Journal of Surgical Research 142, 287–294 (2007) doi:10.1016/j.jss.2007.03.034
A Surgical Skills Elective to Expose Preclinical Medical Students to Surgery Amanda Sammann, M.P.H.,* Frank Tendick, Ph.D.,†,1 Derek Ward, B.S.,* Harras Zaid, B.S.,* Patricia O’Sullivan, Ed.D.,* and Nancy Ascher, M.D., Ph.D.† *School of Medicine and †Department of Surgery, University of California, San Francisco, San Francisco, California Submitted for publication January 8, 2007
Background. Early introduction to surgical skills may serve several valuable purposes; medical students will acquire skills that will reduce their anxiety in approaching clerkships and improve the quality of patient care, and they will possibly become interested in surgery as a career. Materials and methods. We designed an elective called “OR assist” for first and second year medical students based on needs identified from the literature and third year students. The elective comprised three sessions for a total of 6 hours and included instruction in surgical skills and operating room etiquette. We surveyed the students before and after the experience and also surveyed a group of control students. We assessed confidence in surgical skills and OR etiquette and concerns about surgical lifestyle, environment, and enthusiasm. Results. Eight-six students participated and generally had some operating room experience. The 75 students with pre/post match data reported significant improvement in confidence in suturing, knots, and instrumentation (P < 0.001; effect sizes >1.0) and less concern about issues related to enthusiasm for surgery (P < 0.001; effect size ⴝ 0.5). The participants and controls did not differ at baseline except for identification of surgical instruments, which was higher for participants. After the experience, the participants were significantly more confident and had less concern about enthusiasm in surgery than the controls. Conclusions. An elective can be effective in improving students’ confidence and reducing their concerns
1
To whom correspondence and reprint requests should be addressed at Department of Surgery, University of California, San Francisco, 1600 Divisadero St., Rm. C-315, Box 1674 San Francisco, CA 94143-1674. E-mail:
[email protected].
about surgery as a career. This is a unique opportunity for early exposure to surgical role models. © 2007 Elsevier Inc. All rights reserved.
Key Words: medical student; surgical education; attitudes; surgical skills; suturing. INTRODUCTION
Nationally, providing medical students with a meaningful introduction to surgery is a significant challenge. Schools have integrated longitudinal clinical training into the first 2 years with emphasis on physical exam skills. However, medical students’ exposure to surgical skills is often limited to a surgical clerkship during the third year that varies greatly in the quality and quantity of the learning experience. While many surgical clerkships offer a brief skill training session prior to the start of the clerkship, the majority of surgical skill training traditionally occurs in the operating room as students learn to gown, scrub, tie, and suture by trial and error. Learning theory suggests that successful skill acquisition requires that the learner receive expert assistance and practice the skill repeatedly with regular reinforcement in a safe environment [1]. In contrast, learning that does occur in the operating room is dependent on students’ direct instructional contact with attendings, the quality of the house staff teaching, and the conduciveness of the operating room environment to teaching [2, 3]. The operating room is thus a suboptimal learning environment as it does not allow for sustained and reinforced practice and does not provide students with consistent, standardized teaching. Additionally, students may feel unprepared to participate in the operating room environment, as they often perceive themselves to be a burden to the surgical team [4]. Upon completion of the clerkship, these stu-
287
0022-4804/07 $32.00 © 2007 Elsevier Inc. All rights reserved.
288
JOURNAL OF SURGICAL RESEARCH: VOL. 142, NO. 2, OCTOBER 2007
dents desire more hours of instruction, believe they performed fewer procedures per week and think they received poor feedback compared with the opinion of the residents and attendings. This lack of preparation further compromises students’ educational experience because without formal instruction in procedural methods, students are less likely to accept an invitation to perform procedures and are therefore less involved in the operating theater [5]. Alarmingly, these concerns extend into surgical internship as interns believe they are ill-equipped to perform the skills necessary in residency [6]. Formal surgical skills training in tying, suturing, and instrument handling is also necessary to decrease the risk of accidents and improve patient care. Without sufficient training, medical students are more likely to harm themselves and others in the operating room environment where space is tight and stress is high. Patterson et al. found that an alarming 30% of medical students experienced at least one needlestick injury, with the majority of these needlesticks occurring in the operating room [7]. Skills training is also necessary to improve surgical outcomes and patient care. Studies have shown that procedures such as surgical knot tying have a lower failure rate after formal training [8]. In light of these realities, the 2004 American Surgical Association Blue Ribbon Committee Report on Surgical Education called for greater involvement by surgical departments in the teaching of undergraduate medical students [9]. The Committee called for an increased focus on education, particularly of preclinical medical students in their first and second year. The Committee also recognized the need for students to develop technical proficiency in surgical skills prior to encountering patients and recommended the use of surgical skills labs in preclinical education. Although the surgical education literature is becoming more robust, we have found no published reports on a surgical skills curriculum for preclinical medical students. There are studies that have shown surgical skills training to be successful in more advanced medical students and residents. Numerous skills electives have been developed to train third and fourth year medical students in preparation for residency. The skills laboratory experiences have been found to be the highest rated elements of the training [10]. The electives improve students’ surgical knowledge and skills, increase written and practical examination scores [11], and bolster student confidence prior to internship [6]. Early exposure can improve students’ attitudes toward surgery as a career. Interventions in the first and second year of medical school such as surgical panels [12] and surgical mentors [13, 14] improve medical students’ attitudes toward and interest in surgery. Exposure to surgical cases correlates with students’ in-
terests in surgery and selection of a career in surgery or the surgical subspecialties [15, 16]. The purpose of this article is to describe the creation and evaluation of the Operating Room Assist (“OR Assist”) elective developed and implemented by the University of California, San Francisco’s Department of Surgery for first and second year preclinical students. The goal of this elective is to teach medical students the fundamental skills and knowledge they need to feel comfortable in the operating room and to assist with surgical procedures. METHODS Curriculum Development To guide the development of the elective, we conducted a needs assessment of third year medical students to determine their subjective level of preparation and satisfaction with their OR experience during their surgical clerkship. Fifty-six students (1/3 of the class) completed self-report surveys at the end of the third year with responses rated on a five point Likert Scale. When asked whether they would have liked formal skills training prior to the clerkship, 84% believed it would have been helpful or very helpful to learn to scrub and gown correctly, 82% to maintain the sterile field, 86% to tie basic knots, 89% to perform basic sutures, and 75% to identify and appropriately handle surgical instruments. While 77% agreed or strongly agreed they felt comfortable in the OR, only 47% felt useful and 45% felt confident. Based on this survey, we set our first goal to teach basic skills to preclinical students. From one of the author’s (F.T.) experience teaching basic skills to surgery interns as director of the UCSF Surgical Skills Center, we based the knot tying and suturing instruction on the Ethicon Knot Tying Manual [17] and Sherris and Kern’s textbook [18], respectively. We have found these sources to be thorough in the topics covered and to possess high quality diagrams demonstrating the techniques. To determine other skills that would be valuable for students to know, a second-year medical student (A.S.) met with the surgery clerkship director and associate director and the chiefs of the services where students would be volunteering. Based on these discussions, three additional skills were added to the curriculum: skin stapling, electrosurgery (bovie) operation, and use of the laparoscopic camera. We also wanted to teach students the fundamental skills and knowledge they would need to assist in the operating room. To this end we enlisted a nursing educator who had previously developed educational material for use with residents to teach operating room etiquette including how to scrub, glove, gown, and maintain a sterile field.
Curriculum Implementation The planned curriculum included three 2-hour training sessions and a clinical experience. The 24 skills covered are given in Table 1. Sessions 1 and 3 provided surgical skills instruction. Session 2 covered operating room etiquette. The surgical skills sessions were held at the UCSF Surgical Skills Center where 6 to 8 students were arranged at each of six lab tables in the room. Fourteen surgical attendings, emeritus faculty, and residents provided instruction at each session. The 86 students were divided into two groups and accommodated in back-to-back sessions. Thus, we had a student-faculty ratio of 3:1 to ensure the optimum recommended by current research [19]. Each skills training session began with a 5 min introduction followed by knot tying, identification and handling of surgical instruments, and suturing. Lesson plans and course texts were provided at each table.
289
SAMMANN ET AL.: PRECLINICAL SURGICAL SKILLS ELECTIVE
TABLE 1 Objectives of the OR Assist Elective Objectives Session 1: Successfully demonstrate each of the following skills and proper handling of instruments Knot tying Two-handed square knot Surgeon’s knot Tying under tension Instrument handling/identification Hemostat Scalpel Needle driver Mayo scissors Suturing Running simple suture Interrupted simple suture Instrument tie Session 2: Demonstrate proper gloving and gowning technique and describe proper OR etiquette Scrub and gown correctly Maintain the sterile field Understand traffic patterns in the OR Session 3: Successfully demonstrate each of the following skills and proper handling of instruments Knot tying One-handed square knot Deep tie Instrument handling/identification Metzenbaum scissors Skin hooks Retractors Stapler and staple remover Suction Laparoscopic camera and cautery Suturing Vertical mattress suture Horizontal mattress suture Corner stitch Intracuticular suture
Time in curriculum
60 minutes
10 minutes
35 minutes
Instruments, knot tying boards, and copies of the texts were available for students to borrow for home review and practice. Several drop-in practice sessions were also held at which students were tutored by their peers. Session 2 focused on operating room etiquette and occurred in the evening at the ambulatory surgery center on campus. Again, to accommodate the large number of participants, students were divided into two groups of 43 each. For each group, two nursing educators provided 1 h of instruction on gowning and gloving. Students practiced these skills with their own sterile gowns and gloves. Students spent 30 min in the substerile section of the center where the nurse taught them to scrub using water-based and non-waterbased methods and students were able to practice the non-waterbased Triseptin method. For the last 30 min students went into the operating room where a nurse instructed them about traffic patterns and appropriate operating room conduct. The ultimate goal of the elective was to provide opportunities for preclinical students to assist in the operating room. Although we were partially successful, there were logistical difficulties that will be described in the Discussion section.
Evaluation
60 minutes 30 minutes 30 minutes
30 minutes
10 minutes
The study design is shown in Fig. 1. The intervention group of OR Assist participants were pre- (Observation 1; O1) and post-tested (Observation 2; O2). For comparison, a volunteer group of nonparticipant preclinical students provided data after the elective ended (Observation 3; O3). Quantitative data were gathered by self report surveys. The surveys included demographic data, information on previous experience, confidence in skills that were taught in the elective and concern over performance, clerkships, and surgical careers. Studies were performed with the approval of the UCSF institutional review board. The surveys rated student confidence in each of the skills listed in Table 1. Students rated their confidence on a five-point Likert scale
TABLE 2 Budget and Personnel 20 minutes 45 minutes
Materials included colored ropes and several sizes of silk ties for knot tying and 3-0 nylon and absorbable sutures for suturing. At the first session, foam suturing pads (Limbs and Things, Savannah, GA) were the suturing medium; pig feet were used at the second. Pig liver was the medium for practice with the bovie cautery. The total budget was $2750 for these materials as outlined in Table 2. We reduced the actual cost, however, by obtaining suture donations from the manufacturer and expired suture from the hospital. Development and execution of the elective required a total of 440 person-hours. The execution of the elective required a total of 104 h of faculty and resident teaching time. Surgical faculty contributed an additional 16 h in curriculum development meetings. The second year medical student (A.S.) contributed about 200 h over the course of 4 mo assisting with the development of the curriculum, completing elective paperwork, procuring supplies, organizing students, and recruiting residents and faculty for the training. An additional 40 person-hours were contributed by other first and second year student volunteers. The skills center director (F.T.) oversaw the process.
Supplies Item Suture Pig feet Pig liver Foam suture pads (Limbs & Things) Sterile gowns Sterile gloves Antiseptic hand soap
Quantity
Cost/Item
Total
$2.50 $1
$1800 $90 $10
$38 $3.50 $1
$305 $315 $180 $50 $2750
720 90
8 doz 90 180 pairs
Total: Person-hours
Person
Number
Hours/week
No. of weeks
Total
Consulting faculty Teaching faculty Teaching residents Skills center director Medical student organizer Student volunteers
4 7 6 1
2h 4h 4h 5h
2 wk 2 wk 2 wk 16 wk
16 h 56 h 48 h 80 h
1 5
10–15 h 4
16 wk 2 wk Total:
200 h 40 h 440 h
290
JOURNAL OF SURGICAL RESEARCH: VOL. 142, NO. 2, OCTOBER 2007
FIG. 1.
Design of the evaluation study.
of (1) “Very Unconfident” to (5) “Very Confident.” We conducted a principal components factor analysis of the skills in which all of the variance of the items is analyzed to form a few coherent subsets, or factors, of items that are highly correlated with each other, but the factors are relatively independent of each other [20]. Laparoscopic camera did not fit into the factor structure and so was not included in the score. The first factor included all knots and sutures except for running and interrupted simple suture. For ease of explanation, we included these two sutures into the first score called “knots and sutures.” The second factor grouped the seven instruments so this formed the second score called “instrument identification and handling.” The third factor included the interrupted and running sutures and cautery. We included instrument tie in this score since these skills are considered basic ones that a student would do in an operating theater. We called this factor “basic skills.” The last factor comprised three items that grouped together were called “OR Etiquette.” The domains of student concern were derived from research by Pettitt [21] and included: fatigue/long hours; mental abuse; poor performance; physical hardship; lifestyle/family; finding joy in surgery (“Will I like surgery?”); enthusiasm; and personal safety. These eight concern domains were rated on a five-point Likert scale of (1) “Very Unconcerned” to (5) “Very Concerned.” We conducted a principal components factor analysis for the concerns items. We generated three factors called concerns about environment (concern about fatigue, pimping, and safety), lifestyle (physical hardship and family/lifestyle), and joy and enthusiasm toward surgery (concerns about finding joy in surgery, demonstrating enthusiasm, performing poorly). In this case, a higher score (scaled from 1 to 5) means that the students had concern about that aspect of surgery. We calculated descriptive statistics for the items on the survey including percents, means, and standard deviations. We used paired t-tests to compare performance pre to post for those students participating in OR Assist. We also used independent t-test to compare the nonparticipants’ scores both to the pre and post measures. We hypothesized the following: ● Participants would significantly gain in confidence and decrease in concern. ● Participants would have pre confidence and concern scores that did not differ significantly from nonparticipants’ scores. ● Participants’ post measures would be significantly higher for confidence and lower for concern compared with nonparticipants’ scores. Supporting these hypotheses would support that OR Assist was an effective program. We also calculated effect sizes to determine the magnitude of the program’s effect [22].
While completing the post-training survey, students were also asked to respond to two open ended questions: “How could we have improved this training?” and “Do you have any additional comments?” These written, qualitative responses were entered into an Excel database and reviewed independently by two researchers to identify general themes. The qualitative data were then coded and organized within these themes and simple frequencies were calculated.
RESULTS
Eighty-six first and second year medical students (out of 280 eligible) participated in OR assist. We could match pre and post data for 75 students. Of these participants, 61% were first year students and 39% were second years. Fifty-five percent were female and 45% were male. Forty-two percent were white, 39% were Asian, 9% were Hispanic, 5% were African American, and 5% were Native American or Other. Some (5.8%) students stated that it was very likely that they would choose a career in surgery and 8% stated that it was very likely that they would choose a surgical subspecialty. Among the participating students, 16% had never been in the operating room before. Thirty-five percent had been in the OR once or twice, 15% had been in three times and 30% had been in the OR four or more times. Forty-two percent had never scrubbed and gowned. Sixty-four percent of students had never practiced suturing, 22% had practiced once, 14% two or more times. Eighty-three percent of students had never practiced knot tying, 9% had practiced once, and 8% more than once. When comparing the participants to the nonparticipants, we found that the participants were more likely to have OR experience and a greater interest in surgery or surgical subspecialty residency than our nonparticipants. However, the groups were comparable in their skills (Table 3). Table 4 shows the results of testing the first hypothesis that participants would significantly gain in confidence and decrease in concern. Students participating in OR assist improved significantly in confidence in their skills and operating room knowledge and their concerns about having joy and enthusiasm in surgery. The exposure did not change their concerns about the environment or lifestyle in surgery. Likelihood of choosing a career in surgery or a subspecialty also did not change significantly. The effect sizes support that OR assist had a large effect on confidence and a modest effect on decreasing concern about the joy and enthusiasm in surgery. To show that our participants did not differ from nonparticipants, we tested the second hypothesis that
291
SAMMANN ET AL.: PRECLINICAL SURGICAL SKILLS ELECTIVE
TABLE 3
DISCUSSION
Comparison of OR Assist Participants and Nonparticipants
Challenges and Successes
MS1 Male Caucasian Have you been in the OR Have you scrubbed and gowned Have you practiced suturing Have you practiced knot tying Have you operated a laparoscopic camera How likely is it that you will enroll in a general surgery residency? (mean on scale of 1 to 5) How likely is it that you will enroll in a surgical subspecialty residency? (mean on scale of 1 to 5)
Cases
%
P-value
Participants Nonparticipants Participants Nonparticipants Participants Nonparticipants Participants Nonparticipants Participants Nonparticipants Participants Nonparticipants Participants Nonparticipants Participants Nonparticipants Participants Nonparticipants
60.5 100.0 45.3 28.0 41.9 59.6 83.7 61.5 58.1 42.3 36.0 23.1 17.4 17.3 1.2 3.8 3.10 2.00
0.001
Participants Nonparticipants
3.15 2.10
0.001
0.045 0.051 0.003 0.071 0.111 0.984 0.295 0.001
participants’ would have pre confidence and concern scores that did not differ significantly from nonparticipants’ scores. The data for this hypothesis is shown in Table 5 in the O1 to O3 comparison columns. The two groups were not different from each other except for one variable. The OR Assist participants reported greater confidence in their knowledge of surgical instruments. Overall, the controls appear comparable to the participants. We then compared the participants’ post scores with the nonparticipants’ scores (the third hypothesis). These results are in Table 5 in the O2 to O3 comparison. We found that OR Assist had led to significantly greater confidence when compared with nonparticipants, but reduced concerns only for the joy and enthusiasm factor. Of the 86 students who participated in the elective, 54 participants (63%) opted to contribute qualitative feedback. Improvement themes related to course length, teaching organization, and review materials/ tools. Fifty-two percent of students wanted a longer training course. Forty-three percent wanted better organization and standardization of the teaching: “Standardizing the material taught by the different surgeons would be nice because some people learned a lot more than others . . .” Thirty percent wanted additional review materials and tools for practice: “Give us the syllabus/knot tying module before our first training session.” The theme of additional comments related to the close interaction with surgical faculty (31%): “Fantastic that so many surgeons were available to help.”
Even for an established surgical skills laboratory, organizing a preclinical elective can involve challenges that are not encountered with residents or clerkship students. The first major challenge was the large number of students enrolled: 86 students, or 30% of the first-and second year classes, wanted to participate. We had to plan and budget well ahead to ensure that we had sufficient supplies, including suture, gloves, gowns, and suturing pads. Arrangements were made with a local butcher to have sufficient pig feet and liver available for suturing and electrosurgery. We applied to the campus medical student association for funding so that the department of surgery would not bear the full cost of supplies. Six medical students in the UCSF Surgery Interest Group assisted with organization. Even after dividing the students into two groups, providing space, instruments, and faculty for 43 students at a time was a challenge. We collected used disposable instruments from the sterile processing department to stretch our stock of instruments. Tying boards were donated by several industry sources. To have sufficient instructors, we recruited both current and emeritus faculty plus research residents. A second major challenge was to efficiently train the students so that they would be useful and confident in TABLE 4 Pre/Post Measures for Students Participating in OR Assist
Confidence Knots and sutures Pre Post Instrument identification and handling Pre Post Basic skills Pre Post OR etiquette Pre Post Concerns Environment Pre Post Joy/enthusiasm Pre Post Lifestyle Pre Post
Effect size P-value
Mean
N
Std. dev.
1.35 3.18
74 74
0.54 0.62
2.84
0.001
2.40 3.78
74 74
1.02 0.85
1.46
0.001
1.47 3.50
74 74
0.74 0.72
2.72
0.001
2.70 3.59
73 73
0.96 0.73
1.07
0.001
3.46 3.38
75 75
0.80 0.74
⫺0.11
0.334
3.60 3.22
75 75
0.82 0.73
⫺0.51
0.001
3.83 3.80
75 75
0.74 0.67
⫺0.04
0.732
292
JOURNAL OF SURGICAL RESEARCH: VOL. 142, NO. 2, OCTOBER 2007
TABLE 5 Comparisons of OR Assist Participants to Control Scores (See Figure 1) Comparison Scores Confidence Knots and suturing Participants Nonparticipants Instrument identification and handling Participants Nonparticipants Basic skills Participants Nonparticipants OR Etiquette Participants Nonparticipants Concerns Environment Participants Nonparticipants Joy/enthusiasm Participants Nonparticipants Lifestyle Participants Nonparticipants
O1 to O3
O2 to O3
N
Mean
Std. dev.
P-value
N
Mean
Std. dev
P-value
75 52
1.31 1.27
0.52 0.54
0.669
75 52
3.18 1.27
0.62 0.54
0.001
75 52
2.35 1.94
1.01 0.88
0.018
75 52
3.78 1.94
0.84 0.88
0.001
75 52
1.42 1.28
0.70 0.59
0.251
75 52
3.48 1.28
0.72 0.59
0.001
74 52
2.72 2.39
0.96 1.05
0.058
75 52
3.18 1.27
0.62 0.54
0.001
75 52
3.50 3.62
0.80 0.74
0.387
74 52
3.38 3.62
0.74 0.74
0.085
75 52
3.55 3.54
0.85 0.69
0.969
75 52
3.22 3.54
0.73 0.69
0.013
75 51
3.84 3.96
0.74 0.65
0.323
75 52
3.80 3.96
0.67 0.65
0.182
the OR. Our surveys of preclinical students found that most participants had no experience in suturing or tying knots. The curriculum covered the basic surgical skills that are essential for the surgery clerkship, as suggested by the survey of third year students and faculty feedback. Furthermore, these skills not only have applicability in the surgery environment, but also in many other fields of medicine. Basic instrument handling and suturing are important skills that benefit many nonsurgical practitioners. The elective was very successful in improving students’ confidence, with surveys showing increased confidence in all of the skills taught and reduced concern about performing poorly in the OR. We had also hoped to evaluate the students’ newly acquired skills in the skills laboratory and the OR environment; however, time constraints made this goal challenging. Changes that will be made to ameliorate this shortcoming are described in the Improvements section below. A third challenge was to improve students’ attitudes toward and interest in surgery. Although we did not find a significant change in the likelihood of participants to pursue a residency in surgery, or in their concerns about the hardships of the clerkship and lifestyle, there were clearly positive changes in attitudes about surgery. Participants were more likely to demonstrate enthusiasm and find joy in surgery after the elective. An important benefit of this elective was the positive interactions many students had with the surgeon teachers, as illustrated by the enthusiastic com-
ments students provided in their surveys. These early experiences and mentorship opportunities have been shown to positively influence many students’ decisions to eventually select a career in a surgical field [11, 13]. Lastly, it is important to address the limitations of the study. We were unable to randomly assign participants and we acknowledge that our participants were likely students more interested in surgery and with a knowledge advantage concerning surgical tools. However, given the magnitude of the effect sizes we found and the similarity between the participants and nonparticipants on most measures, we would anticipate that the findings would be replicated in a study with random assignment. Improvements
There are several significant changes planned for the 2007 offering of the elective to address the challenges and shortcomings listed above. Primarily, the elective will be divided in two and held during consecutive quarters. The new electives are titled “OR Assist: Skills Training” and “OR Assist: Clinical Experience.” Several changes will be made to the skills training based on participants’ feedback. Students wanted more training time, better standardization, and more review materials. We are expanding the skills training from 4 to 6 h plus an optional 2 h session for basic laparoscopic skills and additional review. We are creating an online manual with videos and still shots of each of the skills.
SAMMANN ET AL.: PRECLINICAL SURGICAL SKILLS ELECTIVE
Practice is also facilitated with drop-in practice sessions led by second-year students. To improve standardization, a detailed syllabus will be provided at each table and instructors will be directed to follow the diagrams and teaching methods listed in the suturing and knot tying texts. Students who completed the elective the previous year will serve as teaching assistants to address the increased demand on faculty time. They will be matched with surgical faculty to continue to provide a 3:1 student-faculty ratio and to help standardize teaching. The most significant change to the program is to offer the additional “OR Assist: Clinical Experience” elective. The ultimate goal of the original elective was to provide opportunities for preclinical students to assist in the operating room. However, logistical challenges prevented many students from gaining this experience. Initially, students signed up via an online calendar for nightly shifts to be on call with one of several surgery teams at UCSF affiliated hospitals. Unfortunately, due to a number of factors, including staff failure to page students, paucity of available night cases, or no need for additional student assistance, this pager system did not work well. We changed the program so that the student would liaise with the charge nurse on his or her assigned night in an attempt to scrub into whatever surgery was available. While this approach worked better, it still failed to give students significant clinical experience due to limited demand and a lack of overall communication between parties. The lack of consistency also made it difficult to obtain the attending and resident surgeons’ evaluation of students’ technical skills. Clinical exposure is fundamental to improving students’ knowledge of surgery and confidence in their skills. In the coming year, students will enroll in the separate “OR Assist: Clinical Experience” elective. Students will be paired with a volunteer surgical mentor whom they will assist in a minimum of four scheduled procedures. This mentorship system will eliminate scheduling challenges and facilitate more consistent and directed feedback. It will also allow for a more informed assessment of students’ skills upon completion of the elective. To ensure that students’ skills are sufficient prior to assisting in the OR, we will require that all students demonstrate competence in tying and suturing skills before they can sign up for the clinical experience. To establish criteria for competence, we videotaped 35 participants from this year’s elective as they performed simple sutures and two-handed ties. Simultaneously, we tracked their motions using an electromagnetic tracking system similar to Datta et al. [23]. We are analyzing these data using a variety of methods with the goal of determining which measures can reliably predict competence as gauged by faculty raters. How-
293
ever, the measures must be automated or able to be performed reliably by trained student raters because it will be impractical to have faculty individually score so many participants. OR Assist is an important component of our efforts to provide longitudinal skills exposure throughout medical school and to study the effects of the exposure. This year, we also introduced instrument identification and suturing training within the required anatomy laboratory for first-year students. We now have extensive data on the confidence and concerns of first through third year students and are continuing to track all groups as they progress through medical school to see how students’ attitudes change with increased opportunities to learn and practice essential surgical skills. We are also tracking needlestick incidents to study whether increased skills training will lead to improved safety and fewer incidents. CONCLUSION
Medical educators have recently focused growing concern on the lack of preclinical surgical education in American medical schools. Here, we have described a successful intervention to address this important gap in training. The OR Assist elective for first and second year medical students at UCSF provided an opportunity for early exposure to and acquisition of important surgical skills. Ideally, this intervention will benefit students on the wards, increasing their confidence and competence as they begin to interact with surgeon teachers and patients. OR Assist may potentially serve as a model for other schools seeking to enhance surgical education in their curricula. ACKNOWLEDGMENTS The authors are grateful to Sheila Greeley, RN and Drs. John Maa, Andre Campbell, and Mary McGrath for their help in designing the curriculum; they acknowledge students Tina Kao, Jasmine Lai, Justin Tan, Sam Truong, and Doug White for help with organization; they thank Debbie Wolfe of Syneture for contributing suture.
REFERENCES 1. 2.
3.
4.
5.
Kneebone R. Evaluating clinical simulations for learning procedural skills: A theory-based approach. Acad Med 2005;80:549. Redlich PN, Milkowski T, Bragg D, et al. Multiple variables influence the educational value of surgical clerkship sites. Am J Surg 2006;191:178. Schwind CJ, Boehler ML, Rogers DA, et al. Variables influencing medical student learning in the operating room. Am J Surg 2004;187:198. De SK, Henke PK, Ailawandi G, et al. Attending house officer and medical student perceptions about teaching in the thirdyear medical school general surgery clerkship. J Am Coll Surg 2004;199:932. McMahon DJ, Chen S, MacLellan DG. Formal teaching of basic surgical skills. Aust NZ J Surg 1995;65:607.
294 6.
7.
8. 9.
10.
11.
12.
13.
14.
JOURNAL OF SURGICAL RESEARCH: VOL. 142, NO. 2, OCTOBER 2007 Peyre SE, Peyre CG, Sullivan ME, et al. A surgical skills elective can improve student confidence prior to internship. J Surg Res 2006;133:11. Patterson JM, Novak CB, Mackinnon SE, et al. Needlestick injuries among medical students. Am J Infect Control 2003;31: 226. Ind TE, Shelton JC, Shepherd JH. Influence of training on reliability of surgical knots. BJOG 2001;108:1013. Debas HT, Bass BL, Brennan MF, et al. American surgical association blue ribbon committee report on surgical education: 2004. Ann Surg 2005;241:1. Boehler ML, Rogers DA, Schwind CJ, et al. A senior elective designed to prepare medical students for surgical residency. Am J Surg 2004;187:695. Vogelgesang SA, Karplus TM, Kreiter CD. An instructional program to facilitate teaching joint/soft-tissue injection and aspiration. J Gen Intern Med 2002;17:441. 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. 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. Erzurum VZ, Obermeyer RJ, Fecher A, et al. What influences medical students’ choice of surgical careers. Surgery 2000;128: 253.
15.
O’Herrin JK, Lewis BJ, Rikkers LF, et al. Why do students choose careers in surgery? J Surg Res 2004;119:124.
16.
O’Herrin JK, Lewis BJ, Rikkers LF, et al. Medical student operative experience correlates with a match to a categorical surgical program. Am J Surg 2003;186:125.
17.
Ethicon Inc. Knot Tying Manual. Available at: http:// www.jnjgateway.com/public/USENG/Knot_Tying_Manual.pdf. 2005.
18.
Sherris DA, Kern EB. Essential Surgical Skills, 2nd ed. Philadelphia, PA: Saunders, 2004.
19.
Dubrowski A, MacRae H. Randomized, controlled study investigating the optimal instructor:student ratios for teaching suturing skills. Med Educ 2006;40:59.
20.
Tabachnick BG, Fidell LS. Principal components and factor analysis. In: Using multivariate statistics, 3rd ed. New York: Harper Collins College Publishers, 1996;635.
21.
Pettitt BJ. Medical student concerns and fears before their third-year surgical clerkship. Am J Surg 2004;189:492.
22.
Hojat M, Xu G. A visitor’s guide to effect sizes. Adv Health Sci Educ Theory Pract 2004;9241.
23.
Datta V, Mackay S, Mandalia M, et al. The use of electromagnetic motion tracking analysis to objectively measure open surgical skill in the laboratory-based model. J Am Coll Surg 2001;193:479.