland Palatinate (Ethikkommission der Landesärztekammer Rheinland-Pfalz) from Ethics approval and from written consent..\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent for publication:\u003c/em\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eData Availability:\u0026nbsp;\u003c/em\u003edata is available upon reasonable request with the corresponding author in anonymized fashion.\u003c/p\u003e\n\u003cp\u003eCompeting Interests: There are no competing interests of the authors.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding Declaration:\u003c/em\u003e no funding received.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthors’ contribution:\u0026nbsp;\u003c/em\u003eLIH and TH conceptualized the survey, TB programmed the survey, LIH, TB and FH distributed the survey, LIH wrote the manuscript, FH, HL and TH corrected the mansucript, TH and HL oversaw and coordinated the study, all authors reviewed the manuscript\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAcknowledgements:\u003c/em\u003e none\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBaum, K.D. and S. Axtell, \u003cem\u003eTrends in North American medical education.\u003c/em\u003e Keio J Med, 2005. \u003cstrong\u003e54\u003c/strong\u003e(1): p. 22-8.\u003c/li\u003e\n\u003cli\u003eBiggs, J., C. Tang, and G. Kennedy, \u003cem\u003eTeaching for quality learning at university 5e\u003c/em\u003e. 2022: McGraw-hill education (UK).\u003c/li\u003e\n\u003cli\u003eBai, H., \u003cem\u003eModernizing Medical Education through Leadership Development.\u003c/em\u003e Yale J Biol Med, 2020. \u003cstrong\u003e93\u003c/strong\u003e(3): p. 433-439.\u003c/li\u003e\n\u003cli\u003eJones, R.W., \u003cem\u003eLearning and teaching in small groups: characteristics, benefits, problems and approaches.\u003c/em\u003e Anaesth Intensive Care, 2007. \u003cstrong\u003e35\u003c/strong\u003e(4): p. 587-92.\u003c/li\u003e\n\u003cli\u003eZhang, H., et al., \u003cem\u003eEffectiveness of peer teaching in health professions education: A systematic review and meta-analysis.\u003c/em\u003e Nurse Educ Today, 2022. \u003cstrong\u003e118\u003c/strong\u003e: p. 105499.\u003c/li\u003e\n\u003cli\u003eD\u0026apos;Eon, M.F. and D. AuYeung, \u003cem\u003eFollow-up in train-the-trainer continuing medical education events.\u003c/em\u003e J Contin Educ Health Prof, 2001. \u003cstrong\u003e21\u003c/strong\u003e(1): p. 33-9.\u003c/li\u003e\n\u003cli\u003eRiedel, M., et al., \u003cem\u003eExperiences with alternative online lectures in medical education in obstetrics and gynecology during the COVID-19 pandemic-possible efficient and student-orientated models for the future?\u003c/em\u003e Arch Gynecol Obstet, 2022. \u003cstrong\u003e305\u003c/strong\u003e(4): p. 1041-1053.\u003c/li\u003e\n\u003cli\u003eHanke, L.I., et al., \u003cem\u003e[Surgical Education of Medical Students in Times of COVID-19 - Necessary Adjustments are Chances for the Future].\u003c/em\u003e Zentralbl Chir, 2021. \u003cstrong\u003e146\u003c/strong\u003e(6): p. 586-596.\u003c/li\u003e\n\u003cli\u003eRose, S., \u003cem\u003eMedical Student Education in the Time of COVID-19.\u003c/em\u003e Jama, 2020. \u003cstrong\u003e323\u003c/strong\u003e(21): p. 2131-2132.\u003c/li\u003e\n\u003cli\u003eDing, A., \u003cem\u003eMedical education-collateral damage of COVID-19?\u003c/em\u003e Postgrad Med J, 2021. \u003cstrong\u003e97\u003c/strong\u003e(1148): p. 404-405.\u003c/li\u003e\n\u003cli\u003eSawant, N.S., et al., \u003cem\u003eOnline teaching, learning, and health outcomes: Impact on medical undergraduate students.\u003c/em\u003e Ind Psychiatry J, 2023. \u003cstrong\u003e32\u003c/strong\u003e(1): p. 59-64.\u003c/li\u003e\n\u003cli\u003eGuze, P.A., \u003cem\u003eUsing Technology to Meet the Challenges of Medical Education.\u003c/em\u003e Trans Am Clin Climatol Assoc, 2015. \u003cstrong\u003e126\u003c/strong\u003e: p. 260-70.\u003c/li\u003e\n\u003cli\u003eBall, C., et al., \u003cem\u003eThe Physical-Digital Divide: Exploring the Social Gap Between Digital Natives and Physical Natives.\u003c/em\u003e J Appl Gerontol, 2019. \u003cstrong\u003e38\u003c/strong\u003e(8): p. 1167-1184.\u003c/li\u003e\n\u003cli\u003eStatista. \u003cem\u003eDigitalisierung an Schulen - Daten \u0026amp; Fakten\u003c/em\u003e. 2025 [cited 2025 08.04.2025]; Available from: https://de.statista.com/themen/6104/digitale-bildung-in-der-schule/#topicOverview.\u003c/li\u003e\n\u003cli\u003eStoehr, F., et al., \u003cem\u003eHow COVID-19 kick-started online learning in medical education-The DigiMed study.\u003c/em\u003e PLoS One, 2021. \u003cstrong\u003e16\u003c/strong\u003e(9): p. e0257394.\u003c/li\u003e\n\u003cli\u003eEnoch, L.C., R.M. Abraham, and V.S. Singaram, \u003cem\u003eA comparative analysis of the impact of online, blended, and face-to-face learning on medical students\u0026apos; clinical competency in the affective, cognitive, and psychomotor domains.\u003c/em\u003e BMC Med Educ, 2022. \u003cstrong\u003e22\u003c/strong\u003e(1): p. 753.\u003c/li\u003e\n\u003cli\u003ePeters, M. and O. Ten Cate, \u003cem\u003eBedside teaching in medical education: a literature review.\u003c/em\u003e Perspect Med Educ, 2014. \u003cstrong\u003e3\u003c/strong\u003e(2): p. 76-88.\u003c/li\u003e\n\u003cli\u003eDas, S., et al., \u003cem\u003eCase-based learning: A \u0026apos;Case\u0026apos; for restructuring anatomy education in Indian nursing curriculum.\u003c/em\u003e J Educ Health Promot, 2022. \u003cstrong\u003e11\u003c/strong\u003e: p. 258.\u003c/li\u003e\n\u003cli\u003eHerchenr\u0026ouml;der, M.V., Edgar, \u003cem\u003eStudierendenumfrage zur Corronakrise: Deutlicher Einschnitt.\u003c/em\u003e Deutsches \u0026Auml;rzteblatt, Medizin studieren, 2020. \u003cstrong\u003eWS 2020/21\u003c/strong\u003e(10): p. 10-11.\u003c/li\u003e\n\u003cli\u003eSharma, D. and S. Bhaskar, \u003cem\u003eAddressing the Covid-19 Burden on Medical Education and Training: The Role of Telemedicine and Tele-Education During and Beyond the Pandemic.\u003c/em\u003e Front Public Health, 2020. \u003cstrong\u003e8\u003c/strong\u003e: p. 589669.\u003c/li\u003e\n\u003cli\u003eKortemeyer, G., et al., \u003cem\u003eAttending lectures in person, hybrid or online-how do students choose, and what about the outcome?\u003c/em\u003e Int J Educ Technol High Educ, 2023. \u003cstrong\u003e20\u003c/strong\u003e(1): p. 19.\u003c/li\u003e\n\u003cli\u003eSeymour-Walsh, A.E., A. Weber, and A. Bell, \u003cem\u003ePedagogical foundations to online lectures in health professions education.\u003c/em\u003e Rural Remote Health, 2020. \u003cstrong\u003e20\u003c/strong\u003e(2): p. 6038.\u003c/li\u003e\n\u003cli\u003eForschung, B.f.B.u. \u003cem\u003eDie wirtschaftliche und soziale Lage der Studierenden in der Bundesreupublik Deutschland 2003 - 17. Sozialerhebung des Deutschen Studentenwerks\u003c/em\u003e. 2003 [cited 2025 08.04.2025]; Available from: extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.sozialpolitik-aktuell.de/files/sozialpolitik-aktuell/_Politikfelder/Einkommen-Armut/Dokumente/Hauptbericht_soz_117.SozialerhebungStudenten.pdf.\u003c/li\u003e\n\u003cli\u003eForschung, B.f.B.u. \u003cem\u003eDie Studierendenbefragung in Deutschland: 22. Sozialerhebung - Die wirtschaftliche und soziale Lage der Studierenden in Deutschland 2021\u003c/em\u003e. 2021 [cited 2025 08.04.2025]; Available from: extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.bmbf.de/SharedDocs/Publikationen/DE/4/31790_22_Sozialerhebung_2021.pdf?__blob=publicationFile\u0026amp;v=9.\u003c/li\u003e\n\u003cli\u003eRaffing, R., L. Konge, and H. T\u0026oslash;nnesen, \u003cem\u003eLearning effect of online versus onsite education in health and medical scholarship - protocol for a cluster randomized trial.\u003c/em\u003e BMC Med Educ, 2024. \u003cstrong\u003e24\u003c/strong\u003e(1): p. 927.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":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":"Surgical Education, digital education, e-learning, sustainability, medical education","lastPublishedDoi":"10.21203/rs.3.rs-6557289/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6557289/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eIntroduction\u003c/p\u003e\n\u003cp\u003eEducation as a whole has undergone a remarkable amount of change in the last 100 years. The age of digitalization had a considerable influence on education, providing new media and new techniques to convey content. Not only technical changes have had an impact on education but also scientific findings about how we learn effectively. Surgical education is no exception here and it should be considered that our teachers learned in a different way than medical students and junior residents do today. The international COVID-19 pandemic has boosted the use of digital media due to necessary social distancing measures. After reintroduction of teaching on-site opinions on the necessity of the digital teaching contents appeared to diverge between students and teachers. This representative survey aimed to highlight the “needs” and “wants” of German medical students and to analyze the use of digital teaching media in our institute.\u003c/p\u003e\n\u003cp\u003eMaterial and Method\u003c/p\u003e\n\u003cp\u003eWe performed a survey using Lime Survey including students of human medicine of the Johannes Gutenberg-University Mainz, Germany. Students were asked about their use of online materials provided to them and what kind of courses they preferred for different aspects of surgical education and why. They were also asked what aspects of teaching they missed most during social distancing. Furthermore, we analyzed the use of online content created by our institute over three semesters (summer semester 2023 – summer semester 2024).\u003c/p\u003e\n\u003cp\u003eResults\u003c/p\u003e\n\u003cp\u003e481 students answered the survey the majority of which were female (n = 345, 71.7%) and were in the clinical part of their studies (n = 300, 62.4%). Students by a vast majority preferred practical courses as on-site teaching, i.e. studying surgical sutures (n(completely prefer and mostly prefer on-site) = 342, 71.1%) and lectures as online classes (n(completely prefer and mostly prefer online) = 363, 75.5%). Responses were mixed regarding seminars (n(completely prefer online) = 98, 20.4%, n(completely prefer on-site) = 158, 32.9%). While attendance in the facultative lecture was comparatively low (0 to 10 students per lecture), use of online lectures was satisfactory with a median of 53 views per semester (SD 32.355, n(min) = 10, n(max) = 169).\u003c/p\u003e\n\u003cp\u003eDiscussion\u003c/p\u003e\n\u003cp\u003eA combination of teaching in person and using digital media facilitates efficient learning for students as well as sustainable use of time for teachers. While theoretical classes like lectures lend themselves to online teaching, practical classes should be taught in person. The use of online and on-site teaching should be evaluated for every course and a mindful balance should be the overall goal.\u003c/p\u003e","manuscriptTitle":"Surgical education – online or on-site? A single-center survey of German medical students","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-18 19:33:17","doi":"10.21203/rs.3.rs-6557289/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-07-11T09:00:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"33689877584738366624579665645899161095","date":"2025-07-01T09:32:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"28583301561523377866121459012505798319","date":"2025-06-27T10:57:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"300877154988260293173503272676026918642","date":"2025-06-20T15:09:29+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-13T09:00:45+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-11T12:14:26+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-23T16:14:22+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-23T06:52:37+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2025-05-23T06:51:27+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":"14931e3f-209f-499e-8a4b-790bc4ea8ac1","owner":[],"postedDate":"June 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-06-18T19:33:17+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-18 19:33:17","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6557289","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6557289","identity":"rs-6557289","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}