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A Pocketbook to Enhance Intraoperative Learning on the Core Surgery Clerkship: A Mixed Methods Study
Sierra Tseng1, Nathaniel F Wu2, Dandan Chen1
1Department of Surgery, Mass General Brigham, Boston, Massachusetts.
Objective:
To evaluate whether a Surgical Cases Pocketbook enhances medical student engagement and perceived learning in the operating room (OR) during the core surgery clerkship.
Design:
Explanatory sequential mixed-methods study. Quantitative surveys on Pocketbook use, perceived utility, engagement, and confidence were followed by inductive thematic analysis of semi-structured interviews.
Setting:
Core surgery clerkship at a single academic institution.
Participants:
Third-year medical students (39 eligible students) on the core surgery clerkship between April and December 2025. Twenty-seven students completed the survey (69.2% participation rate); 11 of the surveyed students (40.7% of survey participants) completed interviews.
Results:
Most students adopted the Pocketbook (77.8% of survey respondents); the majority used it at least weekly (66.7%). Students rated the anatomical landmarks and surgical steps as most useful and the reflective/patient documentation sections as least useful. OR engagement increased after Pocketbook use (Wilcoxon signed-rank test median change +1 Likert point on 5-point scale, p < 0.05) with 95.2% of students classified as "Engaged" after use and no students becoming less engaged. Case preparation confidence was higher for Pocketbook-included cases (Wilcoxon signed-rank test median change +1 Likert point on 5-point scale, p < 0.05). Qualitative analysis demonstrated that the Pocketbook functioned as a concise, medical student-level framework that reduced cognitive load, oriented students intraoperatively, and helped transform passive observation into active participation. However, the Pocketbook's impact was mediated by OR power dynamics and psychological safety.
Conclusions:
The Pocketbook appears to provide an effective framework for student-driven OR preparation and thus active intraoperative learning. The Pocketbook was widely adopted and associated with increased self-reported OR engagement and case preparation confidence; these engagement and confidence gains were contextualized by the interpersonal climate of the OR. Future study may reveal ideal Pocketbook incorporation into clerkship experiences to optimize student intraoperative learning and engagement.
