Climbing the ladder of confidence: effects of the step ladder system on medical students' self-efficacy during a surgical clerkship.

backgroundSelf-efficacy is a key factor in motivation, persistence, and performance in medical education. However, surgical clerkships often provide limited hands-on practice and inconsistent feedback, hindering students’ ability to recognize their learning progress or readiness. The Step Ladder System (SLS), a structured competency-based framework, was introduced to clarify expectations and support incremental learning by helping students visualize progress and document task achievements. This study examined changes in medical students’ self-efficacy during a surgical clerkship and investigated whether participation in the SLS was linked to self-efficacy growth.

methodsAn observational study using prospective and retrospective data was conducted among 24 sixth-year medical students who completed a four-week clerkship in gastroentintestinal and pediatric surgery at Tottori University in 2025. Self-efficacy was measured with the General Self-Efficacy Scale (GSES) at the start and end of the rotation. SLS engagement was calculated as the total number of task entries submitted via the mobile app. Paired t-tests evaluated pre- and post-rotation changes, while binomial tests analyzed directional trends in ΔGSES.

resultsStandardized GSES scores increased significantly from pre- to post-clerkship (49.8 ± 11.0 to 53.8 ± 12.2; p = 0.009). Students with high SLS engagement were more likely to show positive rather than negative ΔGSES (p = 0.021), while no clear trend was observed in low-engagement students. Learners with lower baseline GSES showed a significant predominance of positive ΔGSES (p = 0.031).

conclusionsMedical students’ self-efficacy improved over the clerkship. The SLS is designed as a learner-facing scaffold that supports clarification of expectations and structured preparation, rather than a tool for summative competency assessment. The SLS may support this growth by clarifying expected learning targets and expectations, encouraging purposeful preparation, and providing clearer goals and structured mastery experiences. Although SLS engagement and the magnitude of ΔGSES were not proportional, greater engagement and lower initial self-efficacy were consistently associated with positive change, suggesting that structured task engagement influences self-efficacy through non-linear mechanisms. The SLS appears to be a feasible and potentially beneficial framework for learner-centered surgical education.