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Attracting Surgical Clerks to Surgical Careers: Role Models, Mentoring, and Engagement in the Operating Room
ORIGINAL SCIENTIFIC ARTICLES
Attracting Surgical Clerks to Surgical Careers: Role Models, Mentoring, and Engagement in the Operating Room Loren Berman, MD, Marjorie S Rosenthal, MD, MPH, Leslie A Curry, PhD, MPH, Leigh V Evans, MD, Richard J Gusberg, MD Declining interest in careers in surgery among medical students has contributed to growing concerns about the surgical workforce. Although the medical student clerkship is likely to play an important role in shaping students’ impressions of careers in surgery, little is known about the nature of this process. This study was designed to identify those aspects of the clerkship that are associated with medical students expressing an interest in surgery at the end of the clerkship. STUDY DESIGN: Medical students completed a survey at the end of the surgical clerkship assessing characteristics of the clerkship experience and students’ level of interest in pursuing a career in surgery. The survey also included open-ended questions about students’ reasons for having increased or decreased interest in surgery, which were systematically analyzed to complement quantitative findings. RESULTS: Students who sutured (p ⫽ 0.001), drove the camera (p ⫽ 0.01), stated that they felt involved in the operating room (p ⫽ 0.009), and saw residents (p ⫽ 0.03) and attendings (p ⫽ 0.0003) as positive role models were more likely to be interested in surgery. After adjusting for covariates, students who sutured in the operating room were 4.8 times as likely to be interested in surgery (95% CI, 1.5 to 14.9) and students who drove the camera were 7.2 times as likely to be interested in surgery (95% CI, 1.1 to 46.8). CONCLUSIONS: Students who participate actively in the operating room and those who are exposed to positive role models are more likely to be interested in pursuing a career in surgery. To optimize students’ clerkship experiences and attract top candidates to the field of surgery, clerkship directors should encourage meaningful engagement of students in the operating room and facilitate mentoring experiences. (J Am Coll Surg 2008;207:793–800. © 2008 by the American College of Surgeons) BACKGROUND:
in surgery.13-16 Attrition from surgical residency programs has also been identified as a growing problem,17-20 suggesting that some students who choose surgical residencies might not have had sufficient exposure during medical school to make a decision that is optimally suited to their skills and interest. The surgical clerkship is one of the core educational experiences for medical students. Students not only build technical skills during the clerkship, but they also learn about patient care, doctor⫺patient communication, and how to efficiently process complex information. Students interact with residents and attendings who might become role models, and formulate opinions about surgeons and surgical careers. In recent years, the traditional surgical educational paradigm has been challenged by the 80-hour work week and a national trend toward decreasing the amount of time that students spend on the surgical clerkship.21 These changes are likely to diminish students’ interface with patients, teachers, and potential role models.
The number of medical students who choose careers in surgery has declined in recent years.1 Today’s medical students are attracted to fields with controllable lifestyles.2-4 Students are deterred by the clinical demands of surgery and the challenges of balancing these demands with the desire to pursue interests and fulfill responsibilities outside of medicine.5-12 Additionally, concerns have been raised about the quality of the medical students choosing careers Disclosure Information: Nothing to disclose. Received June 2, 2008; Revised July 11, 2008; Accepted August 4, 2008. From the Robert Wood Johnson Clinical Scholars Program, Yale University School of Medicine (Berman, Rosenthal), the Robert Wood Johnson Clinical Scholars Program, Yale University School of Epidemiology and Public Health (Curry), Department of Emergency Medicine, Yale University School of Medicine (Evans), and Department of Surgery, Yale University School of Medicine (Gusberg), New Haven, CT. Correspondence address: Loren Berman, MD, Robert Wood Johnson Clinical Scholars Program, Yale University School of Medicine, IE-61 SHM, 333 Cedar St, New Haven, CT 06511.
© 2008 by the American College of Surgeons Published by Elsevier Inc.
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The surgical clerkship is an opportunity to demonstrate to medical students both the rewards and challenges of a career in surgery, and thereby maximize the likelihood that suitable students will choose to pursue careers in surgery. Several studies have shown that medical students’ surgical clerkship experiences can influence their career choices,9,22-25 but no prior report has focused on specific characteristics of the clerkship that could be applied broadly across medical schools. In this study, we sought to identify those aspects of the surgical clerkship that were associated with medical student interest in a career in surgery, to identify ways to optimize the clerkship experience and attract, not only the best applicants, but also those who are most well-suited to careers in surgery.
METHODS Third-year medical students completed an online survey after their surgery clerkship. The data were collected between September 2006 and September 2007. Four groups of students completed 12-week surgery clerkships composed of 4 weeks of general surgery, 4 weeks of subspecialty surgery in two 2-week blocks (ie, vascular surgery, pediatric surgery, orthopaedic surgery, otolaryngology, transplantation, plastics, cardiothoracic surgery, or urology), 2 weeks of anesthesia and 2 weeks of emergency medicine. Throughout the 12-week block, there was a structured mentoring program (each student met weekly with an assigned surgical faculty mentor) and a simulation course. The simulation course is structured around 24 clinical scenarios during which students confront urgent and emergent surgical problems with an interactive high-fidelity human patient mannequin. The course efficiently convenes students and faculty in a unique simulated scenario where the students provide direct patient care, with the option of calling in surgical faculty as consultants. Surgeons also lead debriefing sessions where they discuss problem-solving, communication, team-building, and leadership skills. The mentoring role of the faculty is enhanced through their ongoing involvement. The 38-question survey (see Appendix “Surgical Student Questionnaire” online) assessed students’ level of interest in surgery at the end of the clerkship, whether or not they were planning on doing a surgical subinternship (students are not required to complete a surgical subinternship at our institution), their impressions of surgeon rolemodeling and mentorship, degree of involvement with patients, operative exposure both in the operating room and through simulation exercises with laparoscopic task trainers, and other factors affecting interest in surgery. We used 5-point Likert scales to measure students’ perceptions of their degree of involvement in the operating room, and whether they viewed surgical residents and at-
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tendings as positive role models with respect to patient interactions. Likert-scale responses were dichotomized into two comparison groups: those who answered “strongly disagree,” “disagree,” or “neutral,” and those who answered “agree” or “strongly agree.” We measured students’ involvement on subspecialty and general surgery rotations separately, and combined these responses to create composite variables that would reflect the students’ overall experience across the 8 weeks of general and subspecialty surgical rotations and the 12 weeks of simulation and mentoring with regard to the following activities: seeing consults; perioperative patient care; and direct involvement in operating room activities, such as suturing, dissecting, and cameradriving. Each of these variables was dichotomized into two comparison groups: those who performed a given task at least once or twice on at least two out of their three rotations, versus those who never performed the task, or did so only once or twice during the course of the entire clerkship. We performed bivariate analyses to identify which features of the clerkship were associated with having an interest in surgery at the end of the clerkship, using chi-square or Fisher’s exact test, as appropriate. We used multiple logistic regression to adjust for covariates, including all independent variables that were significant on bivariate analysis at the 0.05 level, in addition to demographic information. All statistics were performed using SAS 9.1. The survey also included open-ended questions about factors affecting students’ level of interest in surgery and how the clerkship experience influenced career goals. We analyzed qualitative data using the constant comparative method, a systematic data coding and analysis procedure.26-28 This method involves the categorization of specific quotes from participants with the use of codes developed iteratively to reflect the data. Using the process recommended by experts in qualitative research,29 open-ended responses were reviewed and coded independently by three individuals from diverse backgrounds, including surgery, qualitative and mixed methods research, and medical education. We met in a group session to resolve discrepancies through negotiated consensus, focusing our analysis on those aspects of the qualitative data that would enhance our interpretation of the quantitative findings and provide additional insights into perceptions and experiences not measured quantitatively.30 The study was approved by the Yale University School of Medicine Human Investigation Committee.
RESULTS Our response rate was 89% (116 of 131 students). The majority of students were women (56.9%). Half (50%) were Caucasian, 12% were Asian, 7% were African Amer-
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Table 1. Description of Clerkship Experience Characteristic
Experience in operating room Made incision Dissected Sutured Drove camera Felt involved overall Experience outside of operating room Carried at least 2⫺3 patients Saw consults Saw consults independently Used laparoscopic simulator Experience with role models Saw attendings as positive role models Saw residents as positive role models
n
%
50 35 68 102 100
43.1 30.2 58.6 87.9 86.2
70 74 42 46
66.7 63.8 36.2 39.7
83 82
71.6 70.7
ican, and 3% were Latino. The median age was 25 years. There was an even distribution of previous clerkship experience; about 25% of students were doing surgery as their first clinical clerkship, 25% came to the clerkship with 12 months of clinical experience, and the other 50% had 3 to 6 months of experience. Students’ experiences on the surgical clerkship are described in Table 1. The majority of students were involved in seeing consult patients (64%), but fewer students reported that they saw consults independently (36%). About 40% of students used the laparoscopic simulator. There was substantial variation in students’ degree of participation in the operating room. Although the vast majority (87.9%) were given the opportunity to drive the camera during laparoscopic procedures, fewer students sutured (58.6%), made an incision (43.1%), or dissected tissues (30.2%). Despite this variation in operating room participation, ⬎86% said that they “felt involved overall in the OR.” The majority of students said that they viewed surgical attendings and residents as positive role models in terms of their patient interactions (72% and 71%, respectively). The majority of students reported that their clinical skills had improved during the surgery clerkship (Fig. 1), with the strongest improvements in physical diagnosis, formulating an assessment and plan, and developing technical skills. The majority of students also expressed that they had some interest in surgery at the end of the clerkship (Fig. 2), with 75% considering a surgical subinternship and 64% considering a career in surgery. There were no significant differences in level of interest in surgery according to race or ethnicity (59% of Caucasians, 75% of African Americans, 67% of Latinos, and 57% of Asians were interested in surgery; p ⫽ 0.94) or age (the mean age of interested students was 25.2 years and the mean age of uninterested students was 25.8 years; p ⫽
Figure 1. Did the clerkship improve clinical skills? Purple bar, bedside patient management; light blue bar, assessment/plan; white bar, physical diagnosis; red bar, history-taking; blue bar, technical skills.
0.27). There was no significant difference in the percent of men versus women who were interested in careers in surgery (68% of men versus 61% of women; p ⫽ 0.41). Several aspects of the clerkship experience were positively correlated with having an interest in a career in surgery at the end of the clerkship (Table 2). Students who sutured, drove the camera, or stated that they felt involved in the operating room were more likely to be interested in surgery. The qualitative data highlighted the complex nature of the relationship between operating room experience and level of interest in surgery. In some cases, students described substantive operating room involvement as stimulating their interest in pursuing surgery: “Being able to participate during the surgeries, beyond holding retractors, made me quite interested in surgery.” In other cases, lack of operating room involvement led to general frustration with the clerkship experience.
Figure 2. Are you considering a surgical . . .? Red bar, career; blue bar, subinternship.
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Table 2. Associations Between Clerkship Experience and Interest in a Career in Surgery
Characteristic
Experience in operating room Made incision Dissected Sutured Drove camera Felt involved overall Experience outside of operating room Carried at least 2⫺3 patients Saw consults Saw consults independently Used laparoscopic simulator Experience with role models Saw attendings as positive role models Saw residents as positive role models
Uninterested students
Interested students n %
n
%
p Value
34 24 51 68 68
47.9 33.3 70.8 95.8 94.4
16 11 17 34 32
38.1 26.8 40.5 81.0 78.1
0.09 0.47 0.001 0.01 0.009
49 47 28 31
72.1 66.2 40.0 50.0
21 27 14 15
56.8 64.3 33.3 40.5
0.11 0.83 0.48 0.36
61 57
83.6 78.1
22 25
52.4 59.5
0.0003 0.03
For instance, this student who had been interested in surgery before the clerkship expressed feeling discouraged by his experience: As someone who was somewhat interested in surgery and anxious to learn more, I felt disappointed by my experience. The majority of my time was spent in the operating room, where I was largely ignored, and essentially focused on maintaining sterility while not being able to see much, and without attendings or residents discussing much with me. Thus, I finished many days feeling frustrated because I had spent 14⫹ hours in the hospital and didn’t feel that I had been taught or learned much of anything, despite my desire to learn. I felt that I had no role on this clerkship, and my frustration with that inevitably feeds into a less positive feeling about my time spent in the operating room and with surgical teams. Although the results were not statistically significant, there was a trend toward interested students carrying more patients on the service (72% of interested students had carried at least two to three patients at a time, compared with only 57% of uninterested students, p ⫽ 0.11) and seeing consults independently (40% of interested students saw consults independently versus 33% of uninterested students, p ⫽ 0.48). The importance of direct involvement in clinical problem solving was emphasized in open-ended responses, for example, in this quote from a student who had limited opportunities for critical thinking in the context of patient care plans: I was generally disappointed in the amount I was able to be involved and my opportunities to think criti-
cally about patient problems. I saw very few patients on consults (two over the course of the clerkship), and never alone. I followed patients on surgical oncology, but the interns were generally following the patients also, and would often present them on rounds. Even when I presented a patient, I never felt I had an opportunity to really discuss what the plan should be for the patient. It seems that empowering students by giving them more patient care responsibilities on the clerkship might contribute to developing their interest in a career in surgery. We found that participation in laparoscopic simulation exercises did not correlate with increased interest in surgery: 50% of interested students and 40% of uninterested students participated in operative simulation exercises (p ⫽ 0.36). Although students regarded the use of task trainers in the simulation laboratory as providing useful skill development, they expressed disappointment in the subsequent lack of actual operating room involvement: “I completed the laparoscopic simulation laboratory; I only wish my attendings had let me do a little more laparoscopy in the operating room after I had finished it.” Experiences with role modeling and mentorship, as expected, were important in shaping students’ interest in surgery. There was increased interest among students who viewed attending surgeons or residents as positive role models in terms of their patient interactions (84% of interested students versus 52% of uninterested students saw attendings as positive role models; p ⫽ 0.0003; 78% of interested students versus 60% of uninterested students saw residents as positive role models; p ⫽ 0.03).
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The structured role modeling that occurred through the clerkship’s mentorship program was viewed as particularly valuable: My mentor was fantastic—he had me come with him to be his first-assist most weeks, which was incredible, and which was where I did most of my skilllearning to be honest—the only surgery in which I made any incisions! He is a private surgeon and I think he’s pretty satisfied with his life, and I think most surgeons were satisfied with their life as residents and attendings because they love what they do. The importance of having a gender-concordant mentor, only 7% of women said they would be more comfortable with a gender-concordant mentor, compared with 24% of men. One woman was profoundly influenced by her experience with a female mentor: “My experience with a female mentor entirely changed my perception of surgery and opened my mind to the possibility of applying for a surgery residency. The mentorship program shaped my 12-week surgery rotation and was the highlight of my third year of medical school.” Students’ informal mentoring experiences were just as important as those with the structured mentoring program, with both positive and negative implications for student interest in surgery: “The unofficial mentorship of various attendings and residents I worked with during the surgery clerkship have inspired a strong interest in surgery. The trouble they took to share their knowledge had a profound impact on my desire to one day acquire such a body of skills and knowledge.” In some cases, students’ perceptions of surgeons as role models were just as powerfully unfavorable. For instance, this student witnessed interactions between attendings and residents that negatively influenced her interest in surgery: “Although no one was unreasonably critical of me, I saw attendings being unreasonably critical of residents to an extent that I have not seen before on any other rotation and that is not a learning environment that I want to put myself in.” Students expressed a relationship between the interest that their residents and attendings took in them and their subsequent level of enthusiasm for surgery. For example, this student’s experience differed on the general surgery and subspecialty rotations, leaving distinctly contrasting impressions: “I did not have a great time on my general surgery month. I felt like I fell through the cracks and no one really was at all invested in teaching me anything. On my subspecialty, I really had a great time. The residents and attendings really tried to teach me and help me and encourage me and that really changed things for me. I am now seriously thinking about surgery as a career.”
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Table 3. Adjusted Odds of Being Interested in Career in Surgery Characteristic
Sutured in operating room Drove camera in operating room Saw attendings as role models Felt involved in operating room Race African American Asian Latino Caucasian Gender, female versus male
Odds ratio (95% CI)
4.8 (1.5⫺15.0) 7.2 (1.1⫺46.8) 2.4 (0.8⫺7.3) 2.7 (0.6⫺13.2) 2.9 (0.3⫺26.2) 1.1 (0.3⫺4.5) 1.6 (0.1⫺47.1) Reference 0.9 (0.3⫺2.9)
Adjusted for race, gender, and opinions about whether residents and attendings were positive role models.
After adjusting for covariates (race, ethnicity, gender, and opinions about whether residents and attendings were positive role models), we found that operating room participation was most strongly correlated with having an interest in a career in surgery. Students who sutured were 4.8 times more likely, and those who drove the camera were 7.2 times more likely to express an interest in a career in surgery, compared with those who did not participate actively in the operating room (Table 3). The most commonly cited factor affecting students’ level of interest in surgery as a career was the perceived job satisfaction of residents and attendings. This was true for all students, whether or not they were interested in surgery as a career. Students who were interested in surgery reported that they were influenced by role models in the clerkship, and those who were not interested cited lifestyle as the main reason. The open-ended responses substantiated these quantitative findings about the importance of lifestyle, role models, and perceived job satisfaction. In addition, the narrative data revealed an additional dimension that we had not included in the survey: the culture of the working environment. Some students described an environment characterized by hostility and disrespect: “Many students are drawn to surgery by the work, only to be repelled by the sometimes hostile environment created by surgeons, or by the demands on their time that surgery imposes.” Another student said, “I felt like residents were often left to completely fend for themselves and ‘hung out to dry’ unlike the team mentality I have appreciated while on other rotations.” Some students observed that this notorious culture is undergoing positive change, a perception that led to increased interest in a career in surgery: “I think the hierarchal/military system could be toned down a bit, but I am glad to see more women in surgery and that diverse, vibrant personalities are present within the field. Given my
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own personality, surgery seems more appealing now that the atmosphere has changed than it did a couple of years ago.”
DISCUSSION Although there is a wealth of data available on why medical students choose (or do not choose) careers in surgery, this is the first study we are aware of that has specifically identified aspects of the surgical clerkship that influence students’ level of interest. We found that students were more likely to express interest in a career in surgery if, during the surgical clerkship, they had hands-on experience in the operating room, strong mentorship, and positive role models. Simulation is being used more commonly in residency training programs, and medical students are also increasingly likely to be exposed to simulation exercises in technical skills laboratories. Although these exercises can be useful in developing and honing operative skills, our data suggest that they cannot replace actual operation room experience. Importantly, we found that students who had participated in laparoscopic simulation exercises were no more likely to be interested in a career in surgery than those who had not been exposed to task trainers. Similarly, involvement in patient care activities outside of the operating room, such as carrying several patients or seeing consults (particularly if students’ level of responsibility was low), was not independently associated with students having an interest in a career in surgery. Simply put, there seems to be no substitute for operating room participation. This notion has been supported in the literature. Madan and colleagues31 evaluated students’ experiences with a simulated laparoscopic training course, and found that simulation did not increase interest in surgery. O’Herrin and colleagues32 found that there was an increased categorical general surgical match rate among students who had exposure to more abdominal and general surgical procedures during their third-year clerkships. These authors did not specifically evaluate the nature of this exposure. Our data suggest that simply being present in the operating room is not enough. We found on bivariate analysis that students who “felt involved” in the operating room were more likely to be interested in surgery, but after adjusting for other factors, suturing and driving the camera were the only features of the clerkship experience that were substantially correlated with students having an interest in a surgical career. Structuring the operating room experience so that students “feel involved” is important and likely to help cultivate interest in the field, but ideally, students should be active participants in surgery. There are several barriers to providing hands-on experience for students in the operating room. All surgeons strug-
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gle with competing demands on their time, and some might perceive that the additional time required for meaningful medical student involvement as an insurmountable barrier. Also, surgeons might believe that it is not appropriate for medical students to be doing anything in the operating room beyond observation, a view that is likely to be shared by many patients. There are time-efficient and patient-sensitive ways to enhance medical students’ participation in the operating room, for example, engaging students in an ongoing dialogue about operative plans and progress. Taking an extra 10 seconds for a student to feel the pulse of an aorta or the texture of a cirrhotic liver may make the difference as to whether a student feels involved or ignored, but our findings suggest that some degree of hands-on experience is even more ideal. Surgeons choose to become surgeons largely because they love to operate. It is unreasonable to expect that students will become captivated with the field if they are not provided with this opportunity during the surgical clerkship. Our study also revealed the importance of positive role models and strong mentorship in encouraging students to pursue careers in surgery, a phenomenon that has surfaced consistently in other reports.7,8,33,34 Clearly, positive experiences with surgeons as role models will encourage more students to enter the field. If a student is able to develop a strong mentoring relationship with a surgeon during the clerkship, it is likely that this mentor will create opportunities for the student to participate in the operating room. Informal mentoring and role modeling opportunities can be created through structured faculty participation in medical student activities, such as the human patient simulation course. This course sets up a unique interaction between surgical faculty and students: surgeons observe student interactions as they confront “patients” and solve real clinical problems, creating a faculty⫺student encounter during which communication, team-building, leadership, and clinical decision-making can be discussed. Positive formal and informal mentoring experiences which expose students to surgeons’ skills not only in the operating room but also as leaders and communicators are likely to improve perceptions of surgical culture. It is also critical that mentoring relationships extend beyond the clerkship. Although 64% of the students in our study expressed interest in surgery at the end of the clerkship, it is likely that far fewer than this number will ultimately pursue a career in surgery (at our institution, only about 20% of the 2008 graduating class matched in general surgery or a surgical subspecialty, a percentage that is consistent with reports from other institutions1,11).
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Providing meaningful experiences on the surgical clerkship is essential not only to increase interest in the field, but also to attract students who have an informed appreciation of the rewards and challenges of the field to which they are committing. Attrition has been documented as a major problem among surgical residents, with rates approaching 20% or higher in recent reports.19,20 It is likely that more comprehensive, hands-on exposure to all aspects of the field during the surgical clerkship would lead to the development of a pool of surgical residents who begin their training with an accurate perception of what life as a surgery resident, and as an attending, will be like. This study has several limitations. It reflects the experience of four groups of medical students at a single institution; our results might not generalize to all medical students. Additional studies on larger populations in multiple institutions are necessary to confirm these findings. In addition, as with any nonexperimental observational study, we cannot determine causal relationships. We did not gather baseline data before the start of the clerkship, and are unable to examine the causal relationship between operating room participation and students’ level of interest. It is possible that those students who were more interested in surgery to begin with were more engaged in general, took more initiative, and were allowed to do more in the operating room. Our qualitative data do suggest that increased operating room participation enhanced students’ interest in surgical careers even when they were not interested to begin with, or conversely, detracted from the level of interest for some students who entered thinking they wanted to be surgeons. Finally, although it seems likely that the structured mentoring program and human patient simulation course enriched the clerkship experience, we were unable to measure the direct impact of these aspects of the clerkship. To optimize students’ clerkship experiences, clerkship directors should encourage meaningful engagement of students in the operating room and with patient care, and facilitate formal and informal mentoring experiences. Students will then be able to make a fully informed assessment as to whether a career in surgery is right for them. One student observed, “Operating is the most interesting experience I have had in medicine, but this enormous privilege comes with a price. I still need to discern whether I am willing to pay this price.” If we want to continue to inspire medical students to pursue careers in surgery, surgical educators must be poised to demonstrate that, for the right individual, the rewards of a career in surgery far outweigh the sacrifices. Author Contributions Study conception and design: Berman, Gusberg Acquisition of data: Berman
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Analysis and interpretation of data: Berman, Rosenthal, Curry, Evans, Gusberg Drafting of manuscript: Berman Critical revision: Berman, Rosenthal, Curry, Evans, Gusberg
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APPENDIX
SURGICAL STUDENT QUESTIONNAIRE 1. What is your gender? e Female e Male 2. How old are you? 3. How would you describe your ethnicity? e Caucasian e Nonhispanic black e Nonhispanic white eHispanic eAsian e other (please specify) 4. Which service were you on for your 4-week rotation? 5. Which services were you on for your two 2-week rotations? (Please list in chronological order.) 6. Which month did you do first (4-week block or two 2-week blocks)? The following questions apply to your 4-week block: 7. On average, how many patients did you carry at a time? e 0 e 1 to 2 e 2 to 3 e 3 to 4 e 5 or more e other (please specify) 8. Were you involved in seeing consults? e Yes e No 9. Did you see consults independently (ie, do H&P, write consult note or present to resident/attending)? e Yes e No e I did not see consults 10. On average, what proportion of your time in the hospital was spent in the operating room? e Greater than 75% e 50% to 75% e 25% to 50% e 10 to 25% e less than 10% 11. In the operating room, did you ever . . . Drive the camera for laparoscopic cases? e I did not scrub in on any lap cases e Never e Once or twice e During most lap cases Make an incision? e Never e Once or twice e During many cases Suture tissues (including skin)? e Never e Once or twice e During many cases Assist in dissection? e Never e Once or twice e During many cases 12. In the operating room, residents and attendings took time to explain what they were doing and involve you in the case. e Strongly disagree e Disagree e Neutral e Agree e Strongly agree 13. Being in the operating room was a good learning experience. e Strongly disagree e Disagree e Neutral e Agree e Strongly agree The following questions apply to your month of two 2-week blocks.
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14. On average, how many patients did you carry at a time? First block: e 0 e 1 to 2 e 2 to 3 e 3 to 4 e 5 or more e other (please specify) Second block: e 0 e 1 to 2 e 2 to 3 e 3 to 4 e 5 or more e other (please specify) 15. Were you involved in seeing consults? First block: e Yes e No Second block: e Yes e No 16. Did you see consults independently (ie, do H&P, write consult note or present to resident/attending)? First block: e Yes e No e I did not see consults Second block: e Yes e No e I did not see consults 17. On average, what proportion of your time in the hospital was spent in the operating room? First block: e Greater than 75% e 50% to 75% e 25% to 50% e 10% to 25% e Less than 10% Second block: e Greater than 75% e 50% to 75% e 25% to 50% e 10% to 25% e Less than 10% 18. In the operating room, did you ever . . . Drive the camera for laparoscopic cases? First block: e I did not scrub in on any lap cases e Never e Once or twice e During most lap cases Second block: e I did not scrub in on any lap cases e Never e Once or twice e During most lap cases Make an incision? First block: e Never e Once or twice e During many cases Second block: e Never e Once or twice e During many cases Suture tissues (including skin)? First block: e Never e Once or twice e During many cases Second block: e Never e Once or twice e During many cases Assist in dissection? First block: e Never e Once or twice e During many cases Second block: e Never e Once or twice e During many cases
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19. In the operating room, residents and attendings took time to explain what they were doing and involve you in the case. First block: e Strongly disagree e Disagree e Neutral e Agree e Strongly agree Second block: e Strongly disagree e Disagree e Neutral e Agree e Strongly agree 20. Being in the operating room was a good learning experience. First block: e Strongly disagree e Disagree e Neutral e Agree e Strongly agree Second block: e Strongly disagree e Disagree e Neutral e Agree e Strongly agree The remainder of the questions apply to the clerkship as a whole. 21. My technical skills improved over the course of the clerkship. e Not at all e A little bit e A great deal 22. My history-taking skills improved over the course of the clerkship. e Not at all e A little bit e A great deal 23. My ability to make physical diagnoses improved over the course of the clerkship. e Not at all e A little bit e A great deal 24. I felt more confident with forming an assessment and plan for surgical patients as the clerkship progressed. e Not at all e A little bit e A great deal 25. My bedside patient management skills improved over the course of the clerkship. e Not at all e A little bit e A great deal 26. Which of the following best describes your feelings about a career in surgery? e I am not considering going into surgery e I think it might be a possibility that I will go into surgery e I am pretty sure I want to go into surgery e I definitely want to go into surgery 27. Are you planning to do a surgery subinternship? e Definitely not e Maybe e Definitely 28. Which of the following factors affected your level of interest in surgery? (Used Likert scales with five levels ranging from “not at all important” to “most important”) e Lifestyle as a resident
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30. 31.
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e Lifestyle as an attending e Length of training e Mentorship experience e Role models in your own family e Role models within the clerkship e 80-hour work-week Please elaborate on the above factors, and any additional factors, and explain how they have affected your level of interest in surgery. How many times did you meet with your mentor over the course of the clerkship? How satisfied are you with the mentorship experience? e Very dissatisfied e Somewhat dissatisfied e Neutral e Somewhat satisfied e Very satisfied Which of the following statements do you agree with? (please choose one) e I would be more comfortable with a male surgeon as a mentor. e I would be equally comfortable with a female or male surgeon as a mentor. e I would be more comfortable with a female surgeon as a mentor. The majority of surgical attendings I encountered were good role models in terms of patient interactions. e Disagree e Neutral e Agree e Strongly agree The majority of surgical residents I encountered were good role models in terms of patient interactions. e Disagree e Neutral e Agree e Strongly agree The human-patient simulator program was a valuable experience. e Disagree e Neutral e Agree e Strongly agree What did you regard as principle benefits of the human-patient simulators? Please rank the following in descending order. Only rank those which you feel were benefits. e Overcoming anxiety of dealing with emergencies e Learning medical decision-making/priority-setting e Developing leadership skills e Teambuilding e Improving patient-doctor communication skills Other (please explain) Did you get a password to the laparoscopic simulator laboratory? Y/N How many times did you go? Please use this space to elaborate on any of the questions above.
Attracting Surgical Clerks to Surgical Careers: Role Models, Mentoring, and Engagement in the Operating Room Loren Berman, MD, Marjorie S Rosenthal, MD, MPH, Leslie A Curry, PhD, MPH, Leigh V Evans, MD, Richard J Gusberg, MD Declining interest in careers in surgery among medical students has contributed to growing concerns about the surgical workforce. Although the medical student clerkship is likely to play an important role in shaping students’ impressions of careers in surgery, little is known about the nature of this process. This study was designed to identify those aspects of the clerkship that are associated with medical students expressing an interest in surgery at the end of the clerkship. STUDY DESIGN: Medical students completed a survey at the end of the surgical clerkship assessing characteristics of the clerkship experience and students’ level of interest in pursuing a career in surgery. The survey also included open-ended questions about students’ reasons for having increased or decreased interest in surgery, which were systematically analyzed to complement quantitative findings. RESULTS: Students who sutured (p ⫽ 0.001), drove the camera (p ⫽ 0.01), stated that they felt involved in the operating room (p ⫽ 0.009), and saw residents (p ⫽ 0.03) and attendings (p ⫽ 0.0003) as positive role models were more likely to be interested in surgery. After adjusting for covariates, students who sutured in the operating room were 4.8 times as likely to be interested in surgery (95% CI, 1.5 to 14.9) and students who drove the camera were 7.2 times as likely to be interested in surgery (95% CI, 1.1 to 46.8). CONCLUSIONS: Students who participate actively in the operating room and those who are exposed to positive role models are more likely to be interested in pursuing a career in surgery. To optimize students’ clerkship experiences and attract top candidates to the field of surgery, clerkship directors should encourage meaningful engagement of students in the operating room and facilitate mentoring experiences. (J Am Coll Surg 2008;207:793–800. © 2008 by the American College of Surgeons) BACKGROUND:
in surgery.13-16 Attrition from surgical residency programs has also been identified as a growing problem,17-20 suggesting that some students who choose surgical residencies might not have had sufficient exposure during medical school to make a decision that is optimally suited to their skills and interest. The surgical clerkship is one of the core educational experiences for medical students. Students not only build technical skills during the clerkship, but they also learn about patient care, doctor⫺patient communication, and how to efficiently process complex information. Students interact with residents and attendings who might become role models, and formulate opinions about surgeons and surgical careers. In recent years, the traditional surgical educational paradigm has been challenged by the 80-hour work week and a national trend toward decreasing the amount of time that students spend on the surgical clerkship.21 These changes are likely to diminish students’ interface with patients, teachers, and potential role models.
The number of medical students who choose careers in surgery has declined in recent years.1 Today’s medical students are attracted to fields with controllable lifestyles.2-4 Students are deterred by the clinical demands of surgery and the challenges of balancing these demands with the desire to pursue interests and fulfill responsibilities outside of medicine.5-12 Additionally, concerns have been raised about the quality of the medical students choosing careers Disclosure Information: Nothing to disclose. Received June 2, 2008; Revised July 11, 2008; Accepted August 4, 2008. From the Robert Wood Johnson Clinical Scholars Program, Yale University School of Medicine (Berman, Rosenthal), the Robert Wood Johnson Clinical Scholars Program, Yale University School of Epidemiology and Public Health (Curry), Department of Emergency Medicine, Yale University School of Medicine (Evans), and Department of Surgery, Yale University School of Medicine (Gusberg), New Haven, CT. Correspondence address: Loren Berman, MD, Robert Wood Johnson Clinical Scholars Program, Yale University School of Medicine, IE-61 SHM, 333 Cedar St, New Haven, CT 06511.
© 2008 by the American College of Surgeons Published by Elsevier Inc.
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The surgical clerkship is an opportunity to demonstrate to medical students both the rewards and challenges of a career in surgery, and thereby maximize the likelihood that suitable students will choose to pursue careers in surgery. Several studies have shown that medical students’ surgical clerkship experiences can influence their career choices,9,22-25 but no prior report has focused on specific characteristics of the clerkship that could be applied broadly across medical schools. In this study, we sought to identify those aspects of the surgical clerkship that were associated with medical student interest in a career in surgery, to identify ways to optimize the clerkship experience and attract, not only the best applicants, but also those who are most well-suited to careers in surgery.
METHODS Third-year medical students completed an online survey after their surgery clerkship. The data were collected between September 2006 and September 2007. Four groups of students completed 12-week surgery clerkships composed of 4 weeks of general surgery, 4 weeks of subspecialty surgery in two 2-week blocks (ie, vascular surgery, pediatric surgery, orthopaedic surgery, otolaryngology, transplantation, plastics, cardiothoracic surgery, or urology), 2 weeks of anesthesia and 2 weeks of emergency medicine. Throughout the 12-week block, there was a structured mentoring program (each student met weekly with an assigned surgical faculty mentor) and a simulation course. The simulation course is structured around 24 clinical scenarios during which students confront urgent and emergent surgical problems with an interactive high-fidelity human patient mannequin. The course efficiently convenes students and faculty in a unique simulated scenario where the students provide direct patient care, with the option of calling in surgical faculty as consultants. Surgeons also lead debriefing sessions where they discuss problem-solving, communication, team-building, and leadership skills. The mentoring role of the faculty is enhanced through their ongoing involvement. The 38-question survey (see Appendix “Surgical Student Questionnaire” online) assessed students’ level of interest in surgery at the end of the clerkship, whether or not they were planning on doing a surgical subinternship (students are not required to complete a surgical subinternship at our institution), their impressions of surgeon rolemodeling and mentorship, degree of involvement with patients, operative exposure both in the operating room and through simulation exercises with laparoscopic task trainers, and other factors affecting interest in surgery. We used 5-point Likert scales to measure students’ perceptions of their degree of involvement in the operating room, and whether they viewed surgical residents and at-
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tendings as positive role models with respect to patient interactions. Likert-scale responses were dichotomized into two comparison groups: those who answered “strongly disagree,” “disagree,” or “neutral,” and those who answered “agree” or “strongly agree.” We measured students’ involvement on subspecialty and general surgery rotations separately, and combined these responses to create composite variables that would reflect the students’ overall experience across the 8 weeks of general and subspecialty surgical rotations and the 12 weeks of simulation and mentoring with regard to the following activities: seeing consults; perioperative patient care; and direct involvement in operating room activities, such as suturing, dissecting, and cameradriving. Each of these variables was dichotomized into two comparison groups: those who performed a given task at least once or twice on at least two out of their three rotations, versus those who never performed the task, or did so only once or twice during the course of the entire clerkship. We performed bivariate analyses to identify which features of the clerkship were associated with having an interest in surgery at the end of the clerkship, using chi-square or Fisher’s exact test, as appropriate. We used multiple logistic regression to adjust for covariates, including all independent variables that were significant on bivariate analysis at the 0.05 level, in addition to demographic information. All statistics were performed using SAS 9.1. The survey also included open-ended questions about factors affecting students’ level of interest in surgery and how the clerkship experience influenced career goals. We analyzed qualitative data using the constant comparative method, a systematic data coding and analysis procedure.26-28 This method involves the categorization of specific quotes from participants with the use of codes developed iteratively to reflect the data. Using the process recommended by experts in qualitative research,29 open-ended responses were reviewed and coded independently by three individuals from diverse backgrounds, including surgery, qualitative and mixed methods research, and medical education. We met in a group session to resolve discrepancies through negotiated consensus, focusing our analysis on those aspects of the qualitative data that would enhance our interpretation of the quantitative findings and provide additional insights into perceptions and experiences not measured quantitatively.30 The study was approved by the Yale University School of Medicine Human Investigation Committee.
RESULTS Our response rate was 89% (116 of 131 students). The majority of students were women (56.9%). Half (50%) were Caucasian, 12% were Asian, 7% were African Amer-
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Table 1. Description of Clerkship Experience Characteristic
Experience in operating room Made incision Dissected Sutured Drove camera Felt involved overall Experience outside of operating room Carried at least 2⫺3 patients Saw consults Saw consults independently Used laparoscopic simulator Experience with role models Saw attendings as positive role models Saw residents as positive role models
n
%
50 35 68 102 100
43.1 30.2 58.6 87.9 86.2
70 74 42 46
66.7 63.8 36.2 39.7
83 82
71.6 70.7
ican, and 3% were Latino. The median age was 25 years. There was an even distribution of previous clerkship experience; about 25% of students were doing surgery as their first clinical clerkship, 25% came to the clerkship with 12 months of clinical experience, and the other 50% had 3 to 6 months of experience. Students’ experiences on the surgical clerkship are described in Table 1. The majority of students were involved in seeing consult patients (64%), but fewer students reported that they saw consults independently (36%). About 40% of students used the laparoscopic simulator. There was substantial variation in students’ degree of participation in the operating room. Although the vast majority (87.9%) were given the opportunity to drive the camera during laparoscopic procedures, fewer students sutured (58.6%), made an incision (43.1%), or dissected tissues (30.2%). Despite this variation in operating room participation, ⬎86% said that they “felt involved overall in the OR.” The majority of students said that they viewed surgical attendings and residents as positive role models in terms of their patient interactions (72% and 71%, respectively). The majority of students reported that their clinical skills had improved during the surgery clerkship (Fig. 1), with the strongest improvements in physical diagnosis, formulating an assessment and plan, and developing technical skills. The majority of students also expressed that they had some interest in surgery at the end of the clerkship (Fig. 2), with 75% considering a surgical subinternship and 64% considering a career in surgery. There were no significant differences in level of interest in surgery according to race or ethnicity (59% of Caucasians, 75% of African Americans, 67% of Latinos, and 57% of Asians were interested in surgery; p ⫽ 0.94) or age (the mean age of interested students was 25.2 years and the mean age of uninterested students was 25.8 years; p ⫽
Figure 1. Did the clerkship improve clinical skills? Purple bar, bedside patient management; light blue bar, assessment/plan; white bar, physical diagnosis; red bar, history-taking; blue bar, technical skills.
0.27). There was no significant difference in the percent of men versus women who were interested in careers in surgery (68% of men versus 61% of women; p ⫽ 0.41). Several aspects of the clerkship experience were positively correlated with having an interest in a career in surgery at the end of the clerkship (Table 2). Students who sutured, drove the camera, or stated that they felt involved in the operating room were more likely to be interested in surgery. The qualitative data highlighted the complex nature of the relationship between operating room experience and level of interest in surgery. In some cases, students described substantive operating room involvement as stimulating their interest in pursuing surgery: “Being able to participate during the surgeries, beyond holding retractors, made me quite interested in surgery.” In other cases, lack of operating room involvement led to general frustration with the clerkship experience.
Figure 2. Are you considering a surgical . . .? Red bar, career; blue bar, subinternship.
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Table 2. Associations Between Clerkship Experience and Interest in a Career in Surgery
Characteristic
Experience in operating room Made incision Dissected Sutured Drove camera Felt involved overall Experience outside of operating room Carried at least 2⫺3 patients Saw consults Saw consults independently Used laparoscopic simulator Experience with role models Saw attendings as positive role models Saw residents as positive role models
Uninterested students
Interested students n %
n
%
p Value
34 24 51 68 68
47.9 33.3 70.8 95.8 94.4
16 11 17 34 32
38.1 26.8 40.5 81.0 78.1
0.09 0.47 0.001 0.01 0.009
49 47 28 31
72.1 66.2 40.0 50.0
21 27 14 15
56.8 64.3 33.3 40.5
0.11 0.83 0.48 0.36
61 57
83.6 78.1
22 25
52.4 59.5
0.0003 0.03
For instance, this student who had been interested in surgery before the clerkship expressed feeling discouraged by his experience: As someone who was somewhat interested in surgery and anxious to learn more, I felt disappointed by my experience. The majority of my time was spent in the operating room, where I was largely ignored, and essentially focused on maintaining sterility while not being able to see much, and without attendings or residents discussing much with me. Thus, I finished many days feeling frustrated because I had spent 14⫹ hours in the hospital and didn’t feel that I had been taught or learned much of anything, despite my desire to learn. I felt that I had no role on this clerkship, and my frustration with that inevitably feeds into a less positive feeling about my time spent in the operating room and with surgical teams. Although the results were not statistically significant, there was a trend toward interested students carrying more patients on the service (72% of interested students had carried at least two to three patients at a time, compared with only 57% of uninterested students, p ⫽ 0.11) and seeing consults independently (40% of interested students saw consults independently versus 33% of uninterested students, p ⫽ 0.48). The importance of direct involvement in clinical problem solving was emphasized in open-ended responses, for example, in this quote from a student who had limited opportunities for critical thinking in the context of patient care plans: I was generally disappointed in the amount I was able to be involved and my opportunities to think criti-
cally about patient problems. I saw very few patients on consults (two over the course of the clerkship), and never alone. I followed patients on surgical oncology, but the interns were generally following the patients also, and would often present them on rounds. Even when I presented a patient, I never felt I had an opportunity to really discuss what the plan should be for the patient. It seems that empowering students by giving them more patient care responsibilities on the clerkship might contribute to developing their interest in a career in surgery. We found that participation in laparoscopic simulation exercises did not correlate with increased interest in surgery: 50% of interested students and 40% of uninterested students participated in operative simulation exercises (p ⫽ 0.36). Although students regarded the use of task trainers in the simulation laboratory as providing useful skill development, they expressed disappointment in the subsequent lack of actual operating room involvement: “I completed the laparoscopic simulation laboratory; I only wish my attendings had let me do a little more laparoscopy in the operating room after I had finished it.” Experiences with role modeling and mentorship, as expected, were important in shaping students’ interest in surgery. There was increased interest among students who viewed attending surgeons or residents as positive role models in terms of their patient interactions (84% of interested students versus 52% of uninterested students saw attendings as positive role models; p ⫽ 0.0003; 78% of interested students versus 60% of uninterested students saw residents as positive role models; p ⫽ 0.03).
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The structured role modeling that occurred through the clerkship’s mentorship program was viewed as particularly valuable: My mentor was fantastic—he had me come with him to be his first-assist most weeks, which was incredible, and which was where I did most of my skilllearning to be honest—the only surgery in which I made any incisions! He is a private surgeon and I think he’s pretty satisfied with his life, and I think most surgeons were satisfied with their life as residents and attendings because they love what they do. The importance of having a gender-concordant mentor, only 7% of women said they would be more comfortable with a gender-concordant mentor, compared with 24% of men. One woman was profoundly influenced by her experience with a female mentor: “My experience with a female mentor entirely changed my perception of surgery and opened my mind to the possibility of applying for a surgery residency. The mentorship program shaped my 12-week surgery rotation and was the highlight of my third year of medical school.” Students’ informal mentoring experiences were just as important as those with the structured mentoring program, with both positive and negative implications for student interest in surgery: “The unofficial mentorship of various attendings and residents I worked with during the surgery clerkship have inspired a strong interest in surgery. The trouble they took to share their knowledge had a profound impact on my desire to one day acquire such a body of skills and knowledge.” In some cases, students’ perceptions of surgeons as role models were just as powerfully unfavorable. For instance, this student witnessed interactions between attendings and residents that negatively influenced her interest in surgery: “Although no one was unreasonably critical of me, I saw attendings being unreasonably critical of residents to an extent that I have not seen before on any other rotation and that is not a learning environment that I want to put myself in.” Students expressed a relationship between the interest that their residents and attendings took in them and their subsequent level of enthusiasm for surgery. For example, this student’s experience differed on the general surgery and subspecialty rotations, leaving distinctly contrasting impressions: “I did not have a great time on my general surgery month. I felt like I fell through the cracks and no one really was at all invested in teaching me anything. On my subspecialty, I really had a great time. The residents and attendings really tried to teach me and help me and encourage me and that really changed things for me. I am now seriously thinking about surgery as a career.”
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Table 3. Adjusted Odds of Being Interested in Career in Surgery Characteristic
Sutured in operating room Drove camera in operating room Saw attendings as role models Felt involved in operating room Race African American Asian Latino Caucasian Gender, female versus male
Odds ratio (95% CI)
4.8 (1.5⫺15.0) 7.2 (1.1⫺46.8) 2.4 (0.8⫺7.3) 2.7 (0.6⫺13.2) 2.9 (0.3⫺26.2) 1.1 (0.3⫺4.5) 1.6 (0.1⫺47.1) Reference 0.9 (0.3⫺2.9)
Adjusted for race, gender, and opinions about whether residents and attendings were positive role models.
After adjusting for covariates (race, ethnicity, gender, and opinions about whether residents and attendings were positive role models), we found that operating room participation was most strongly correlated with having an interest in a career in surgery. Students who sutured were 4.8 times more likely, and those who drove the camera were 7.2 times more likely to express an interest in a career in surgery, compared with those who did not participate actively in the operating room (Table 3). The most commonly cited factor affecting students’ level of interest in surgery as a career was the perceived job satisfaction of residents and attendings. This was true for all students, whether or not they were interested in surgery as a career. Students who were interested in surgery reported that they were influenced by role models in the clerkship, and those who were not interested cited lifestyle as the main reason. The open-ended responses substantiated these quantitative findings about the importance of lifestyle, role models, and perceived job satisfaction. In addition, the narrative data revealed an additional dimension that we had not included in the survey: the culture of the working environment. Some students described an environment characterized by hostility and disrespect: “Many students are drawn to surgery by the work, only to be repelled by the sometimes hostile environment created by surgeons, or by the demands on their time that surgery imposes.” Another student said, “I felt like residents were often left to completely fend for themselves and ‘hung out to dry’ unlike the team mentality I have appreciated while on other rotations.” Some students observed that this notorious culture is undergoing positive change, a perception that led to increased interest in a career in surgery: “I think the hierarchal/military system could be toned down a bit, but I am glad to see more women in surgery and that diverse, vibrant personalities are present within the field. Given my
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own personality, surgery seems more appealing now that the atmosphere has changed than it did a couple of years ago.”
DISCUSSION Although there is a wealth of data available on why medical students choose (or do not choose) careers in surgery, this is the first study we are aware of that has specifically identified aspects of the surgical clerkship that influence students’ level of interest. We found that students were more likely to express interest in a career in surgery if, during the surgical clerkship, they had hands-on experience in the operating room, strong mentorship, and positive role models. Simulation is being used more commonly in residency training programs, and medical students are also increasingly likely to be exposed to simulation exercises in technical skills laboratories. Although these exercises can be useful in developing and honing operative skills, our data suggest that they cannot replace actual operation room experience. Importantly, we found that students who had participated in laparoscopic simulation exercises were no more likely to be interested in a career in surgery than those who had not been exposed to task trainers. Similarly, involvement in patient care activities outside of the operating room, such as carrying several patients or seeing consults (particularly if students’ level of responsibility was low), was not independently associated with students having an interest in a career in surgery. Simply put, there seems to be no substitute for operating room participation. This notion has been supported in the literature. Madan and colleagues31 evaluated students’ experiences with a simulated laparoscopic training course, and found that simulation did not increase interest in surgery. O’Herrin and colleagues32 found that there was an increased categorical general surgical match rate among students who had exposure to more abdominal and general surgical procedures during their third-year clerkships. These authors did not specifically evaluate the nature of this exposure. Our data suggest that simply being present in the operating room is not enough. We found on bivariate analysis that students who “felt involved” in the operating room were more likely to be interested in surgery, but after adjusting for other factors, suturing and driving the camera were the only features of the clerkship experience that were substantially correlated with students having an interest in a surgical career. Structuring the operating room experience so that students “feel involved” is important and likely to help cultivate interest in the field, but ideally, students should be active participants in surgery. There are several barriers to providing hands-on experience for students in the operating room. All surgeons strug-
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gle with competing demands on their time, and some might perceive that the additional time required for meaningful medical student involvement as an insurmountable barrier. Also, surgeons might believe that it is not appropriate for medical students to be doing anything in the operating room beyond observation, a view that is likely to be shared by many patients. There are time-efficient and patient-sensitive ways to enhance medical students’ participation in the operating room, for example, engaging students in an ongoing dialogue about operative plans and progress. Taking an extra 10 seconds for a student to feel the pulse of an aorta or the texture of a cirrhotic liver may make the difference as to whether a student feels involved or ignored, but our findings suggest that some degree of hands-on experience is even more ideal. Surgeons choose to become surgeons largely because they love to operate. It is unreasonable to expect that students will become captivated with the field if they are not provided with this opportunity during the surgical clerkship. Our study also revealed the importance of positive role models and strong mentorship in encouraging students to pursue careers in surgery, a phenomenon that has surfaced consistently in other reports.7,8,33,34 Clearly, positive experiences with surgeons as role models will encourage more students to enter the field. If a student is able to develop a strong mentoring relationship with a surgeon during the clerkship, it is likely that this mentor will create opportunities for the student to participate in the operating room. Informal mentoring and role modeling opportunities can be created through structured faculty participation in medical student activities, such as the human patient simulation course. This course sets up a unique interaction between surgical faculty and students: surgeons observe student interactions as they confront “patients” and solve real clinical problems, creating a faculty⫺student encounter during which communication, team-building, leadership, and clinical decision-making can be discussed. Positive formal and informal mentoring experiences which expose students to surgeons’ skills not only in the operating room but also as leaders and communicators are likely to improve perceptions of surgical culture. It is also critical that mentoring relationships extend beyond the clerkship. Although 64% of the students in our study expressed interest in surgery at the end of the clerkship, it is likely that far fewer than this number will ultimately pursue a career in surgery (at our institution, only about 20% of the 2008 graduating class matched in general surgery or a surgical subspecialty, a percentage that is consistent with reports from other institutions1,11).
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Providing meaningful experiences on the surgical clerkship is essential not only to increase interest in the field, but also to attract students who have an informed appreciation of the rewards and challenges of the field to which they are committing. Attrition has been documented as a major problem among surgical residents, with rates approaching 20% or higher in recent reports.19,20 It is likely that more comprehensive, hands-on exposure to all aspects of the field during the surgical clerkship would lead to the development of a pool of surgical residents who begin their training with an accurate perception of what life as a surgery resident, and as an attending, will be like. This study has several limitations. It reflects the experience of four groups of medical students at a single institution; our results might not generalize to all medical students. Additional studies on larger populations in multiple institutions are necessary to confirm these findings. In addition, as with any nonexperimental observational study, we cannot determine causal relationships. We did not gather baseline data before the start of the clerkship, and are unable to examine the causal relationship between operating room participation and students’ level of interest. It is possible that those students who were more interested in surgery to begin with were more engaged in general, took more initiative, and were allowed to do more in the operating room. Our qualitative data do suggest that increased operating room participation enhanced students’ interest in surgical careers even when they were not interested to begin with, or conversely, detracted from the level of interest for some students who entered thinking they wanted to be surgeons. Finally, although it seems likely that the structured mentoring program and human patient simulation course enriched the clerkship experience, we were unable to measure the direct impact of these aspects of the clerkship. To optimize students’ clerkship experiences, clerkship directors should encourage meaningful engagement of students in the operating room and with patient care, and facilitate formal and informal mentoring experiences. Students will then be able to make a fully informed assessment as to whether a career in surgery is right for them. One student observed, “Operating is the most interesting experience I have had in medicine, but this enormous privilege comes with a price. I still need to discern whether I am willing to pay this price.” If we want to continue to inspire medical students to pursue careers in surgery, surgical educators must be poised to demonstrate that, for the right individual, the rewards of a career in surgery far outweigh the sacrifices. Author Contributions Study conception and design: Berman, Gusberg Acquisition of data: Berman
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Analysis and interpretation of data: Berman, Rosenthal, Curry, Evans, Gusberg Drafting of manuscript: Berman Critical revision: Berman, Rosenthal, Curry, Evans, Gusberg
REFERENCES 1. Andriole DA, Klingensmith ME, Jeffe DB. Who are our future surgeons? Characteristics of medical school graduates planning surgical careers: analysis of the 1997 to 2004 Association of American Medical Colleges’ Graduation Questionnaire National Database. J Am Coll Surg 2006;203:177–185. 2. Dorsey ER, Jarjoura D, Rutecki GW. The influence of controllable lifestyle and sex on the specialty choices of graduating US medical students, 1996—2003. Acad Med 2005;80:791–796. 3. Newton DA, Grayson MS. Trends in career choice by US medical school graduates. JAMA 2003;290:1179–1182. 4. Newton DA, Grayson MS, Thompson LF. The variable influence of lifestyle and income on medical students’ career specialty choices: data from two US medical schools, 1998⫺2004. Acad Med 2005;80:809–814. 5. Azizzadeh A, McCollum CH, Miller CC 3rd, et al. Factors influencing career choice among medical students interested in surgery. Curr Surg 2003;60:210–213. 6. Barshes NR, Vavra AK, Miller A, et al. General surgery as a career: a contemporary review of factors central to medical student specialty choice. J Am Coll Surg 2004;199:792–799. 7. Brundage SI, Lucci A, Miller CC, et al. Potential targets to encourage a surgical career. J Am Coll Surg 2005;200:946–953. 8. Cochran A, Melby S, Neumayer LA. An internet-based survey of factors influencing medical student selection of a general surgery career. Am J Surg 2005;189:742–746. 9. Gelfand DV, Podnos YD, Wilson SE, et al. Choosing general surgery: insights into career choices of current medical students. Arch Surg 2002;137:941–945, discussion 945⫺947. 10. Lind DS, Cendan JC. Two decades of student career choice at the University of Florida: increasingly a lifestyle decision. Am Surg 2003;69:53–55. 11. Sanfey HA, Saalwachter-Schulman AR, Nyhof-Young JM, et al. Influences on medical student career choice: gender or generation? Arch Surg 2006;141:1086–1094; discussion 1094. 12. Schwartz RW, Haley JV, Williams C, et al. The controllable lifestyle factor and students’ attitudes about specialty selection. Acad Med 1990;65:207–210. 13. Bland KI, Isaacs G. Contemporary trends in student selection of medical specialties: the potential impact on general surgery. Arch Surg 2002;137:259–267. 14. Callcut R, Snow M, Lewis B, Chen H. Do the best students go into general surgery? J Surg Res 2003;115:69–73. 15. Cockerham WT, Cofer JB, Biderman MD, et al. Is there declining interest in general surgery training? Curr Surg 2004;61:231– 235. 16. Cofer JB, Biderman MD, Lewis PL, et al. Is the quality of surgical residency applicants deteriorating? Am J Surg 2001; 181:44–49. 17. Aufses AH Jr, Slater GI, Hollier LH. The nature and fate of categorical surgical residents who “drop out.” Am J Surg 1998; 175:236–239.
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18. Bergen PC, Turnage RH, Carrico CJ. Gender-related attrition in a general surgery training program. J Surg Res 1998;77: 59–62. 19. Dodson TF, Webb AL. Why do residents leave general surgery? The hidden problem in today’s programs. Curr Surg 2005;62: 128–131. 20. Farley DR, Cook JK. Whatever happened to the general surgery graduating class of 2001? Curr Surg 2001;58:587–590. 21. Liaison Committee on Medical Education. LCME Part II Annual Medical School Questionnaire. 1997⫺2007. Washington, DC and Chicago, IL. 22. Carter MB, Larson GM, Polk HC Jr. A brief private group practice rotation changes junior medical students’ perception of the surgical lifestyle. Am J Surg 2005;189:458–461. 23. Chen H, Hardacre JM, Martin C, Lillemoe KD. Do medical school surgical rotations influence subspecialty choice? J Surg Res 2001;97:172–178. 24. Cochran A, Paukert JL, Neumayer LA. Does a general surgery clerkship influence student perceptions of surgeons and surgical careers? Surgery 2003;134:153–157. 25. O’Herrin JK, Lewis BJ, Rikkers LF, Chen H. Why do students choose careers in surgery? J Surg Res 2004;119:124–129. 26. Glaser BG, Strauss AL. The discovery of grounded theory: strategies for qualitative research. Chicago: Aldine; 1967.
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27. Miles MB, Huberman AM. Qualitative data analysis: an expanded sourcebook. 2nd ed. Thousand Oaks, CA: Sage Publications; 1994. 28. Strauss AL, Corbin J. Basics of qualitative research: grounded theory procedures and techniques. London: Sage Publications; 1998. 29. Bradley EH, Curry LA, Devers KJ. Qualitative data analysis for health services research: developing taxonomy, themes, and theory. Health Serv Res 2007;42:1758–1772. 30. Creswell J, Plano Clark V. Designing and conducting mixed methods research. London: Sage; 2006. 31. Madan AK, Frantzides CT, Quiros R, et al. Effects of a laparoscopic course on student interest in surgical residency. JSLS 2005;9:134–137. 32. O’Herrin JK, Lewis BJ, Rikkers LF, Chen H. Medical student operative experience correlates with a match to a categorical surgical program. Am J Surg 2003;186:125–128. 33. Erzurum VZ, Obermeyer RJ, Fecher A, et al. What influences medical students’ choice of surgical careers. Surgery 2000;128: 253–256. 34. Kozar RA, Lucci A, Miller CC, et al. Brief intervention by surgeons can influence students toward a career in surgery. J Surg Res 2003;111:166–169.
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APPENDIX
SURGICAL STUDENT QUESTIONNAIRE 1. What is your gender? e Female e Male 2. How old are you? 3. How would you describe your ethnicity? e Caucasian e Nonhispanic black e Nonhispanic white eHispanic eAsian e other (please specify) 4. Which service were you on for your 4-week rotation? 5. Which services were you on for your two 2-week rotations? (Please list in chronological order.) 6. Which month did you do first (4-week block or two 2-week blocks)? The following questions apply to your 4-week block: 7. On average, how many patients did you carry at a time? e 0 e 1 to 2 e 2 to 3 e 3 to 4 e 5 or more e other (please specify) 8. Were you involved in seeing consults? e Yes e No 9. Did you see consults independently (ie, do H&P, write consult note or present to resident/attending)? e Yes e No e I did not see consults 10. On average, what proportion of your time in the hospital was spent in the operating room? e Greater than 75% e 50% to 75% e 25% to 50% e 10 to 25% e less than 10% 11. In the operating room, did you ever . . . Drive the camera for laparoscopic cases? e I did not scrub in on any lap cases e Never e Once or twice e During most lap cases Make an incision? e Never e Once or twice e During many cases Suture tissues (including skin)? e Never e Once or twice e During many cases Assist in dissection? e Never e Once or twice e During many cases 12. In the operating room, residents and attendings took time to explain what they were doing and involve you in the case. e Strongly disagree e Disagree e Neutral e Agree e Strongly agree 13. Being in the operating room was a good learning experience. e Strongly disagree e Disagree e Neutral e Agree e Strongly agree The following questions apply to your month of two 2-week blocks.
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14. On average, how many patients did you carry at a time? First block: e 0 e 1 to 2 e 2 to 3 e 3 to 4 e 5 or more e other (please specify) Second block: e 0 e 1 to 2 e 2 to 3 e 3 to 4 e 5 or more e other (please specify) 15. Were you involved in seeing consults? First block: e Yes e No Second block: e Yes e No 16. Did you see consults independently (ie, do H&P, write consult note or present to resident/attending)? First block: e Yes e No e I did not see consults Second block: e Yes e No e I did not see consults 17. On average, what proportion of your time in the hospital was spent in the operating room? First block: e Greater than 75% e 50% to 75% e 25% to 50% e 10% to 25% e Less than 10% Second block: e Greater than 75% e 50% to 75% e 25% to 50% e 10% to 25% e Less than 10% 18. In the operating room, did you ever . . . Drive the camera for laparoscopic cases? First block: e I did not scrub in on any lap cases e Never e Once or twice e During most lap cases Second block: e I did not scrub in on any lap cases e Never e Once or twice e During most lap cases Make an incision? First block: e Never e Once or twice e During many cases Second block: e Never e Once or twice e During many cases Suture tissues (including skin)? First block: e Never e Once or twice e During many cases Second block: e Never e Once or twice e During many cases Assist in dissection? First block: e Never e Once or twice e During many cases Second block: e Never e Once or twice e During many cases
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19. In the operating room, residents and attendings took time to explain what they were doing and involve you in the case. First block: e Strongly disagree e Disagree e Neutral e Agree e Strongly agree Second block: e Strongly disagree e Disagree e Neutral e Agree e Strongly agree 20. Being in the operating room was a good learning experience. First block: e Strongly disagree e Disagree e Neutral e Agree e Strongly agree Second block: e Strongly disagree e Disagree e Neutral e Agree e Strongly agree The remainder of the questions apply to the clerkship as a whole. 21. My technical skills improved over the course of the clerkship. e Not at all e A little bit e A great deal 22. My history-taking skills improved over the course of the clerkship. e Not at all e A little bit e A great deal 23. My ability to make physical diagnoses improved over the course of the clerkship. e Not at all e A little bit e A great deal 24. I felt more confident with forming an assessment and plan for surgical patients as the clerkship progressed. e Not at all e A little bit e A great deal 25. My bedside patient management skills improved over the course of the clerkship. e Not at all e A little bit e A great deal 26. Which of the following best describes your feelings about a career in surgery? e I am not considering going into surgery e I think it might be a possibility that I will go into surgery e I am pretty sure I want to go into surgery e I definitely want to go into surgery 27. Are you planning to do a surgery subinternship? e Definitely not e Maybe e Definitely 28. Which of the following factors affected your level of interest in surgery? (Used Likert scales with five levels ranging from “not at all important” to “most important”) e Lifestyle as a resident
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e Lifestyle as an attending e Length of training e Mentorship experience e Role models in your own family e Role models within the clerkship e 80-hour work-week Please elaborate on the above factors, and any additional factors, and explain how they have affected your level of interest in surgery. How many times did you meet with your mentor over the course of the clerkship? How satisfied are you with the mentorship experience? e Very dissatisfied e Somewhat dissatisfied e Neutral e Somewhat satisfied e Very satisfied Which of the following statements do you agree with? (please choose one) e I would be more comfortable with a male surgeon as a mentor. e I would be equally comfortable with a female or male surgeon as a mentor. e I would be more comfortable with a female surgeon as a mentor. The majority of surgical attendings I encountered were good role models in terms of patient interactions. e Disagree e Neutral e Agree e Strongly agree The majority of surgical residents I encountered were good role models in terms of patient interactions. e Disagree e Neutral e Agree e Strongly agree The human-patient simulator program was a valuable experience. e Disagree e Neutral e Agree e Strongly agree What did you regard as principle benefits of the human-patient simulators? Please rank the following in descending order. Only rank those which you feel were benefits. e Overcoming anxiety of dealing with emergencies e Learning medical decision-making/priority-setting e Developing leadership skills e Teambuilding e Improving patient-doctor communication skills Other (please explain) Did you get a password to the laparoscopic simulator laboratory? Y/N How many times did you go? Please use this space to elaborate on any of the questions above.