Integrating the History of Neurosurgery into Clinical Teaching: A Historically Controlled Study of Knowledge Acquisition and Student Perceptions

Abstract

Purpose

To examine whether integrating the history of neurosurgery into standard clinical teaching is associated with improved performance on a knowledge assessment and more favorable student perceptions of the educational experience, compared with conventional clinical teaching without dedicated historical content.

Methods

We conducted a non-randomized, historically controlled study of clinical medical students completing a neurosurgery rotation at the First Affiliated Hospital of Wannan Medical College between September 2023 and July 2025. Students who completed training before June 2024 (control group, n = 37) received standard clinical teaching; those who completed training after July 2024 (research group, n = 44) received the same curriculum enriched with integrated neurosurgical history content. Outcomes were assessed using a purpose-designed knowledge test and a locally developed questionnaire measuring students’ self-reported perceptions across seven educational domains.

Results

Eighty-one valid assessments were analyzed. The research group achieved significantly higher composite knowledge scores (85.68 ± 1.890 vs 65.57 ± 2.754; mean difference 20.11 [95% CI: 19.04, 21.18]; t=37.60, P<0.001; Cohen’s d=8.66), neurosurgical knowledge scores (93.86 ± 2.299 vs 80.86 ± 2.689; mean difference 13.00 [95% CI: 11.88, 14.12]; t=23.14, P<0.001; Cohen’s d=5.23), and medical history knowledge scores (77.50 ± 3.084 vs 50.27 ± 4.765; mean difference 27.23 [95% CI: 25.41, 29.05]; t=29.89, P<0.001; Cohen’s d=6.91). Across all seven questionnaire domains, significantly higher proportions of research group students reported perceived educational benefit (all unadjusted P<0.05; four of seven comparisons remained significant at the Bonferroni-adjusted threshold of P<0.0071).

Conclusion

This historically controlled study provides preliminary evidence that integrating the history of neurosurgery into clinical teaching may be associated with improved knowledge-test performance and more favorable student perceptions. These findings are hypothesis-generating and require confirmation through prospective, randomized, multicenter studies.

Introduction

Medical humanities education is widely recognized as integral to the formation of clinically competent and professionally committed physicians. Yet formal instruction in the history of medicine, and in specialty-specific historical content in particular, remains limited in Chinese medical curricula.^1,2 Traditional medical history courses are commonly delivered by humanities faculty members with limited clinical experience, creating a disconnect that reduces the perceived relevance of historical content to trainees.

Neurosurgery presents particular pedagogical challenges. Its core concepts—intracranial pressure dynamics, the localization of cerebral function, the development of stereotactic techniques, and the refinement of cerebrovascular surgery—emerged from rich intellectual and clinical histories that provide a natural scaffold for contextual learning.^3,4 Prior work in gastrointestinal surgery has demonstrated that specialty-specific historical enrichment of bedside clinical teaching can activate student engagement and deepen humanistic professional formation.⁵ Educational theory suggests that embedding factual knowledge within meaningful narrative frameworks enhances elaborative encoding and promotes durable memory consolidation.^6,7 Narrative-based and contextual learning approaches have been shown to activate prior knowledge structures, facilitate schema formation, and support the development of professional identity—outcomes that align directly with the goals of specialty clinical training.^8,9

To our knowledge, based on a search of PubMed and CNKI using the terms “neurosurgery”, “medical history”, “clinical teaching”, and “historical narrative” (search period: January 2000 to August 2023), no quantitative comparative study has examined this approach in neurosurgery. The present study was therefore designed to evaluate, using a historically controlled design, whether integrating neurosurgical history into an established clinical curriculum is associated with differences in knowledge-test performance and student-reported perceptions of the educational experience.

Materials and Methods

Study Design and Setting

This was a non-randomized, historically controlled educational study conducted in the Department of Neurosurgery at the First Affiliated Hospital of Wannan Medical College (Yijishan Hospital), Wuhu, China. This study was submitted to the Medical Ethics Committee of Wannan Medical College, which formally granted a written ethical exemption in accordance with national and institutional regulations for teaching research projects. The study was conducted in accordance with the Declaration of Helsinki. All students participated voluntarily and provided written informed consent prior to enrolment.

Participants

Clinical medical students who completed a neurosurgery rotation at our institution between September 2023 and July 2025 were consecutively enrolled. Students who completed their rotation before June 2024 constituted the control group; those who completed their rotation from July 2024 onward constituted the research group. Eligible students had completed undergraduate-level clinical and anatomical coursework. Students were excluded if their rotation lasted fewer than two weeks or if they had previously received structured or dedicated training specifically focused on the history of neurosurgery. No student was excluded on the basis of academic performance. Of 85 students who commenced rotations during the study period, 4 were excluded (2 rotation duration < 2 weeks; 2 withdrew consent), yielding a final sample of 81 (37 control, 44 research). As this was an exploratory, retrospective educational study, no prospective sample-size or statistical-power calculation was performed; the implications for statistical precision are discussed in the Limitations.

Cohort Comparability

To minimize the risk of cohort confounding, the following conditions were maintained across both periods: (1) the same three neurosurgery attending physicians supervised all rotations throughout the study period; (2) the clinical rotation structure, duration (four weeks for all students), and total scheduled teaching hours (40 hours per rotation) were identical; (3) all students participated in the same core activities—patient history-taking, physical examination, imaging interpretation, case discussions, didactic mini-lectures, skills training, surgical observation, and teaching ward rounds; (4) no substantial curricular changes, new examinations, or institutional policy changes occurred between the two periods.

Teaching Interventions

Both groups received identical foundational clinical teaching delivered via micro-video instruction, the picture archiving and communication system (PACS), multimedia presentations, and anatomical specimen demonstrations.

In the research group, neurosurgical history content was additionally integrated into each of the four weekly teaching sessions (approximately 20–30 minutes per session, totaling 80–120 additional minutes over the rotation). Content was structured around five thematic modules: (1) the history of intracranial pressure and the Cushing reflex; (2) the origins of cerebral localization and lumbar puncture; (3) the development of transsphenoidal and skull-base approaches; (4) pioneers of cerebrovascular neurosurgery; and (5) the evolution of neuroimaging and intraoperative technology. Instructors used a case-based and problem-based narrative approach to connect historical events to contemporary clinical concepts. A standardized teaching guide was developed for the three supervising physicians prior to the study; all three participated in a four-hour orientation session to ensure content consistency. The control group curriculum was otherwise identical but contained no historical enrichment content.

Assessment Instruments

Knowledge Test

A purpose-designed, closed-book knowledge test was administered at the end of each rotation. The test comprised 20 multiple-response questions: 10 items assessing neurosurgical foundational knowledge (pathophysiology, anatomy, clinical manifestations, diagnostic criteria, and treatment principles) and 10 items assessing familiarity with key historical figures, landmark techniques, and classical theoretical frameworks in neurosurgery. Each question contained five response options and was worth a maximum of 10 points. A fully correct response received 10 points. For an incomplete response containing no incorrect selections, 2 points were awarded for each correctly selected option. If any incorrect option was selected, the entire question received 0 points. Scores for the 10 questions within each domain were summed to yield subscale scores ranging from 0 to 100 points. The composite score was calculated as the mean of the two subscale scores. Items were developed by two senior neurosurgery faculty members and reviewed by an independent educational specialist for content clarity and appropriateness.

Questionnaire

A locally developed, anonymously completed questionnaire of seven items assessed students’ self-reported perceptions of the educational value of neurosurgical history teaching. Research group students rated items based on their actual experience. Control group students were instructed to respond based on their hypothetical perceptions, providing baseline attitudinal data for comparison. Response options were binary (agree/disagree). The questionnaire was reviewed for face validity by three faculty members and piloted with five students not included in the main study. Questionnaire responses are interpreted as self-reported perceptions rather than objective measures of competence. Given that seven questionnaire items were compared, a Bonferroni-adjusted significance threshold of α = 0.05/7 = 0.0071 was applied.

Statistical Analysis

Data were analyzed using GraphPad Prism 8 (GraphPad Software, San Diego, CA, USA). Continuous data are presented as mean ± standard deviation (SD) and compared using the independent-samples Welch’s t-test. Categorical data are reported as frequency and percentage and compared using Pearson’s chi-square (χ²) test. Effect sizes for continuous outcomes are reported as Cohen’s d (pooled SD) and presented in the text. P < 0.05 (two-tailed) was considered statistically significant.

Results

Baseline Characteristics

Eighty-one students completed valid assessments: 37 in the control group and 44 in the research group. The two groups did not differ significantly in sex distribution (56.8% female control vs 54.5% female research; χ²=0.040, P=0.842) or in prior exposure to neurosurgical history content in formal coursework (40.5% control vs 38.6% research; χ²=0.030, P=0.861). Baseline characteristics are presented in Table 1.

Table 1.

Baseline Characteristics of the Two Groups

Characteristic	Control Group (n=37)	Research Group (n=44)	χ2/t	P value
Sex			0.040	0.842
Female, n (%)	21 (56.8%)	24 (54.5%)
Male, n (%)	16 (43.2%)	20 (45.5%)
Prior exposure to neurosurgery history teaching			0.030	0.861
Yes, n (%)	15 (40.5%)	17 (38.6%)
No, n (%)	22 (59.5%)	27 (61.4%)

Knowledge Test Scores

Research group students achieved significantly higher scores than control group students on all three knowledge outcomes (Table 2). The neurosurgical knowledge subscale score was higher in the research group (93.86 ± 2.299 vs 80.86 ± 2.689; mean difference 13.00 [95% CI: 11.88, 14.12]; t=23.14, P<0.001; Cohen’s d=5.23). The medical history knowledge subscale score was also higher (77.50 ± 3.084 vs 50.27 ± 4.765; mean difference 27.23 [95% CI: 25.41, 29.05]; t=29.89, P<0.001; Cohen’s d=6.91). The composite score was higher in the research group (85.68 ± 1.890 vs 65.57 ± 2.754; mean difference 20.11 [95% CI: 19.04, 21.18]; t=37.60, P<0.001; Cohen’s d=8.66). Effect sizes were very large for all three comparisons.

Table 2.

Knowledge Test Scores: Between-Group Comparison (Mean ± SD)

Assessment Item	Control Group (n=37) Mean ± SD	Research Group (n=44) Mean ± SD	Mean Difference (95% CI)	t	P value	Cohen’s d
Neurosurgical Knowledge Test	80.86 ± 2.689	93.86 ± 2.299	13.00 (11.88, 14.12)	23.14	<0.001	5.23
Medical History Knowledge Test	50.27 ± 4.765	77.50 ± 3.084	27.23 (25.41, 29.05)	29.89	<0.001	6.91
Composite Score	65.57 ± 2.754	85.68 ± 1.890	20.11 (19.04, 21.18)	37.60	<0.001	8.66

Notes: All dispersion values are SD. P values are two-tailed from Welch’s independent-samples t-test.

Abbreviations: SD, standard deviation; CI, confidence interval; Cohen’s d calculated using pooled SD.

Student Perceptions of Neurosurgical History Teaching

Across all seven questionnaire domains, significantly higher proportions of research group students reported perceived educational benefit compared with control group students (Table 3; all unadjusted P<0.05; four of seven comparisons remained significant at the Bonferroni-adjusted threshold of P<0.0071). The largest between-group differences were observed for broadening of thinking and stimulation of learning interest (95.5% research vs 64.9% control; χ²=12.46, P<0.001) and perceived helpfulness for mastering neurosurgical foundational knowledge (93.2% vs 62.2%; χ²=11.66, P<0.001).

Table 3.

Student Perceptions of Neurosurgical History Teaching: Questionnaire Results

Survey Item	Control Group (n=37) n	Agree (%)	Research Group (n=44) n	Agree (%)	χ2 (P value)
Helpful for mastering neurosurgical knowledge	23	62.2%	41	93.2%	11.66 (<0.001)
Helpful for developing clinical reasoning skills	26	70.3%	40	90.9%	5.67 (0.017)
Helpful for inspiring logical analytical ability	24	64.9%	38	86.4%	5.17 (0.023)
Influential on specialty direction choice	20	54.1%	33	75.0%	3.90 (0.048)
Helpful for broadening thinking and stimulating interest	24	64.9%	42	95.5%	12.46 (<0.001)
Helpful for improving judgment and overall quality	22	59.5%	39	88.6%	9.20 (0.002)
Helpful for appreciating masters’ professional dedication	19	51.4%	37	84.1%	10.10(0.001)

Notes: χ² = Pearson chi-square statistic. Four of seven comparisons remained significant at the Bonferroni-adjusted threshold (P < 0.0071). Questionnaire responses are self-reported perceptions; control group students responded hypothetically, research group students based on direct experience.

Discussion

This historically controlled study provides preliminary evidence that integrating neurosurgical history into standard clinical teaching is associated with higher performance on an immediately administered knowledge test and more favorable student perceptions across all measured educational domains. While the design precludes causal inference, the consistency and magnitude of the observed associations support the educational plausibility of this approach.

Several features of the present study deserve particular attention. The most robust finding is the improvement in the neurosurgical knowledge subscale, on which both groups received identical foundational teaching. When students encounter core concepts—intracranial pressure physiology, cerebral localization, or cerebrospinal fluid dynamics—within the narrative context of their historical discovery,¹⁰ those concepts acquire additional associative cues that may facilitate elaborative encoding and durable retrieval.^11,12 This mechanism is supported by educational neuroscience, which consistently demonstrates that semantic and narrative richness at the point of encoding strengthens long-term memory consolidation relative to decontextualized instruction.^6,13 The very large effect sizes observed (Cohen’s d = 5.23 on the neurosurgical knowledge subscale) indicate that the between-group difference substantially exceeded chance variation, lending credibility to a genuine educational signal even within the constraints of the study design.

To our knowledge, this is the first quantitative comparative study to examine the integration of specialty-specific historical content into neurosurgical clinical teaching. The consistent pattern of findings across seven independent questionnaire domains—with four remaining significant at the Bonferroni-adjusted threshold—indicates that the perceived educational value of historical enrichment extends beyond knowledge acquisition to encompass clinical reasoning interest, analytical thinking, and professional engagement.^14,15 These student perceptions are educationally meaningful: favorable attitudes toward a learning approach have been shown to correlate with sustained engagement and intrinsic motivation,^16,17 both of which support long-term professional development.^18,19 Furthermore, the practical implementation characteristics of this approach—integration into existing teaching sessions, no requirement for additional faculty or resources, and a standardizable curriculum guide—suggest that it is scalable and replicable in similar clinical training settings.

The study has important limitations that must be considered when interpreting these findings. The historically controlled design introduces potential for temporal, cohort, instructor-enthusiasm, and teaching-time confounding: research group students received approximately 80–120 additional minutes of instruction, and differences in cohort-level motivation or prior knowledge cannot be excluded. In the absence of individual-level covariate data for the control cohort, regression-adjusted analysis was not feasible, and causal attribution is not warranted. Additionally, social desirability bias cannot be excluded from the questionnaire responses, as research group students who received the intervention may have been inclined to rate its perceived benefits more favorably than warranted; the anonymized, binary response format was intended to mitigate but cannot eliminate this risk. The medical history knowledge subscale—on which the largest difference was observed (27.23 points)—included content explicitly taught only to the research group, representing a testing-intervention alignment bias; this subscale therefore measures recall of taught material rather than a generalizable knowledge gain, and the neurosurgical knowledge subscale provides the cleaner comparison. The sample was drawn from a single center, outcomes were assessed immediately after rotation (precluding retention assessment), and no prospective power calculation was performed. These limitations are characteristic of exploratory educational studies and are addressed by framing the present work as hypothesis-generating proof-of-concept evidence.

Future studies should employ prospective randomized designs with individual-level baseline covariates, objective measures of clinical reasoning (such as OSCE-based assessments), longer-term follow-up of knowledge retention, and multicenter recruitment. Such designs would allow rigorous evaluation of whether the associations observed here reflect a replicable and generalizable educational benefit of integrating neurosurgical history into clinical training.

Conclusion

This historically controlled, single-center study provides preliminary evidence that integrating the history of neurosurgery into clinical teaching may be associated with higher immediate knowledge-test performance and more favorable student perceptions of the educational experience. The approach is theoretically grounded, practically scalable, and consistent with the broader literature on narrative-based medical education. These findings do not establish causality and should not be used to recommend widespread implementation; confirmation through prospective randomized multicenter studies with objective outcome measures is required.

Funding Statement

This work was supported by the National Center for Medical Education Development (2023B269) and the Anhui Provincial Teaching Research Project of Colleges and Universities (2023jyxm1235).

Ethics Approval

This study was submitted to the Medical Ethics Committee of Wannan Medical College, which formally granted a written ethical exemption in accordance with national and institutional regulations for teaching research projects. The study was conducted in accordance with the Declaration of Helsinki. All students participated voluntarily and provided written informed consent prior to enrolment.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

All authors declare no conflicts of interest.