- Email: [email protected]
Impact of a Third-Year Surgical Apprenticeship Model: Perceptions and Attitudes Compared with the Traditional Medical Student Clerkship Experience
Impact of a Third-Year Surgical Apprenticeship Model: Perceptions and Attitudes Compared with the Traditional Medical Student Clerkship Experience Chris M Reid, MD, Dennis Y Kim, MD, Jess Mandel, Mark A Talamini, MD, FACS, Vishal Bansal, MD, FACS
MD,
Alan Smith,
PhD, MPH,
Current literature suggests that medical students may have negative misconceptions of a surgical career partly due to the traditional hierarchical structure of the surgical clerkship. We hypothesized that a novel medical student apprenticeship would result in positive changes in perceptions of both surgeons and surgical careers. STUDY DESIGN: In the 2011 academic year, third-year medical students were offered a 2-week apprenticeship elective, in addition to the standard 8-week surgical clerkship. Unlike a traditional service, students apprenticed directly with participating faculty on a one-on-one basis. At the clerkship’s end, students received a structured questionnaire assessing perceptions and attitudes toward surgeons and a career in surgery. Subjects responded anonymously using a 5-point Likert scale. A Wilcoxon Rank-Sum was performed comparing students who participated vs those who did not participate in the apprenticeship. RESULTS: There was a 99% survey response (105 of 106). Of those, 50 (48%) participated in the apprenticeship. Apprenticeship students were more likely to view surgeons as content (p < 0.001), well-balanced (p < 0.01), respectful (p ¼ 0.01), and as role models (p < 0.005). Apprenticeship students were also more likely to participate in the operating room (p < 0.05) and in patient management (p < 0.05). There was no difference in an interest to pursue a surgical career between groups both before and on completion of the clerkship. CONCLUSIONS: Students participating in a surgical apprenticeship had a more positive view of surgeons and the field of surgery compared with students not participating. An apprenticeship model enhances the surgical clerkship experience and improves medical student perceptions of surgery as a career. (J Am Coll Surg 2014;218:1032e1037. 2014 by the American College of Surgeons)
BACKGROUND:
Adequacy of the future general surgery workforce in the United States has been increasingly under scrutiny. Despite previous predictions indicating a sufficient supply or even a surplus of surgeons,1 it has recently become clearer that an impending shortage of surgeons in the United States is likely.2-8 Fraher and colleagues9 predicted that by 2028 there will be an 18% decrease in the general Disclosure Information: Nothing to disclose. Presented at the American College of Surgeons 99th Annual Clinical Congress, Surgical Forum, Washington DC, October 2013. Received October 29, 2013; Accepted January 10, 2014. From the Department of Surgery (Reid, Talamini), the Division of Trauma, Surgical Critical Care and Burns (Kim, Smith, Bansal), Department of Surgery, University of California San Diego Medical Center, and University of California San Diego School of Medicine (Mandel), San Diego, CA. Correspondence address: Vishal Bansal, MD, FACS, University of California San Diego, Department of Surgery, Division of Trauma, Surgical Critical Care and Burns, 200 W Arbor Dr #8896, San Diego, CA 92103. email: [email protected]
ª 2014 by the American College of Surgeons Published by Elsevier Inc.
surgery workforce. Even though the population of the United States is rising, the number of certifications granted by the American Board of Surgery has remained unchanged for the past 30 years.1,10 Several explanations for this shortage have been proposed. A continued decline in new applicants and a larger proportion of residents planning part-time careers, contribute, at least in part, to a decreasing national pool of surgeons.9,11 The third-year medical student surgical clerkship is an integral component of medical school curricula. The clerkship has been identified as a key formative experience that has the potential to influence medical students’ decision to pursue a surgical career.12-14 Patient interaction including suturing, controlling the laparoscope, and actively participating in the operating room have been linked as predictors of selecting surgical careers.15 Other studies have documented the positive impact that faculty and housestaff have as educators, mentors, and role models in attracting future surgical trainees.15-19
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The perception of surgeons may also affect career decisions. Previous surveys have demonstrated that perceived length of surgical training and increasing student financial debt may negatively affect a desire to pursue surgery. Furthermore, evidence suggests that medical students, by and large, may view surgeons as less respectful to colleagues and less satisfied in their career choice. Other less quantifiable considerations, such as “lifestyle,” may also dissuade applicants from a surgical career due to the perception of sacrificing family and overall personal well-being.12,20,21 Recently we initiated a new apprenticeship model of surgical education designed to facilitate more meaningful professional and personal interactions between medical students and surgical faculty. This educational initiative provides students with opportunities to develop a realistic and encompassing impression of surgeons and surgery as a possible surgical career. We hypothesized that the introduction of an apprenticeship model would improve the medical student perception of surgeons, and consideration of pursuing a surgical career.
METHODS During the 2011 academic year, third-year medical students were offered an elective 2-week surgical apprenticeship elective rotation, which was incorporated as an adjunct to their 8-week surgical clerkship. Faculty members were solicited to participate as mentors on a volunteer basis and a variety of surgical specialties were represented, including surgical oncology, breast, plastic, cardiothoracic, colorectal, general, bariatric, pediatric, endocrine, and general surgery. All faculty were clinically active and had faculty appointments at our tertiary, referral academic center. The structure of the apprenticeship consisted of a oneon-one 2-week clinical rotation with a faculty member that was all encompassing. Students participated in all clinical, educational, professional, and training-related activities alongside their respective faculty member for the entirety of the 2 weeks. Students had limited interaction with housestaff, with the exception of clinical situations in which assigned faculty were present. There was limited resident-led service-related activity from participating students aside from efforts directly carried out by their faculty. In addition to the apprenticeship, students also completed the required 8-week surgical rotation (divided into two 4-week rotations). At the end of the clerkship, students received a structured questionnaire assessing perceptions and attitudes toward surgeons and a surgical career (Table 1). Students responded anonymously to the 23 questions using a 5point Likert scale assessing their level of agreement with
Third-Year Surgical Apprenticeship Model
1033
each statement. Responses of students who participated vs those who did not participate in the apprenticeship were compared. The distribution of responses to survey questions was compared using the Wilcoxon Rank-Sum test. A p value less than 0.05 was considered significant for this analysis. Statistical analysis was performed using IBM SPSS Statistics version 20.0 for Windows.
RESULTS There were 106 students who completed the surgical clerkship in the study period, and there was a 99% (n ¼ 105) response rate to the survey. Of the 106 students, 50 (48%) participated in the surgical apprenticeship elective. Importantly, there was no significant difference in reported interest in pursuing surgery as a career between those who did and those who did not participate in the elective before the clerkship (p ¼ 0.14) (Fig. 1). Of the 23 questions asked in the survey, 12 questions had statistically significant differences in the responses between the 2 groups (Figs. 2 and 3). Questions pertaining to a student’s perception of surgeons are listed in Figure 2. Questions pertaining to a student’s perception of the clerkship experience are listed in Figure 3. Grouping themes together, students who completed the surgical apprenticeship believed surgeons are content with career choice (p < 0.001), lead well-balanced lives (p ¼ 0.003), and encourage the pursuit of surgery as a career (p ¼ 0.026). Furthermore, the apprenticeship group responded that surgeons are respectful of their colleagues (p ¼ 0.014), are not ill-tempered (p < 0.001), are appropriate role models (p ¼ 0.004), and provide strong mentorship (p ¼ 0.017). Regarding students’ perceptions of the overall surgical clerkship, those completing the apprenticeship felt more strongly that they participated in patient management (p ¼ 0.044), actively participated in the operating room (p ¼ 0.040), were active members of the surgical team (0.042), and believed that surgeons were respectful of medical students (p ¼ 0.013). Interestingly, at the completion of the clerkship, there was no significant difference between groups in pursuing surgery as a career (p ¼ 0.063). DISCUSSION The structure of third-year medical student rotations has varied surprisingly little since the recommendation of clerkship structure by Abraham Flexner in 1910. Beyond the important core educational facets of any third year clerkship, it is well documented that the experience of a clerkship can have a profound impact on the career selection of medical students. Indeed, Berman and colleagues
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Table 1.
Reid et al
J Am Coll Surg
Third-Year Surgical Apprenticeship Model
Student Survey Questions and Responses Agree or strongly agree, % Participants Nonparticipants
Interest in surgery
1. Prior to clerkship I had an interest in pursuing surgery as a career. 2. Following clerkship, I have an interest in pursuing surgery as a career. Students’ perceptions of surgeons 3. Surgeons are content with their career choice. 4. Surgeons lead well balanced lives. 5. Surgeons are financially well compensated for their work. 6. Surgeons are caring physicians. 7. Surgeons are dedicated to their patients. 8. Surgeons are respected by their colleagues. 9. Surgeons are respectful of their colleagues. 10. Surgeons are respectful of their patients. 11. Surgeons are ill-tempered. 12. Surgeons are dedicated educators. 13. Surgeons are appropriate role models. 14. Surgeons provide mentorship. 15. Surgeons encourage the pursuit of surgery as a career. Students’ perception of their clerkship experience 16. Surgical clerkship met my educational needs. 17. I received adequate clinical teaching. 18. I received adequate bedside teaching. 19. I actively participated in the management of patients. 20. I was an active participant in the operating room. 21. I was included as a member of the surgical team. 22. Surgeons are respectful of medical students. 23. My attending physician was available to address questions or concerns that I had.
recently showed the significant influence that attending surgeons and their roles as mentors and role models have on a student decision to pursue a surgical career.15,16,22,23 Moreover, the quality of the clerkship experience, with specific regard to participation in the operating room and being included in the surgical team, has a strong impact on an interest in surgery.15,24,25 Goldin and associates25 recently showed that students entering their third year with an interest in becoming a surgeon form this interest during the first 2 years of medical school.12,25 As a result, others have described that surgical exposure during
p Value
30 48
27 35
0.143 0.063
78 27 66 64 88 72 44 72 24 48 64 55 78
47 4 49 56 76 61 29 54 54 38 40 40 55
<0.001 0.003 0.117 0.415 0.092 0.182 0.014 0.052 <0.001 0.111 0.004 0.017 0.026
44 48 40 60 58 66 56 62
45 44 42 79 44 51 40 56
0.248 0.185 0.379 0.044 0.04 0.042 0.013 0.101
the preclinical years may solidify interest in the field.26 Of note, there is no uniformity among surgical clerkships nationally and there is variation even within the same institution, similar to ours.27,28 Our results indicate that a surgical apprenticeship model may provide students with a realistic perspective of surgical practice, improving their perceptions of surgeons and the experience of surgical practice. The apprenticeship model is unique because it promotes a separation from traditional resident-led service responsibilities and creates an opportunity for undisturbed faculty fostering and guidance. As a
Figure 1. Questions pertaining to students’ interest in surgery.
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Figure 2. Questions pertaining to students’ perceptions of surgeons. *p < 0.05; **p < 0.01; ***p < 0.001.
result, apprenticeship students demonstrated more positive perceptions of surgeons and their careers. Furthermore, apprenticeship students had statistically significant differences in the overall positivity of their clerkship experience. Our belief is that apprenticeship students are exposed to the totality of attending surgery lifestyle and hopefully they shed previous misconceptions. Though we did not document specifics in this study, anecdotally, many apprenticeship students spent personal time with faculty, including research and administrative meetings, driving with faculty from various hospitals to satellite offices, and even meeting faculty families. What influence these experiences may have in student perceptions has yet to be quantified but would be interesting to investigate.
Apprenticeship students did not uniformly show a difference in all survey questions relating to perceptions of surgeons and the clerkship experience. However, there was an equality of positive responses among both groups to several questions, which may represent a change in perception in both groups. This equality of positive perception may be a function of completing the clerkship, as shown by previous authors.16,24 Even though the apprenticeship did not seem to increase the decision to pursue surgery as a career, the apprenticeship may confirm the decision of students inclined to pursue surgical training. Attrition continues to be a consistent issue for general surgery residencies, with a national rate reported near 20%.26,29-31 In a study evaluating factors in
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Figure 3. Questions pertaining to students’ perceptions of their clerkship experience. *p < 0.05.
choosing a surgical career, Berman and coworkers15 proposed that an understanding that life as an attending differs from life as a resident may lead to a more accurate perception of the rewards in completing surgical residency. Indeed, early educational opportunities with direct faculty engagement, such as an apprenticeship system, may help add clarity to student perceptions. Our study is limited in that it represents a single institution experience at an academic medical center. Additionally, the apprenticeship is offered as an elective rotation with selective faculty availability. Given faculty commitments to their clinical enterprise and operative volume as well as administrative and research responsibilities, we were enthusiastic about the large portion of the faculty who committed to the apprenticeship elective. Even though there was no difference in surgery as a career between groups, it is plausible that students interested in the apprenticeship may have a predilection for surgery that cannot be numerically tabulated. Currently, the apprenticeship is in its third year and reviews continue to be supportive. We hope to expand and diversify this educational model with hopes of developing it into a 4week stand-alone clerkship and extending faculty selection to include community-based surgeons. In addition, we are developing a resident and student mentoring system and a formalized structured approach to engage
committed medical students to the residency application process.
CONCLUSIONS The third-year surgical clerkship is a formative period in which students develop perceptions about surgeons and decide careers. An apprenticeship model, as an adjunct to the traditional clerkship, provides students with a novel environment in which to experience the practice of surgery. Although current data suggest that apprenticeship students are not more likely to pursue a surgical career, the significant increase in positive perception about both surgeons and surgery is educationally valuable and lends credence to further clerkship improvements and reform. Author Contributions Study conception and design: Reid, Kim, Mandel, Talamini, Bansal Acquisition of data: Reid, Kim, Mandel, Smith, Talamini, Bansal Analysis and interpretation of data: Reid, Kim, Smith, Bansal Drafting of manuscript: Reid, Kim, Smith, Bansal Critical revision: Reid, Kim, Smith, Bansal
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REFERENCES 1. Richardson JD. General surgeon shortage in the United States: Fact or fiction, causes and consequences. Soc Work Public Health 2011;26:513e523. 2. Sheldon GF. The evolving surgeon shortage in the health reform era. J Gastrointest Surg 2011;15:1104e1111. 3. Sheldon GF. Access to care and the surgeon shortage: American Surgical Association forum. Ann Surg 2010;252: 582e590. 4. Poley S, Belsky D, Gaul K, et al. Longitudinal trends in the U.S. surgical workforce, 1981-2006. Bull Am Coll Surg 2009;94:27e31. 5. Lynge DC, Larson EH, Thompson MJ, et al. A longitudinal analysis of the general surgery workforce in the United States, 1981-2005. Arch Surg 2008;143:345e350; discussion 351. 6. Satiani B, Williams TE, Ellison EC. The impact of employment of part-time surgeons on the expected surgeon shortage. J Am Coll Surg 2011;213:345e351. 7. Williams TE Jr, Satiani B, Thomas A, Ellison EC. The impending shortage and the estimated cost of training the future surgical workforce. Ann Surg 2009;250:590e597. 8. Williams TE Jr, Ellison EC. Population analysis predicts a future critical shortage of general surgeons. Surgery 2008; 144:548e554; discussion 554e556. 9. Fraher EP, Knapton A, Sheldon GF, et al. Projecting surgeon supply using a dynamic model. Ann Surg 2013;257:867e872. 10. The American Board of Surgery. Available at: http://www. absurgery.org/default.jsp?statgeneral. Accessed October 11, 2013. 11. Williams C, Cantillon P. A surgical career? The views of junior women doctors. Med Educ 2000;34:602e607. 12. O’Herrin JK, Lewis BJ, Rikkers LF, Chen H. Why do students choose careers in surgery? J Surg Res 2004;119:124e129. 13. Cochran A, Paukert JL, Neumayer LA. Does a general surgery clerkship influence student perceptions of surgeons and surgical careers? Surgery 2003;134:153e157. 14. Tahiri M, Liberman M. What is an ideal surgical clerkship? Can J Surg 2013;56:151e152. 15. Berman L, Rosenthal MS, Curry LA, et al. Attracting surgical clerks to surgical careers: Role models, mentoring, and engagement in the operating room. J Am Coll Surg 2008;207: 793e800, 800.e1e2. 16. Quillin RC 3rd, Pritts TA, Davis BR, et al. Surgeons underestimate their influence on medical students entering surgery. J Surg Res 2012;177:201e206. 17. Nguyen SQ, Divino CM. Surgical residents as medical student mentors. Am J Surg 2007;193:90e93.
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18. Evans LV, Gusberg RJ. Creating a surgery clerkship in a changing environment: Reality, simulation, and the rules of engagement. Yale J Biol Med 2012;85:143e152. 19. Musunuru S, Lewis B, Rikkers LF, Chen H. Effective surgical residents strongly influence medical students to pursue surgical careers. J Am Coll Surg 2007;204:164e167. 20. Bale AG, Coutinho K, Swan KG, Heinrich GF. Increasing educational indebtedness influences medical students to pursue specialization: A military recruitment potential? Mil Med 2013;178:202e206. 21. Are C, Stoddard HA, O’Holleran B, Thompson JS. A multinational perspective on "lifestyle" and other perceptions of contemporary medical students about general surgery. Ann Surg 2012;256:378e386. 22. Quillin RC 3rd, Pritts TA, Tevar AD, et al. Students’ expectations on the surgery clerkship exceed those of residents and faculty. J Surg Res 2013;184:495e500. 23. Naylor RA, Reisch JS, Valentine RJ. Do student perceptions of surgeons change during medical school? A longitudinal analysis during a 4-year curriculum. J Am Coll Surg 2010;210: 527e532. 24. Al-Heeti KN, Nassar AK, Decorby K, et al. The effect of general surgery clerkship rotation on the attitude of medical students towards general surgery as a future career. J Surg Educ 2012;69:544e549. 25. Goldin SB, Schnaus MJ, Horn G, et al. Surgical interest and surgical match for third-year students: Results of a prospective multivariate longitudinal cohort study. J Am Coll Surg 2012; 215:599e606. 26. Farley DR, Cook JK. Whatever happened to the general surgery graduating class of 2001? Curr Surg 2001;58:587e590. 27. Seabrook MA, Woodfield SJ, Papagrigoriadis S, et al. Consistency of teaching in parallel surgical firms: An audit of student experience at one medical school. Med Educ 2000;34: 292e298. 28. Lind DS, Deladisma AM, Cue JI, et al. Survey of student education in surgery. J Am Coll Surg 2007;204:969e974; discussion 975e976. 29. Dodson TF, Webb AL. Why do residents leave general surgery? The hidden problem in today’s programs. Curr Surg 2005;62:128e131. 30. Aufses AH Jr, Slater GI, Hollier LH. The nature and fate of categorical surgical residents who "drop out". Am J Surg 1998;175:236e239. 31. Bergen PC, Turnage RH, Carrico CJ. Gender-related attrition in a general surgery training program. J Surg Res 1998;77: 59e62.
MD,
Alan Smith,
PhD, MPH,
Current literature suggests that medical students may have negative misconceptions of a surgical career partly due to the traditional hierarchical structure of the surgical clerkship. We hypothesized that a novel medical student apprenticeship would result in positive changes in perceptions of both surgeons and surgical careers. STUDY DESIGN: In the 2011 academic year, third-year medical students were offered a 2-week apprenticeship elective, in addition to the standard 8-week surgical clerkship. Unlike a traditional service, students apprenticed directly with participating faculty on a one-on-one basis. At the clerkship’s end, students received a structured questionnaire assessing perceptions and attitudes toward surgeons and a career in surgery. Subjects responded anonymously using a 5-point Likert scale. A Wilcoxon Rank-Sum was performed comparing students who participated vs those who did not participate in the apprenticeship. RESULTS: There was a 99% survey response (105 of 106). Of those, 50 (48%) participated in the apprenticeship. Apprenticeship students were more likely to view surgeons as content (p < 0.001), well-balanced (p < 0.01), respectful (p ¼ 0.01), and as role models (p < 0.005). Apprenticeship students were also more likely to participate in the operating room (p < 0.05) and in patient management (p < 0.05). There was no difference in an interest to pursue a surgical career between groups both before and on completion of the clerkship. CONCLUSIONS: Students participating in a surgical apprenticeship had a more positive view of surgeons and the field of surgery compared with students not participating. An apprenticeship model enhances the surgical clerkship experience and improves medical student perceptions of surgery as a career. (J Am Coll Surg 2014;218:1032e1037. 2014 by the American College of Surgeons)
BACKGROUND:
Adequacy of the future general surgery workforce in the United States has been increasingly under scrutiny. Despite previous predictions indicating a sufficient supply or even a surplus of surgeons,1 it has recently become clearer that an impending shortage of surgeons in the United States is likely.2-8 Fraher and colleagues9 predicted that by 2028 there will be an 18% decrease in the general Disclosure Information: Nothing to disclose. Presented at the American College of Surgeons 99th Annual Clinical Congress, Surgical Forum, Washington DC, October 2013. Received October 29, 2013; Accepted January 10, 2014. From the Department of Surgery (Reid, Talamini), the Division of Trauma, Surgical Critical Care and Burns (Kim, Smith, Bansal), Department of Surgery, University of California San Diego Medical Center, and University of California San Diego School of Medicine (Mandel), San Diego, CA. Correspondence address: Vishal Bansal, MD, FACS, University of California San Diego, Department of Surgery, Division of Trauma, Surgical Critical Care and Burns, 200 W Arbor Dr #8896, San Diego, CA 92103. email: [email protected]
ª 2014 by the American College of Surgeons Published by Elsevier Inc.
surgery workforce. Even though the population of the United States is rising, the number of certifications granted by the American Board of Surgery has remained unchanged for the past 30 years.1,10 Several explanations for this shortage have been proposed. A continued decline in new applicants and a larger proportion of residents planning part-time careers, contribute, at least in part, to a decreasing national pool of surgeons.9,11 The third-year medical student surgical clerkship is an integral component of medical school curricula. The clerkship has been identified as a key formative experience that has the potential to influence medical students’ decision to pursue a surgical career.12-14 Patient interaction including suturing, controlling the laparoscope, and actively participating in the operating room have been linked as predictors of selecting surgical careers.15 Other studies have documented the positive impact that faculty and housestaff have as educators, mentors, and role models in attracting future surgical trainees.15-19
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Reid et al
The perception of surgeons may also affect career decisions. Previous surveys have demonstrated that perceived length of surgical training and increasing student financial debt may negatively affect a desire to pursue surgery. Furthermore, evidence suggests that medical students, by and large, may view surgeons as less respectful to colleagues and less satisfied in their career choice. Other less quantifiable considerations, such as “lifestyle,” may also dissuade applicants from a surgical career due to the perception of sacrificing family and overall personal well-being.12,20,21 Recently we initiated a new apprenticeship model of surgical education designed to facilitate more meaningful professional and personal interactions between medical students and surgical faculty. This educational initiative provides students with opportunities to develop a realistic and encompassing impression of surgeons and surgery as a possible surgical career. We hypothesized that the introduction of an apprenticeship model would improve the medical student perception of surgeons, and consideration of pursuing a surgical career.
METHODS During the 2011 academic year, third-year medical students were offered an elective 2-week surgical apprenticeship elective rotation, which was incorporated as an adjunct to their 8-week surgical clerkship. Faculty members were solicited to participate as mentors on a volunteer basis and a variety of surgical specialties were represented, including surgical oncology, breast, plastic, cardiothoracic, colorectal, general, bariatric, pediatric, endocrine, and general surgery. All faculty were clinically active and had faculty appointments at our tertiary, referral academic center. The structure of the apprenticeship consisted of a oneon-one 2-week clinical rotation with a faculty member that was all encompassing. Students participated in all clinical, educational, professional, and training-related activities alongside their respective faculty member for the entirety of the 2 weeks. Students had limited interaction with housestaff, with the exception of clinical situations in which assigned faculty were present. There was limited resident-led service-related activity from participating students aside from efforts directly carried out by their faculty. In addition to the apprenticeship, students also completed the required 8-week surgical rotation (divided into two 4-week rotations). At the end of the clerkship, students received a structured questionnaire assessing perceptions and attitudes toward surgeons and a surgical career (Table 1). Students responded anonymously to the 23 questions using a 5point Likert scale assessing their level of agreement with
Third-Year Surgical Apprenticeship Model
1033
each statement. Responses of students who participated vs those who did not participate in the apprenticeship were compared. The distribution of responses to survey questions was compared using the Wilcoxon Rank-Sum test. A p value less than 0.05 was considered significant for this analysis. Statistical analysis was performed using IBM SPSS Statistics version 20.0 for Windows.
RESULTS There were 106 students who completed the surgical clerkship in the study period, and there was a 99% (n ¼ 105) response rate to the survey. Of the 106 students, 50 (48%) participated in the surgical apprenticeship elective. Importantly, there was no significant difference in reported interest in pursuing surgery as a career between those who did and those who did not participate in the elective before the clerkship (p ¼ 0.14) (Fig. 1). Of the 23 questions asked in the survey, 12 questions had statistically significant differences in the responses between the 2 groups (Figs. 2 and 3). Questions pertaining to a student’s perception of surgeons are listed in Figure 2. Questions pertaining to a student’s perception of the clerkship experience are listed in Figure 3. Grouping themes together, students who completed the surgical apprenticeship believed surgeons are content with career choice (p < 0.001), lead well-balanced lives (p ¼ 0.003), and encourage the pursuit of surgery as a career (p ¼ 0.026). Furthermore, the apprenticeship group responded that surgeons are respectful of their colleagues (p ¼ 0.014), are not ill-tempered (p < 0.001), are appropriate role models (p ¼ 0.004), and provide strong mentorship (p ¼ 0.017). Regarding students’ perceptions of the overall surgical clerkship, those completing the apprenticeship felt more strongly that they participated in patient management (p ¼ 0.044), actively participated in the operating room (p ¼ 0.040), were active members of the surgical team (0.042), and believed that surgeons were respectful of medical students (p ¼ 0.013). Interestingly, at the completion of the clerkship, there was no significant difference between groups in pursuing surgery as a career (p ¼ 0.063). DISCUSSION The structure of third-year medical student rotations has varied surprisingly little since the recommendation of clerkship structure by Abraham Flexner in 1910. Beyond the important core educational facets of any third year clerkship, it is well documented that the experience of a clerkship can have a profound impact on the career selection of medical students. Indeed, Berman and colleagues
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Table 1.
Reid et al
J Am Coll Surg
Third-Year Surgical Apprenticeship Model
Student Survey Questions and Responses Agree or strongly agree, % Participants Nonparticipants
Interest in surgery
1. Prior to clerkship I had an interest in pursuing surgery as a career. 2. Following clerkship, I have an interest in pursuing surgery as a career. Students’ perceptions of surgeons 3. Surgeons are content with their career choice. 4. Surgeons lead well balanced lives. 5. Surgeons are financially well compensated for their work. 6. Surgeons are caring physicians. 7. Surgeons are dedicated to their patients. 8. Surgeons are respected by their colleagues. 9. Surgeons are respectful of their colleagues. 10. Surgeons are respectful of their patients. 11. Surgeons are ill-tempered. 12. Surgeons are dedicated educators. 13. Surgeons are appropriate role models. 14. Surgeons provide mentorship. 15. Surgeons encourage the pursuit of surgery as a career. Students’ perception of their clerkship experience 16. Surgical clerkship met my educational needs. 17. I received adequate clinical teaching. 18. I received adequate bedside teaching. 19. I actively participated in the management of patients. 20. I was an active participant in the operating room. 21. I was included as a member of the surgical team. 22. Surgeons are respectful of medical students. 23. My attending physician was available to address questions or concerns that I had.
recently showed the significant influence that attending surgeons and their roles as mentors and role models have on a student decision to pursue a surgical career.15,16,22,23 Moreover, the quality of the clerkship experience, with specific regard to participation in the operating room and being included in the surgical team, has a strong impact on an interest in surgery.15,24,25 Goldin and associates25 recently showed that students entering their third year with an interest in becoming a surgeon form this interest during the first 2 years of medical school.12,25 As a result, others have described that surgical exposure during
p Value
30 48
27 35
0.143 0.063
78 27 66 64 88 72 44 72 24 48 64 55 78
47 4 49 56 76 61 29 54 54 38 40 40 55
<0.001 0.003 0.117 0.415 0.092 0.182 0.014 0.052 <0.001 0.111 0.004 0.017 0.026
44 48 40 60 58 66 56 62
45 44 42 79 44 51 40 56
0.248 0.185 0.379 0.044 0.04 0.042 0.013 0.101
the preclinical years may solidify interest in the field.26 Of note, there is no uniformity among surgical clerkships nationally and there is variation even within the same institution, similar to ours.27,28 Our results indicate that a surgical apprenticeship model may provide students with a realistic perspective of surgical practice, improving their perceptions of surgeons and the experience of surgical practice. The apprenticeship model is unique because it promotes a separation from traditional resident-led service responsibilities and creates an opportunity for undisturbed faculty fostering and guidance. As a
Figure 1. Questions pertaining to students’ interest in surgery.
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Figure 2. Questions pertaining to students’ perceptions of surgeons. *p < 0.05; **p < 0.01; ***p < 0.001.
result, apprenticeship students demonstrated more positive perceptions of surgeons and their careers. Furthermore, apprenticeship students had statistically significant differences in the overall positivity of their clerkship experience. Our belief is that apprenticeship students are exposed to the totality of attending surgery lifestyle and hopefully they shed previous misconceptions. Though we did not document specifics in this study, anecdotally, many apprenticeship students spent personal time with faculty, including research and administrative meetings, driving with faculty from various hospitals to satellite offices, and even meeting faculty families. What influence these experiences may have in student perceptions has yet to be quantified but would be interesting to investigate.
Apprenticeship students did not uniformly show a difference in all survey questions relating to perceptions of surgeons and the clerkship experience. However, there was an equality of positive responses among both groups to several questions, which may represent a change in perception in both groups. This equality of positive perception may be a function of completing the clerkship, as shown by previous authors.16,24 Even though the apprenticeship did not seem to increase the decision to pursue surgery as a career, the apprenticeship may confirm the decision of students inclined to pursue surgical training. Attrition continues to be a consistent issue for general surgery residencies, with a national rate reported near 20%.26,29-31 In a study evaluating factors in
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J Am Coll Surg
Figure 3. Questions pertaining to students’ perceptions of their clerkship experience. *p < 0.05.
choosing a surgical career, Berman and coworkers15 proposed that an understanding that life as an attending differs from life as a resident may lead to a more accurate perception of the rewards in completing surgical residency. Indeed, early educational opportunities with direct faculty engagement, such as an apprenticeship system, may help add clarity to student perceptions. Our study is limited in that it represents a single institution experience at an academic medical center. Additionally, the apprenticeship is offered as an elective rotation with selective faculty availability. Given faculty commitments to their clinical enterprise and operative volume as well as administrative and research responsibilities, we were enthusiastic about the large portion of the faculty who committed to the apprenticeship elective. Even though there was no difference in surgery as a career between groups, it is plausible that students interested in the apprenticeship may have a predilection for surgery that cannot be numerically tabulated. Currently, the apprenticeship is in its third year and reviews continue to be supportive. We hope to expand and diversify this educational model with hopes of developing it into a 4week stand-alone clerkship and extending faculty selection to include community-based surgeons. In addition, we are developing a resident and student mentoring system and a formalized structured approach to engage
committed medical students to the residency application process.
CONCLUSIONS The third-year surgical clerkship is a formative period in which students develop perceptions about surgeons and decide careers. An apprenticeship model, as an adjunct to the traditional clerkship, provides students with a novel environment in which to experience the practice of surgery. Although current data suggest that apprenticeship students are not more likely to pursue a surgical career, the significant increase in positive perception about both surgeons and surgery is educationally valuable and lends credence to further clerkship improvements and reform. Author Contributions Study conception and design: Reid, Kim, Mandel, Talamini, Bansal Acquisition of data: Reid, Kim, Mandel, Smith, Talamini, Bansal Analysis and interpretation of data: Reid, Kim, Smith, Bansal Drafting of manuscript: Reid, Kim, Smith, Bansal Critical revision: Reid, Kim, Smith, Bansal
Vol. 218, No. 5, May 2014
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