Enhancing surgical education through output-driven input: implementation and evaluation of the O-SITE teaching model in clinical medical students

Introduction

Surgery is a core course in undergraduate clinical medicine curriculum, comprising 120 class hours and 6 credits. It emphasizes theory–practice integration and fusion of basic and clinical knowledge. The course covers diagnosis, treatment principles, and basic surgical skills for common surgical diseases, cultivating students’ clinical reasoning, fundamental operative skills, and preliminary clinical decision-making [1]. At the First Clinical Medical College of Gansu University of Chinese Medicine, all surgical teaching is delivered by dual-qualified clinical physicians with both medical practitioner and teaching certifications. Over the past decade, the course has undergone continuous reform and innovation and was recognized as a provincial first-class course in 2021.

Despite these advances, several challenges remain for implementing surgical education. Fragmented teaching content and little systematic knowledge hinder building a coherent knowledge framework and sound clinical thinking. Limited clinical teaching resources and low student engagement prevent the effective integration of theory and practice. Additionally, teaching competencies remain uneven, curriculum design lacks interdisciplinary integration, and students’ development of humanistic care and professional identity receives insufficient attention. These issues significantly constrain surgical education quality and cultivation of competency-based medical professionals.

To address these challenges – students’ low learning initiative, the disconnect between knowledge and skills, and disparities in teaching abilities – this study, guided by competency-based education principles [2], introduces and implements the O-SITE (O emphasizes the Output-driven input concept; SITE fosters student output and improves faculty teaching through Skilled demonstration, Intellectual expression, Train-the-trainer model, and Emotional expression) teaching model for surgical education. This model is grounded in the core concept of “output-driven input” (ODI,O), with the SITE framework facilitating information output across four dimensions: intellectual expression, skilled demonstration, emotional expression, and train-the-trainer (TTT) for faculty development. These dimensions correspond to the educational goals of knowledge acquisition, skill development, competency enhancement, and teaching capacity-building. Through innovative instructional design and resource development, the model supports active student output and fosters autonomous learning, clinical reasoning, technical proficiency, and humanistic values.

Using a systematic evaluation approach combining quantitative analysis and qualitative interviews, this study comprehensively assesses the effectiveness of the O-SITE model to provide scientific evidence and practical insights for medical education reform and to develop competency-based healthcare professionals.

Methods

Developing educational resources to support student-driven output

Instructional content integration

To address the challenges of large dual-qualified teaching teams, fragmented content, and inconsistent instructional styles, the curriculum team proposed and implemented the PICS (stands for Practical, Integrative, Critical, and Scholarly) content-integration framework. This framework optimizes surgical education content in four dimensions to unify instructional approaches, standardize teaching logic, and improve educational quality:

1. Practical: Emphasizes alignment with real-world clinical practice by incorporating multimodal resources such as images, videos, and physical specimens to help students build clinical perceptions and strengthen practical relevance;

2. Integrative: Promotes knowledge integration across systems and modules, particularly bridging basic science with clinical applications and fostering interdisciplinary coherence to help students construct a comprehensive knowledge framework;

3. Critical: Highlights surgery’s dual nature by encouraging students to move beyond technical mastery (“how to”) and focus on clinical judgment and reflection (“whether to” and “why to”);

4. Scholarly: Advocates a research-oriented mindset by integrating the latest disciplinary advances into teaching content, guiding students to approach clinical problems through academic enquiry, and cultivating lifelong-learning competencies.

Building online teaching resources

To meet diverse learning needs and enhance flexibility in pre-class preparation and post-class review, three categories of online teaching resources were developed and fully integrated into the curriculum, providing robust support for output-oriented learning.

First, a self-developed video library covering aseptic techniques, basic surgical skills, and common procedures was created based on students’ cognitive characteristics. This resource enables visualized skill learning outside clinical settings and is an essential, high-usage component.

Second, to assist students who might struggle with new teaching formats, traditional lecture-style resources were constructed, including synchronized audio, text, and PowerPoint materials. These structured and accessible resources allow students to review and fill knowledge gaps at any time.

Third, digital tools, real-time classroom audio, and slide content were leveraged to seamlessly integrate online and offline teaching, supporting personalized post-class review of key and challenging topics and enhancing learning continuity and accessibility (Figure 1).

Figure 1:

The O-SITE model for surgical education. O emphasizes the output-driven input concept; SITE fosters student output and improves faculty teaching through skilled demonstration, intellectual expression, train-the-trainer model, and emotional expression.

Results

DREEM scale results

Baseline characteristics showed no significant between-group differences in gender (control: 52 male and 56 female; O-SITE: 58 male and 61 female, p=0.92), age ([21.3 ± 0.9] vs. [21.2 ± 0.8] years, p=0.45), or grade point average ([3.45 ± 0.22] vs. [3.47 ± 0.25], p=0.38), confirming good comparability.

In the DREEM assessment, 119 questionnaires were distributed to the O-SITE group with 107 valid responses (response rate: 90.0 %); 108 were distributed to the control group with 92 valid responses (response rate: 85.2 %). The O-SITE group scored significantly higher across all five DREEM dimensions: students’ perceptions of learning (SPL: 3.5 vs. 3.1), perceptions of teachers (SPT: 3.6 vs. 3.3), academic self-perceptions (SASP: 3.4 vs. 3.0), perceptions of atmosphere (SPA: 3.7 vs. 3.2), and social self-perceptions (SSSP: 3.1 vs. 2.8) (all p<0.001) (Figure 2).

Figure 2:

Quantitative evaluation of the O-SITE model and the conventional teaching model using the DREEM scale. For O-SITE, O emphasizes the output-driven input concept; SITE fosters student output and improves faculty teaching through skilled demonstration, intellectual expression, train-the-trainer model, and emotional expression. DREEM, dundee ready education environment measure; SPL, students’ perceptions of learning; SPT, students’ perceptions of teachers; SASP, students’ academic self-perceptions; SPA, students’ perceptions of atmosphere; SSSP, students’ social self-perceptions.

Discussion

This study systematically evaluated the implementation and effectiveness of the O-SITE teaching model for Surgery, which is centered on promoting information output, using a combination of quantitative analysis and qualitative interviews. The quantitative results demonstrated that students who received O-SITE-based instruction achieved significantly higher scores in formative assessment, summative assessment, and overall performance than those in the traditional teaching group. Additionally, analysis of the DREEM scale revealed that the O-SITE group scored significantly higher across all five dimensions. The qualitative findings further validated the quantitative data, with students consistently reporting that the O-SITE model enhanced their learning initiative and engagement, improved clinical reasoning and skills, and fostered greater humanistic awareness and professional identity. These results provide preliminary evidence of the practical value of the O-SITE model in advancing medical education reform.

The theoretical foundation of the O-SITE model is the Feynman Technique, which emphasizes that actively outputting information facilitates deeper understanding and knowledge internalization [8]. Unlike traditional medical education, which often overemphasizes passive information input, the O-SITE model shifts focus toward the quality and depth of student information output from the perspective of knowledge transmission. When students are able to express information clearly and logically across cognitive, skill-based, and affective domains, it reflects that they have internalized and integrated this knowledge into their existing cognitive frameworks, thereby constructing a solid, transferable knowledge system [9]. Furthermore, the model introduces an innovative focus on faculty development by applying an output-driven sequential TTT approach [5], which fosters comprehensive improvements in teaching design, instructional skills, and clinical mentorship among dual-qualified faculty. This creates a virtuous cycle of mutual promotion and collaborative growth between students and teachers.

The findings further revealed that various dimensions of information output under the O-SITE model positively influenced student performance, learning experience, clinical reasoning, and humanistic development. In terms of learning outcomes, students in the O-SITE group consistently achieved significantly higher scores across all five dimensions of the DREEM scale than those in the control group (all p<0.0001). Notably, improvements in SPA and SPL were particularly pronounced, indicating that the model’s use of flipped classrooms, video demonstrations, and checklist-based learning effectively enhanced students’ perceptions of the learning environment, increased engagement, and stimulated active learning. These findings align with existing research emphasizing the critical role of classroom atmosphere in fostering learning motivation and improving learning outcomes [10].

Additionally, the O-SITE group performed exceptionally well in SASP and SSSP, suggesting that the output-driven teaching model not only strengthened students’ mastery of professional knowledge and clinical thinking but also promoted humanistic competencies and social responsibility. This aligns with the current direction of medical education, which emphasises integrating clinical competence with humanistic care [11]. In contrast, although the control group maintained moderately high scores across dimensions, clear deficiencies were observed in learning initiative, classroom atmosphere, and humanistic awareness, highlighting the limitations of traditional teaching models in motivating students and enhancing comprehensive competencies [12].

Qualitative interviews further validated the conclusions drawn from the quantitative data. Student feedback indicated that knowledge output activities such as mind mapping, student-generated examinations, and self-selected assignments significantly enhanced the systematization and transferability of knowledge structures. Task-oriented output forms, including clinical case analysis and surgical model construction, enabled students to develop a deeper understanding of surgical anatomy and key procedural concepts, thereby substantially improving clinical decision-making and logical reasoning skills. Moreover, affective output activities such as reverse role-play and values-based discussions effectively strengthened students’ perceptions of medical humanism and professional identity, deepening their sense of medical mission and social responsibility. Overall, the O-SITE teaching model, through a systematic and multidimensional approach to information output, effectively promoted integrated development of knowledge internalization, skill acquisition, clinical reasoning, and humanistic competence.

A growing body of research in medical education supports student-centered, output-driven teaching models such as the Feynman Technique and flipped classrooms [13], which emphasize active student expression and practice to foster knowledge internalization and competency development. Compared to traditional passive learning approaches, these models have been shown to significantly improve students’ learning motivation, engagement, and problem-solving abilities [14] – findings consistent with the advantages of the O-SITE model observed in this study, particularly in enhancing learning initiative, clinical thinking, and skills acquisition. Each O-SITE dimension not only represents an output form but also embodies the ODI principle by requiring learners or faculty to internalize knowledge, skills, values, and teaching methods before expression. However, most existing output-oriented models focus on a single dimension (e.g. knowledge presentation or skill demonstration) without addressing the broader educational landscape [15], 16]. In contrast, the O-SITE model integrates four complementary dimensions – intellectual expression, skilled demonstration, emotional expression, and faculty development – through TTT, thus systematically operationalizing the ODI principle. This integration achieves innovation not only in instructional design (e.g. checklist-based learning, student-generated assessments, video demonstrations) but also in faculty training (through the TTT model). Unlike most existing output-driven models that focus on a single dimension, O-SITE simultaneously enhances students’ knowledge, skills, and affective competencies while systematically improving faculty teaching capacity, thereby creating a reciprocal cycle of student–teacher advancement. This comprehensive and scalable framework demonstrates greater innovation and broader applicability than current models reported in the literature.

Some potential challenges exist in implementing the O-SITE model. Both the iterative TTT approach and student output activities require considerable time investment. This workload can be mitigated by gradually introducing output-driven activities, starting with common surgical conditions in general surgery and then expanding to broader course content. Regarding resource requirements, although self-developed materials are ideal, abundant high-quality online educational resources are readily available to support both teachers and students, providing feasible alternatives in resource-limited settings. Finally, some students initially struggled to adapt to the shift from passive learning to output-driven formats. To ease this transition, we supplemented the O-SITE curriculum with traditional lecture-style online resources, which helped students adjust quickly and gradually embrace the new approach.

This study had several limitations. First, as a single-center study with a relatively limited sample size, the generalizability and external validity may have been constrained. Second, although a mixed-methods approach combining quantitative analysis with qualitative interviews was employed, the small sample size and inherent subjectivity of the qualitative interviews may have introduced potential bias. Third, the observation period was relatively short, and no long-term follow-up was conducted to assess the sustained impact of the O-SITE model on teaching outcomes. Future research should involve multicenter studies with larger sample sizes and extended follow-up periods to further validate the effectiveness and scalability of the model.

Conclusions

This study developed and implemented the O-SITE teaching model for Surgery, which is grounded in the core ODI principle. By systematically integrating information output across four dimensions – knowledge, skills, affective development, and faculty growth – the model significantly enhanced students’ active learning ability, clinical reasoning, procedural skills, and humanistic competence, effectively addressing the limitations of traditional surgical education. The O-SITE model not only improved students’ overall learning experience and clinical competency development but also innovatively facilitated the continuous advancement of dual-qualified teaching faculty. It demonstrates substantial value for educational reform and holds promise for broader application and dissemination.