Introduction
Musculoskeletal (MSK) conditions are among the leading causes of disability globally, accounting for approximately 20% of all primary care and emergency department visits.1–3 Despite this significant burden, current medical education often leaves students underprepared and poorly exposed to MSK surgical specialties, including orthopaedic and hand surgery.1 Surgical careers are frequently perceived as competitive, demanding, and requiring significant personal sacrifice. These misconceptions about surgical culture and work-life balance may be compounded by limited exposure to MSK surgical specialties, further deterring students from pursuing residencies and careers in surgery.4 This underscores the importance of early, targeted interventions to sustain student interest in surgical careers before such misconceptions become entrenched.
Early exposure programs incorporating structured mentorship, hands-on workshops, and technical skills training have been shown to address these gaps.5–7 Such programs have been associated with increased interest in surgical careers, improved perceptions of surgery, greater preparedness for surgical clerkships, and higher rates of entering surgical specialties.4 Simulation-based training using synthetic models have demonstrated particular promise, with a single one-day surgical skills course increasing interest in a surgical career from 56% to 81%.7
In Singapore, hand surgery is recognised as a specialty independent from orthopaedic and plastic surgery. Unlike most countries where hand surgery training follows residency in orthopaedic or plastic surgery, candidates in Singapore may apply directly to a hand surgery residency programme.8,9 Although all medical schools in Singapore provide MSK clinical rotations, the duration and depth of exposure vary significantly, with limited opportunities for hands-on learning and structured mentorship at the medical student level. Such experiences are critical in shaping career choices, as they provide experiential learning, enhance confidence, and allow meaningful engagement with role models who can help dispel misconceptions surrounding surgical culture and work–life balance.6 Students consistently report greater satisfaction and stronger career interest when they engage actively, through scrubbing into cases, performing procedures, or working with surgical instruments, rather than observing passively.4,5
While simulation-based approaches have been extensively studied in general surgery and other procedural disciplines,10–14 there is limited evidence examining their impact on medical student engagement and career interest specifically within orthopaedic and hand surgery. Early, structured experiences combining didactic instruction, practical exercises, and mentorship may not only enhance technical knowledge but also provide students with insight into the clinical workflow and scope of these specialties. This study aims to evaluate the effectiveness of a technical skills MSK surgery workshop for graduate medical students in increasing confidence, knowledge, and interest in pursuing careers in MSK surgical specialties in Singapore’s context.
Methods
Workshop Design
The workshop was designed with both didactic and practical components delivered and supervised by board-certified orthopaedic and hand surgeons. Participants first attended two introductory lectures designed to provide foundational knowledge prior to the practical training. The first focused on general principles of fracture management, followed by a second lecture on distal radius fractures. The didactic content was aligned with the practical component of the workshop, which included the four core procedures: 1) bone drilling, 2) lag screw fixation, 3) distal radius plate fixation, and 4) removal of implants.
Following the didactic sessions, participants formed small groups of seven, each supervised by an MSK surgeon. AO Trauma instructional videos were used to reinforce the skills being taught. Participants first practised on lag screw fixation on synthetic radial mid-shaft fracture models, with guidance on drill bit selection, screw sizing, trajectory, and torque application. They subsequently progressed to distal radius fracture models, where they practised plate-and-screw fixation using a dedicated distal radius plating system. Differences between cortical and locking screws, as well as monoaxial and polyaxial locking mechanisms, were demonstrated. Students practised plate positioning, identification of anatomical landmarks, pre-contouring techniques, and screw sequencing to simulate operative workflow.
Throughout the session, supervising surgeons provided real-time feedback and instruction on surgical principles, including restoration of anatomical alignment, preservation of hypothetical soft tissues, and avoidance of iatrogenic complications. Synthetic saw-bone models, orthopaedic implants, and surgical instruments were provided by DePuy Synthes (DePuy Synthes, Raynham, MA, USA).
Participant Recruitment
All medical students who attended the workshop were eligible to participate in the study. Participants were excluded from analysis if they did not complete the hands-on workshop session. Only fully completed questionnaires were included in the final analysis.
Study Design
This study employed a post-intervention, survey-based educational evaluation design. Participation in both the workshop and survey was voluntary and had no bearing on participants’ academic standing. Responses were collected anonymously to minimise social desirability bias. Following the workshop, participants completed an anonymous questionnaire consisting of 28 items, as shown in the Appendix. Baseline exposure to MSK surgical specialties was assessed through self-reported prior hands-on training experiences, awareness of hand surgery as a standalone specialty, prior use of orthopaedic instruments, and the presence of a faculty mentor.
Participants reported their baseline interest in MSK surgery using a 10-point Likert scale. Post-workshop perceptions were assessed using 5-point Likert scale items evaluating clarity of learning objectives, appropriateness of course duration, perceived educational value, confidence in fracture management, preparedness for clinical encounters, career interest, mentorship exposure, and support for integration of simulation-based training into the medical curriculum. Overall course satisfaction and willingness to recommend or participate in future workshops were also assessed. Open-ended questions explored perceived strengths, areas for improvement, and additional feedback.
Statistical Analysis
Survey responses were analysed using R (v4.3.2; 2023-10-31 ucrt). Likert-scale responses were coded numerically for statistical evaluation. Open-ended responses were extracted for qualitative thematic analysis. Descriptive statistics were used to summarise participant demographics, prior exposure to orthopaedic and hand surgery, and baseline mentorship experience. Non-parametric continuous variables were reported as median and interquartile range. Likert-scale data was treated as ordinal variables. Subgroup analysis was done using non-parametric Mann-Whitney U test. Qualitative responses were analysed using thematic content analysis to identify recurring themes related to educational value, skill acquisition, and career decision-making. Statistical significance was defined a priori as p < 0.05.
Results
Demographic Data
A total of 35 medical students participated in the fracture fixation workshop, of whom 27 students completed the post-workshop survey (77.0% response rate). Among those who completed the survey, 8 (29.6%) were first-year medical students (MS1), 6 (22.2%) were second-year medical students (MS2), 6 (22.2%) were third-year medical students (MS3), 6 (22.2%) were fourth-year medical students (MS4), and 1 (3.7%) was an MD-PhD in his first year of PhD. The cohort comprised of 12 (44.4%) males and 15 (55.6%) females, with a median age of 27 years [IQR 25.5 – 29.5]. The demographic data are illustrated in Table 1.
Interest and Prior Exposure
Baseline interest scores in MSK surgical specialties were similar, with a reported median of 6 out of 10 [IQR 4 – 8] for orthopaedic surgery and 6 out of 10 [IQR 4.5 – 8] for hand surgery. Regarding any prior hands-on MSK surgical specialty training, responses were evenly distributed: 14 participants reported no prior experience, while 13 participants reported between 1 and 5 prior experiences. Subgroup analysis revealed no statistical difference in orthopaedic surgery interest between these two groups with differing experience levels (p=0.21). However, for hand surgery, participants with prior hands-on experience reported significantly higher baseline interest compared to those without (p=0.00022)
In the Singapore context, where hand surgery is an independent specialty, the majority of students (23/27, 85%) were aware of this fact. Only 9 medical students (33%) reported having an orthopaedic or hand surgery faculty mentor, and only 4 students (15%) had previously worked with orthopaedic instruments. The interest and prior exposure data are summarised in Table 2.
Workshop Experience
Regarding the practical component of the workshop itself, most participants (20 out of 27, 74.0%) reported performing all four procedures. All participants reported performing at least one of the four tasks within the given timeframe. The majority of the participants reported that the learning objectives were clearly defined, and the duration of the course was appropriate, with 96% of participants responded with 4 or 5 out of 5 for both items. Workshop experience data are summarised in Table 3.
Post-Workshop
Post-workshop outcomes were captured through questions Q3 to Q25 of the survey questions. All items showed a positive response with a median score of 5 out of 5, except for Q19 and Q20 with a median score of 4 out of 5. A significant majority of respondents (96%) rated the course 4 or 5 out of 5 for overall course quality. Participants reported notably increased interest in orthopaedic and hand surgery after the workshop (85% responded 4 or 5) as well as a positive inclination towards considering a career in orthopaedic and hand surgery (70% responded 4 or 5). The highest rated item was participants’ agreement that MSK surgical training would benefit medical students (100% responded 4 or 5). Other highly rated items include enhanced understanding of fracture fixation (100% responded 4 or 5), perceived value of the course as a learning opportunity (100% responded 4 or 5), support for formal integration of fracture fixation and hands-on MSK training into the curriculum (89% responded 4 or 5), and willingness to recommend the course to other students (96% responded 4 or 5). Post workshop outcome data are summarised in Table 4.
Qualitative Findings
Thematic analysis of free-response items identified three overarching themes: perceived strengths, areas for improvement, and professional impact.
The most cited strength was the “theory-to-practice” structure, with participants noting that the transition from didactic lectures to hands-on simulation was essential for solidifying clinical knowledge. Other strengths included the systematic, algorithmic approach to fracture management, high levels of engagement with surgical instrumentation, the quality and approachability of faculty mentorship, and well-paced delivery.
Areas for optimisation were primarily logistical, including increasing equipment availability to reduce wait times and utilising higher fidelity fracture models. Participants also expressed a desire for the inclusion of more common orthopaedic procedures, such as backslab and cast application to better reflect the breadth of MSK clinical practice.
Overall, the session generated strong professional resonance. Several participants expressed anticipation for future workshops and gratitude to the faculty mentors. Multiple respondents advocated for the formal integration of these workshops into the medical school curriculum.
Discussion
This study aimed to evaluate the effectiveness of a simulation-based MSK surgery workshop in improving medical students’ knowledge, confidence, and interest in orthopaedic surgery and hand surgery. Overall, the results were strongly positive. Participants reported high levels of satisfaction, with clear learning objectives and appropriate course duration. The workshop improved understanding of fracture fixation, increased confidence in approaching MSK cases and operative settings, and increased level of interest in orthopaedic and hand surgery. There was also strong support for incorporating similar hands-on workshops into the medical school curriculum.
Addressing deficiency in MSK education
The positive outcomes of this workshop must be understood against the backdrop of a global deficit in MSK surgical education. DiGiovanni et al. (2016) demonstrated that clinical MSK rotation was the least represented of all required specialties in the United States.1 Skelley et al. (2012) similarly found that the majority of medical students had low to moderate confidence level in dealing with musculoskeletal issues,15 and a UK-wide survey showed final-year students expressed low confidence across fundamental trauma and orthopaedic skills.16 Our findings are consistent with this global pattern, with students reporting limited prior hands-on experience and low mentorship.
Theory-to-practice
A recurring theme in the qualitative data was the value of the sequential “theory-to-practice” structure, where the didactic lectures preceded the hands-on simulation component. This finding aligns with established experiential learning theory, as described by Kolb (1984) who posits that meaningful skill acquisition occurs through a cycle of concrete experience, reflective observation, abstract conceptualisation, and active experimentation.17 McGaghie et al. (2010) and Kneebone (2003) have also argued that simulation-based training is most effective when theoretical grounding and practical application are integrated rather than delivered in isolation.18,19 The positive outcome measures in our study reflect the pedagogical effectiveness of this approach. While it can be argued that the practical aspect of the workshop was not essential for medical students, the integrated delivery with the lectures reinforced learning.
Simulation-Based Training
The effectiveness of simulation-based training in surgical education is well supported in the literature.5,7,16,20,21 Although our workshop was a single session intervention without objective skill measurement, the strong self-reported improvements in confidence and preparedness are consistent with the literature.5–7 Hetaimish (2016) further highlighted that saw-bone models are preferred over virtual reality simulators due to their tactile realism and cost effectiveness,21 advantages that were relevant to our workshop. Our finding that 74% of participants completed all four procedural tasks suggests strong engagement and the feasibility of delivering meaningful training within a single session.
Career Interest and Mentorship
An encouraging finding was the positive inclination towards a career in orthopaedic or hand surgery with increased interest scores. These results are consistent with the literature on early surgical exposure. A systematic review found that 8 out of 12 studies reported increased interest in surgical careers following early exposure programs, and that students who participated in structured pre-clinical programs were more likely to match into surgical specialities.4 Karthik et al. (2023) identified that students with initial surgical interest are at high risk of changing their career trajectory during medical school, with only 42% ultimately pursuing a surgical career.22 This underscores the importance of timely, structured exposure to sustain interest before it wanes. Our workshop aligns with the recommendation that early exposure is valuable for career decision making.
Faculty guidance was also identified as a key strength in the qualitative feedback. Karthik et al. (2023) identified mentorship by physicians in a chosen specialty as the single most positively perceived factor in specialty choice.22 In our cohort, where only 33.3% of participants had an existing orthopaedic or hand surgery mentor, the workshop provided a critical opportunity for meaningful faculty-student interaction that may not be accessible within the standard curriculum.
Notably, 85% of participants were aware that hand surgery exists as an independent specialty in Singapore. Subgroup analysis revealed a statistically significant difference in baseline hand surgery interest between students with and without prior hands-on experience. This suggests that prior experiential exposure may have a strong influence in hand surgery specifically, as it is a less visible specialty and requires active engagement to appreciate its scope. Early awareness and structured exposure may be consequential for recruitment into this pathway.
This study has several limitations. This was a single-session intervention, and the study design does not permit assessment of long-term retention of knowledge, skills, or sustained career interest. The sample size was limited, which may affect generalisability. This was a post-hoc, post-intervention survey without matched pre-intervention data, making it difficult to objectively quantify the degree of change. Additionally, the reliance on self-reported outcomes introduces potential response bias. Finally, the findings may be context-specific, particularly to settings where hand surgery is a standalone specialty and within graduate-entry medical education systems.
Future directions include conducting longitudinal follow-up to assess whether improvements in interest and confidence translate into sustained career exploration or residency applications. Incorporating pre- and post-intervention assessments, including objective measures of technical competency, would strengthen the study design. There is also scope to improve workshop logistics, including increasing equipment availability, improving fracture model fidelity, and incorporating more common orthopaedic procedures such as back-slab and cast application. Given the strong support for curriculum integration, future work should explore scaling and embedding such simulation-based MSK workshops into formal medical education.
Conclusions
Our study showed that early, structured simulation-based workshops can enhance knowledge, confidence, and career interest in orthopaedic and hand surgery. These findings support the integration of such programs into medical curricula to foster early engagement and informed career decision.
Financial Disclosure
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Conflict of Interest
The authors declare no conflict of interest.