Comparison of Flipped vs Traditional Classroom Teaching for Primary Surgical Skills in Postgraduate Surgical Trainees

Introduction

Traditional classroom teaching is the conventional educational approach in which instructors deliver knowledge through face-to-face lectures, demonstrations, textbooks, and classroom discussions. It provides direct interaction, immediate clarification of concepts, and structured learning; however, advances in educational technology have highlighted the need for learner-centered teaching strategies that promote active participation, critical thinking, and practical skill development.

The flipped classroom is an innovative instructional model in which learners study theoretical material before class using videos, presentations, and reading resources. Classroom time is then devoted to interactive discussions, case-based learning, problem-solving, simulation, and supervised hands-on practice. This approach promotes self-directed learning, encourages active participation, and enables instructors to focus on reinforcing concepts and practical skills.

Over the past decade, flipped learning has gained popularity in medical education and has been associated with improved engagement, motivation, knowledge retention, and learner satisfaction. However, most evidence is derived from undergraduate medical education, while studies involving postgraduate surgical trainees remain limited, particularly in low- and middle-income countries. Surgical training requires the integration of theoretical knowledge, technical competence, clinical decision-making, and teamwork. Evaluating innovative teaching methods may therefore improve trainee performance and optimize educational resources.

Literature Review

Traditional classroom teaching primarily emphasizes instructor-led lectures, whereas the flipped classroom shifts theoretical learning outside the classroom and reserves classroom time for active learning. This approach promotes collaborative learning, critical thinking, and practical application of knowledge.

Several studies have demonstrated the educational benefits of flipped learning, including improved learner engagement, deeper understanding, enhanced problem-solving skills, better academic performance, higher motivation, and improved long-term knowledge retention. Pakistani studies have also reported high student satisfaction, greater classroom participation, and improved understanding of medical concepts. Faculty members have similarly perceived flipped learning as an effective strategy that enhances learner engagement and classroom interaction. Successful implementation depends on faculty development, well-designed pre-class learning resources, and institutional support. Despite these encouraging findings, evidence regarding postgraduate surgical education remains scarce, justifying the present study.

Hypothesis

Flipped classroom methodology is more effective than traditional classroom methodology for teaching primary surgical skills to MS Surgery and allied specialty trainees.

Objective

To compare the effectiveness of flipped classroom and traditional classroom teaching in improving the performance of postgraduate surgical trainees in primary surgical skills.

Operational Definitions

Effectiveness: Improvement in OSCE scores following teaching.

Flipped Classroom: A teaching model in which theoretical learning occurs before class and classroom sessions focus on discussion, problem-solving, and practical application.

Traditional Classroom: Teacher-centered instruction delivered through face-to-face lectures, demonstrations, and classroom discussions.

Primary Surgical Skills: Fundamental surgical competencies including aseptic technique, instrument handling, tissue handling, knot tying, suturing, and wound management.

Subjects and Methods

Study Design: Parallel-group randomized controlled trial (CONSORT 2010).

Setting: Services Hospital Lahore and Jinnah Hospital Lahore.

Duration: Four months.

Sample Size: Ninety-two first-year MS Surgery and allied specialty trainees (46 per group), calculated using the WHO sample size calculator with 90% power, 5% significance level, and adjusted for anticipated dropouts.

Sampling Technique: Simple random sampling.

Inclusion Criteria First-year MS Surgery and allied trainees. No previous structured training in primary surgical skills. Written informed consent. Availability for the complete intervention and assessment. Exclusion Criteria Beyond first-year residency. Previous formal surgical skills training. Participation in other educational interventions. Inability or unwillingness to complete the study. Missing more than 20% of teaching sessions. Methodology

Ethical approval will be obtained from the Institutional Review Boards of both participating hospitals. Written informed consent will be obtained before enrolment.

Ninety-two eligible trainees will be randomly allocated into flipped classroom (n = 46) and traditional classroom (n = 46) groups using sealed opaque envelopes prepared separately for each institution to ensure allocation concealment.

The intervention will last eight weeks with one two-hour session weekly. Both groups will receive identical learning objectives, topics, faculty, and lesson plans.

The traditional classroom group will attend lectures, demonstrations, and supervised practical sessions. The flipped classroom group will receive videos, presentations, and reading material three to five days before each session. Classroom time will be dedicated to case discussions, problem-solving, hands-on practice, and instructor feedback.

At the end of the intervention, all trainees will undergo a standardized 10-station Objective Structured Clinical Examination (OSCE) using identical stations, examiners, and assessment criteria. Participants will also complete a confidence questionnaire, while faculty will independently assess procedural competence using standardized evaluation forms.

Statistical Analysis

Data will be entered into SPSS version 27.

Categorical variables will be presented as frequencies and percentages, while continuous variables will be summarized as mean ± standard deviation. Normality will be assessed using the Shapiro-Wilk test. Independent t-test or Mann-Whitney U test will compare OSCE scores between groups according to data distribution. Chi-square or Fisher's exact test will analyze categorical variables. Internal consistency of the assessment tool will be evaluated using Cronbach's alpha, and post-examination item analysis will assess OSCE quality. Statistical significance will be considered at p ≤ 0.05 with a 95% confidence interval.

Outcome and Utilization

This study will determine whether flipped classroom teaching improves the acquisition of primary surgical skills compared with traditional classroom instruction among postgraduate surgical trainees. Outcomes will include objective assessment of technical competence through OSCE, learner confidence, and faculty evaluation. The findings will provide evidence to guide curriculum development in postgraduate surgical education and may support wider integration of flipped learning into residency training programs. If effective, this learner-centered approach could improve trainee competence, engagement, clinical readiness, and efficient utilization of faculty time and educational resources while providing a foundation for future multicenter research.