- Email: [email protected]
A senior elective designed to prepare medical students for surgical residency
The American Journal of Surgery 187 (2004) 695– 697
Association for Surgical Education— core competency
A senior elective designed to prepare medical students for surgical residency Margaret L. Boehler, R.N., M.S.*, David A. Rogers, M.D., Cathy J. Schwind, R.N., M.S., John Fortune, M.D., Janet Ketchum, Gary Dunnington, M.D. From the Department of Surgery, Southern Illinois University School of Medicine, P.O. Box 19655, Springfield, IL 62794-9655, USA Manuscript received October 17, 2003; revised manuscript December 7, 2003 Presented at the 23rd Annual Meeting of the Association of Surgical Education, Vancouver, British Columbia, Canada, May 6 –10, 2003
Abstract Background: The transition from medical student to surgery internship can be stressful. The goal of this project was to design, implement, and evaluate a 1-month long elective course that would meet the majority of the American College of Surgeons Graduate Medical Education Committee prerequisites for graduate surgical education Methods: The major elements of the curriculum included faculty- and resident-facilitated case-based sessions and cadaver dissections. In addition, the students participated in skills laboratory experiences, Intensive Care Unit rounds, and mock interviews and clinical pages. The students took a knowledge pretest and post-test that was compared with the performance of 8 surgical interns on the same examination. Results: The highest rated elements of the course were those that provided hands-on experience or practical knowledge. The post-test knowledge examination scores were significantly higher than pretest scores and surgical intern scores. Conclusions: It was possible to develop a 1-month senior medical student elective course that provided students with the essential prerequisites believed to be essential for all surgical interns. © 2004 Excerpta Medica, Inc. All rights reserved. Keywords: Electives; Medical students; Residency preparation; Surgical education
The transition from medical student to surgery intern can be a stressful one with a steep learning curve. Because a great deal of this stress is attributed to lack of thorough preparation [1–3], we hypothesized that a focused educational intervention designed to equip students with the specific skills required for surgical residency should diminish some of these stresses [4]. As a first step toward this goal, the Graduate Medical Education Committee of the American College of Surgeons (ACOS) developed a set of formal prerequisites for graduate surgical education [5]. Our interest in this project was to design, implement, and evaluate a 1-month long elective that would meet the majority of these prerequisites. We designed the curriculum based on the philosophy that students would benefit most from teaching methods that involved them as active learners [6,7]. Taken as a whole, the design of this curriculum would
* Corresponding author. Tel.: ⫹ 1-217-545-5145; fax: ⫹1-217-5457305. E-mail address: [email protected]
provide an opportunity for each student to enhance clinical competencies and confidence levels as interns and, as a result of early skills acquisition, also promote patient safety [8 –10].
Methods Twelve fourth-year medical students participated in this 1-month elective course. This group included students with interests in general surgery, vascular surgery, otolaryngology, and obstetrics and gynecology. Initially, 1 faculty member designed the first draft of the curriculum using the ACOS prerequisites as a guide. In addition to using the ACOS prerequisites, the blueprint for the curriculum was developed by informally surveying fourth-year medical students, interns, residents, and faculty. As a group, we came to consensus regarding the final curriculum design, which was the culmination of the prerequisites along with subjects and skills the faculty believed
0002-9610/04/$ – see front matter © 2004 Excerpta Medica, Inc. All rights reserved. doi:10.1016/j.amjsurg.2003.12.052
696
M.L. Boehler et al. / The American Journal of Surgery 187 (2004) 695– 697
were of critical importance and/or were previously insufficiently covered by the current medical school curriculum. The primary elements of the curriculum included a total of 27 faculty- and resident-facilitated sessions; cadaver dissections of the head and neck, thorax, abdomen, and pelvis concluding with student-prepared presentations; 10 laboratory skills experiences; Intensive Care Unit (ICU) rounds; standardized patient clinic experiences; mock interviews; and a program of mock clinical pages that provided immediate feedback. There were a total number of 74.5 scheduled hours for each student, which included 29.5 hours of faculty- and resident-facilitated sessions, 20 hours in the surgical skills laboratory, 14 hours of cadaver dissection, 4 hours on the trauma service completing ICU rounds, 3 hours completing the standardized patient clinic experience, 2.5 hours answering mock pages, and 1.5 hours in mock interview. The faculty-facilitated sessions were primarily casebased discussions that also included basic science objectives. The resident-facilitated sessions contained “survivor skills” identified by residents as common areas essential for an intern to be familiar with and know how to manage. Some examples of survivor skill sessions included care of patients with fever, pain, anxiety, hypotension, hypertension, or electrolyte imbalance. The cadaver dissection sessions were derived from student specialty choice, e.g., general surgery applicants performed the abdominal dissection, whereas otolaryngology students performed the head and neck dissection. The students were required to present their dissection to the course participants while a faculty member guided the presentation using common patient case scenarios. To provide a comprehensive learning experience, all of the students participating in the course were required to be present at all of the dissection presentations. The skills laboratory portion of the course was adapted from the established surgical intern skills laboratory curriculum. In the skills laboratory, faculty instructed the students in the art of knot tying, tissue handling and dissection, arterial and venous catheterization, surgical biopsy, chest tube placement and thoracentesis, laparotomy, gastrointestinal anastomosis, and 3 laparoscopic skills sessions. Participants were also given the opportunity to participate in the daily trauma team ICU rounds. Students had no assigned patient responsibilities, but they were expected to fully participate in rounding by asking and answering questions regarding the complex management of this patient population with particular emphasis regarding hemodynamic and ventilator management. The standardized patient clinic experience was designed to give students an opportunity to practice and receive feedback regarding clinic dictation (i.e., history and physical, referral letter), writing prescriptions, obtaining informed consent, and conducting preoperative patient management. The standardized patients provided feedback on the students’ patient interaction skills using a patient satis-
faction checklist. The clinic experience concluded with a faculty-directed discussion regarding appropriate preoperative management and requirements for informed consent. The dictations were transcribed, and formal written feedback was provided. The students were given an opportunity to prepare for residency interviews by participating in mock interviews. The objective of this session was to give the students skills that would improve their interviewing aptitude. The faculty conducted interviews with each student and gave immediate feedback. The final portion of the curriculum was a series of mock pages [9]. This was designed to prepare the students to answer complex questions about patient care, thus simulating the on-call experience of an intern. A multidisciplinary team developed 15 distinct clinical scenarios believed to be the most common and/or critical patient situations encountered by interns (e.g., nausea and vomiting, pain, hypotension, chest pain, hypokalemia, etc.). The students received random pages throughout each day by the department of surgery nurse instructors. In addition, students were “oncall” at least 1 night/wk. These pages consisted of a clinical scenario that required the student to ask pertinent questions, to appropriately assess the problem, and to provide a management plan in the form of verbal orders. At the completion of the mock page experience, the nurse instructors provided verbal feedback regarding the assessment and the management plan. Students completed an evaluation of each curricular element as the course progressed. These evaluations consisted of a simplified 3-point rating scale (i.e., extremely valuable ⫽ 3, valuable ⫽ 2, and low value ⫽ 1) that described the value and quality of the information, presentation style, and activity. Students were also asked to comment on which experiences they found most valuable and to explicitly offer any suggestions that would help improve aspects of each week’s activities. The results of the surveys were computed for a mean score and then ranked in order of perceived value. Additionally, the students took a 50-question knowledge pretest and post-test, the scores of which were compared with the performance of 8 surgical interns taking the same examinations. The faculty developed 3 to 4 case-based multiple-choice questions based on the content of each session. Questions were then randomly selected and included either in the pretest or the post-test. The results of the pretest and post-test for the fourth-year students and interns were averaged, and independent sample Student t tests were performed to determine any significant differences between groups; P ⬍0.05 was considered statistically significant.
Results Twelve medical students interested in pursuing surgical residency participated in this 4-week elective course. A total
M.L. Boehler et al. / The American Journal of Surgery 187 (2004) 695– 697
Fig. 1. Curriculum evaluation.
of 200.5 hours of faculty time, including 72 hours of nurse instructor time, was required to develop and deliver this 4-week senior elective course. Including the cost of written material, cadavers, skills laboratory sessions, and clerical time, the course cost approximately $1324. The highest rated elements of the course were the laboratory skills experiences, the resident-facilitated “survival skills” sessions, the mock interviews, and the program of simulated pages. The lowest rated element was the ICU rounds (Fig. 1). We related the lack of active student participation and/or any specific patient responsibility to the lack of success of the ICU rounds. Overall, written comments from the students were in general very positive and also reflected the extremely favorable verbal feedback faculty received both during and after completion of the course. The students’ knowledge examination pretest scores ( x ⫽ 68, SD ⫽ 9.43) and those of the interns ( x ⫽ 71, SD ⫽ 9.74) were very similar. The posttest scores for the senior students ( x ⫽ 83, SD ⫽ 5.98) were significantly improved and had much less variance. The mean posttest knowledge examination score was significantly higher than the mean pretest score (t ⫽ 3.89, P ⫽ 0.005) and the mean surgical intern score (t ⫽ 2.64, P ⫽ 0.038).
Comments A 1-month senior medical student elective course can provide students with the essential prerequisites believed to be essential for all surgical interns. It was possible to develop and administer this course using existing resources and required a minimal financial investment from the Department of Surgery. The students rated activities as most valuable when they were given the opportunity for hands-on skills acquisition or
697
they were perceived as practical knowledge such as mock paging and resident survivor skills sessions. In contrast, we believed that the ICU rounds were rated as the lowest valued activity due to the lack of opportunity for active participation because students were not given any actual patient responsibility and acted simply as observers. Because the value of critical care exposure to the curriculum is well established in the literature [11], we plan to enhance this segment of the course by directly involving students in the care of critical patients. The most frequently voiced complaint was that the timing of the course was not convenient for a number of students who had scheduled audition electives during the early fall. As a result, we will offer this course during the fall and spring of the next academic year. At the conclusion of this elective course, the students demonstrated more knowledge of these prerequisites than did a group of surgical interns. Longitudinal follow-up research is planned to determine the definitive effect on these students’ level of preparation for surgical residency. If this course is ultimately successful, interns will enter their residency programs more aptly prepared. In addition, the residency program should be able to more effectively and efficiently provide the crucial specialty-specific surgery education required for optimal patient outcomes.
References [1] Barone JE. Problems with the fourth-year curriculum of students entering surgical residencies. Am J Surg 1995;169:334 –7. [2] Nakayama DK, Steiber A. Surgery interns’ experience with surgical procedures as medical students. Am J Surg 1990;159:341–3. [3] Sloan DA, Donnelly MB, Johnson SB, et al. Use of an Objective Structured Clinical Examination (OSCE) to measure improvement in clinical competence during the surgical internship. Surgery 1993;114: 343–50. [4] Langdale A, Schaad DS, Wipf J, et al. Preparing graduates for the first year of residency: are medical schools meeting the need? Acad Med 2003;78:39 – 44. [5] American College of Surgeons Graduate Medical Education Committee. Prerequisite objectives for graduate surgical education: a study of the Graduate Medical Education Committee American College of Surgeons. J Am Coll Surg 1998;186:50 – 62. [6] Vygotsky LS. Theories of Development–Concepts and Applications. Englewood Cliffs, NJ: Prentice Hall. 1992. [7] Knowles M. The Adult Learner. A Neglected Species. Houston, TX: Gulf Publishing; 1990. [8] Lawler FH, Scheid DC, Viviani NJ. The cost of medical dictation transcription at an academic family practice center. Arch Fam Med 1998;7:269 –72. [9] Marshall RL, Gorman PJ, Verne D, et al. Practical training for postgraduate year 1 surgery residents. Am J Surg 2000;179:194 – 6. [10] Qayumi AK, Cheifetz RE, Forward AD, et al. Teaching and evaluation of basic surgical techniques: the University of British Columbia experience. J Invest Surg 1999;12:341–50. [11] Buchman TG, Dellinger RP, Raphaely RC, Todres ID. Undergraduate education in critical care medicine. Crit Care Med 1992;20:1595– 1603.
Association for Surgical Education— core competency
A senior elective designed to prepare medical students for surgical residency Margaret L. Boehler, R.N., M.S.*, David A. Rogers, M.D., Cathy J. Schwind, R.N., M.S., John Fortune, M.D., Janet Ketchum, Gary Dunnington, M.D. From the Department of Surgery, Southern Illinois University School of Medicine, P.O. Box 19655, Springfield, IL 62794-9655, USA Manuscript received October 17, 2003; revised manuscript December 7, 2003 Presented at the 23rd Annual Meeting of the Association of Surgical Education, Vancouver, British Columbia, Canada, May 6 –10, 2003
Abstract Background: The transition from medical student to surgery internship can be stressful. The goal of this project was to design, implement, and evaluate a 1-month long elective course that would meet the majority of the American College of Surgeons Graduate Medical Education Committee prerequisites for graduate surgical education Methods: The major elements of the curriculum included faculty- and resident-facilitated case-based sessions and cadaver dissections. In addition, the students participated in skills laboratory experiences, Intensive Care Unit rounds, and mock interviews and clinical pages. The students took a knowledge pretest and post-test that was compared with the performance of 8 surgical interns on the same examination. Results: The highest rated elements of the course were those that provided hands-on experience or practical knowledge. The post-test knowledge examination scores were significantly higher than pretest scores and surgical intern scores. Conclusions: It was possible to develop a 1-month senior medical student elective course that provided students with the essential prerequisites believed to be essential for all surgical interns. © 2004 Excerpta Medica, Inc. All rights reserved. Keywords: Electives; Medical students; Residency preparation; Surgical education
The transition from medical student to surgery intern can be a stressful one with a steep learning curve. Because a great deal of this stress is attributed to lack of thorough preparation [1–3], we hypothesized that a focused educational intervention designed to equip students with the specific skills required for surgical residency should diminish some of these stresses [4]. As a first step toward this goal, the Graduate Medical Education Committee of the American College of Surgeons (ACOS) developed a set of formal prerequisites for graduate surgical education [5]. Our interest in this project was to design, implement, and evaluate a 1-month long elective that would meet the majority of these prerequisites. We designed the curriculum based on the philosophy that students would benefit most from teaching methods that involved them as active learners [6,7]. Taken as a whole, the design of this curriculum would
* Corresponding author. Tel.: ⫹ 1-217-545-5145; fax: ⫹1-217-5457305. E-mail address: [email protected]
provide an opportunity for each student to enhance clinical competencies and confidence levels as interns and, as a result of early skills acquisition, also promote patient safety [8 –10].
Methods Twelve fourth-year medical students participated in this 1-month elective course. This group included students with interests in general surgery, vascular surgery, otolaryngology, and obstetrics and gynecology. Initially, 1 faculty member designed the first draft of the curriculum using the ACOS prerequisites as a guide. In addition to using the ACOS prerequisites, the blueprint for the curriculum was developed by informally surveying fourth-year medical students, interns, residents, and faculty. As a group, we came to consensus regarding the final curriculum design, which was the culmination of the prerequisites along with subjects and skills the faculty believed
0002-9610/04/$ – see front matter © 2004 Excerpta Medica, Inc. All rights reserved. doi:10.1016/j.amjsurg.2003.12.052
696
M.L. Boehler et al. / The American Journal of Surgery 187 (2004) 695– 697
were of critical importance and/or were previously insufficiently covered by the current medical school curriculum. The primary elements of the curriculum included a total of 27 faculty- and resident-facilitated sessions; cadaver dissections of the head and neck, thorax, abdomen, and pelvis concluding with student-prepared presentations; 10 laboratory skills experiences; Intensive Care Unit (ICU) rounds; standardized patient clinic experiences; mock interviews; and a program of mock clinical pages that provided immediate feedback. There were a total number of 74.5 scheduled hours for each student, which included 29.5 hours of faculty- and resident-facilitated sessions, 20 hours in the surgical skills laboratory, 14 hours of cadaver dissection, 4 hours on the trauma service completing ICU rounds, 3 hours completing the standardized patient clinic experience, 2.5 hours answering mock pages, and 1.5 hours in mock interview. The faculty-facilitated sessions were primarily casebased discussions that also included basic science objectives. The resident-facilitated sessions contained “survivor skills” identified by residents as common areas essential for an intern to be familiar with and know how to manage. Some examples of survivor skill sessions included care of patients with fever, pain, anxiety, hypotension, hypertension, or electrolyte imbalance. The cadaver dissection sessions were derived from student specialty choice, e.g., general surgery applicants performed the abdominal dissection, whereas otolaryngology students performed the head and neck dissection. The students were required to present their dissection to the course participants while a faculty member guided the presentation using common patient case scenarios. To provide a comprehensive learning experience, all of the students participating in the course were required to be present at all of the dissection presentations. The skills laboratory portion of the course was adapted from the established surgical intern skills laboratory curriculum. In the skills laboratory, faculty instructed the students in the art of knot tying, tissue handling and dissection, arterial and venous catheterization, surgical biopsy, chest tube placement and thoracentesis, laparotomy, gastrointestinal anastomosis, and 3 laparoscopic skills sessions. Participants were also given the opportunity to participate in the daily trauma team ICU rounds. Students had no assigned patient responsibilities, but they were expected to fully participate in rounding by asking and answering questions regarding the complex management of this patient population with particular emphasis regarding hemodynamic and ventilator management. The standardized patient clinic experience was designed to give students an opportunity to practice and receive feedback regarding clinic dictation (i.e., history and physical, referral letter), writing prescriptions, obtaining informed consent, and conducting preoperative patient management. The standardized patients provided feedback on the students’ patient interaction skills using a patient satis-
faction checklist. The clinic experience concluded with a faculty-directed discussion regarding appropriate preoperative management and requirements for informed consent. The dictations were transcribed, and formal written feedback was provided. The students were given an opportunity to prepare for residency interviews by participating in mock interviews. The objective of this session was to give the students skills that would improve their interviewing aptitude. The faculty conducted interviews with each student and gave immediate feedback. The final portion of the curriculum was a series of mock pages [9]. This was designed to prepare the students to answer complex questions about patient care, thus simulating the on-call experience of an intern. A multidisciplinary team developed 15 distinct clinical scenarios believed to be the most common and/or critical patient situations encountered by interns (e.g., nausea and vomiting, pain, hypotension, chest pain, hypokalemia, etc.). The students received random pages throughout each day by the department of surgery nurse instructors. In addition, students were “oncall” at least 1 night/wk. These pages consisted of a clinical scenario that required the student to ask pertinent questions, to appropriately assess the problem, and to provide a management plan in the form of verbal orders. At the completion of the mock page experience, the nurse instructors provided verbal feedback regarding the assessment and the management plan. Students completed an evaluation of each curricular element as the course progressed. These evaluations consisted of a simplified 3-point rating scale (i.e., extremely valuable ⫽ 3, valuable ⫽ 2, and low value ⫽ 1) that described the value and quality of the information, presentation style, and activity. Students were also asked to comment on which experiences they found most valuable and to explicitly offer any suggestions that would help improve aspects of each week’s activities. The results of the surveys were computed for a mean score and then ranked in order of perceived value. Additionally, the students took a 50-question knowledge pretest and post-test, the scores of which were compared with the performance of 8 surgical interns taking the same examinations. The faculty developed 3 to 4 case-based multiple-choice questions based on the content of each session. Questions were then randomly selected and included either in the pretest or the post-test. The results of the pretest and post-test for the fourth-year students and interns were averaged, and independent sample Student t tests were performed to determine any significant differences between groups; P ⬍0.05 was considered statistically significant.
Results Twelve medical students interested in pursuing surgical residency participated in this 4-week elective course. A total
M.L. Boehler et al. / The American Journal of Surgery 187 (2004) 695– 697
Fig. 1. Curriculum evaluation.
of 200.5 hours of faculty time, including 72 hours of nurse instructor time, was required to develop and deliver this 4-week senior elective course. Including the cost of written material, cadavers, skills laboratory sessions, and clerical time, the course cost approximately $1324. The highest rated elements of the course were the laboratory skills experiences, the resident-facilitated “survival skills” sessions, the mock interviews, and the program of simulated pages. The lowest rated element was the ICU rounds (Fig. 1). We related the lack of active student participation and/or any specific patient responsibility to the lack of success of the ICU rounds. Overall, written comments from the students were in general very positive and also reflected the extremely favorable verbal feedback faculty received both during and after completion of the course. The students’ knowledge examination pretest scores ( x ⫽ 68, SD ⫽ 9.43) and those of the interns ( x ⫽ 71, SD ⫽ 9.74) were very similar. The posttest scores for the senior students ( x ⫽ 83, SD ⫽ 5.98) were significantly improved and had much less variance. The mean posttest knowledge examination score was significantly higher than the mean pretest score (t ⫽ 3.89, P ⫽ 0.005) and the mean surgical intern score (t ⫽ 2.64, P ⫽ 0.038).
Comments A 1-month senior medical student elective course can provide students with the essential prerequisites believed to be essential for all surgical interns. It was possible to develop and administer this course using existing resources and required a minimal financial investment from the Department of Surgery. The students rated activities as most valuable when they were given the opportunity for hands-on skills acquisition or
697
they were perceived as practical knowledge such as mock paging and resident survivor skills sessions. In contrast, we believed that the ICU rounds were rated as the lowest valued activity due to the lack of opportunity for active participation because students were not given any actual patient responsibility and acted simply as observers. Because the value of critical care exposure to the curriculum is well established in the literature [11], we plan to enhance this segment of the course by directly involving students in the care of critical patients. The most frequently voiced complaint was that the timing of the course was not convenient for a number of students who had scheduled audition electives during the early fall. As a result, we will offer this course during the fall and spring of the next academic year. At the conclusion of this elective course, the students demonstrated more knowledge of these prerequisites than did a group of surgical interns. Longitudinal follow-up research is planned to determine the definitive effect on these students’ level of preparation for surgical residency. If this course is ultimately successful, interns will enter their residency programs more aptly prepared. In addition, the residency program should be able to more effectively and efficiently provide the crucial specialty-specific surgery education required for optimal patient outcomes.
References [1] Barone JE. Problems with the fourth-year curriculum of students entering surgical residencies. Am J Surg 1995;169:334 –7. [2] Nakayama DK, Steiber A. Surgery interns’ experience with surgical procedures as medical students. Am J Surg 1990;159:341–3. [3] Sloan DA, Donnelly MB, Johnson SB, et al. Use of an Objective Structured Clinical Examination (OSCE) to measure improvement in clinical competence during the surgical internship. Surgery 1993;114: 343–50. [4] Langdale A, Schaad DS, Wipf J, et al. Preparing graduates for the first year of residency: are medical schools meeting the need? Acad Med 2003;78:39 – 44. [5] American College of Surgeons Graduate Medical Education Committee. Prerequisite objectives for graduate surgical education: a study of the Graduate Medical Education Committee American College of Surgeons. J Am Coll Surg 1998;186:50 – 62. [6] Vygotsky LS. Theories of Development–Concepts and Applications. Englewood Cliffs, NJ: Prentice Hall. 1992. [7] Knowles M. The Adult Learner. A Neglected Species. Houston, TX: Gulf Publishing; 1990. [8] Lawler FH, Scheid DC, Viviani NJ. The cost of medical dictation transcription at an academic family practice center. Arch Fam Med 1998;7:269 –72. [9] Marshall RL, Gorman PJ, Verne D, et al. Practical training for postgraduate year 1 surgery residents. Am J Surg 2000;179:194 – 6. [10] Qayumi AK, Cheifetz RE, Forward AD, et al. Teaching and evaluation of basic surgical techniques: the University of British Columbia experience. J Invest Surg 1999;12:341–50. [11] Buchman TG, Dellinger RP, Raphaely RC, Todres ID. Undergraduate education in critical care medicine. Crit Care Med 1992;20:1595– 1603.