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Attending, house officer, and medical student perceptions about teaching in the third-year medical school general surgery clerkship
EDUCATION
Attending, House Officer, and Medical Student Perceptions about Teaching in the Third-Year Medical School General Surgery Clerkship Sumit K De, MD, Peter K Henke, MD, FACS, Gorav Ailawadi, MD, Justin B Dimick, MD, Lisa M Colletti, MD, FACS There has been declining interest in surgery among medical students and one reason might be the third-year clerkship experience. The aim of this study was to clarify the perceptions and expectations of attendings, residents, and medical students on the clerkship experience. STUDY DESIGN: A survey was distributed to all general surgery attendings, the entire general surgery house staff, and an entire third year medical school class inclusive of the 2001–2002 academic year at a single institution. Statistic analysis consisted of chi-square and Kruskal-Wallis-ANOVA on ranks with Dunn’s test for multiple comparisons. A p ⬍ 0.05 was significant. RESULTS: Responses were obtained from 59 attending surgeons (50%), 38 surgical residents (32%), and 107 medical students (66%). Of this student cohort, 35% were planning to choose a surgical specialty as a career. Agreement was high among faculty, students, and residents about factors considered important in evaluation, expectations of skills, and level of skills needed before the clerkship. Medical students desired more hours of instruction, believed they performed fewer procedures per week, and thought that feedback was poor compared with the opinions of faculty and residents (p ⬍ 0.002). Nearly 50% of medical students believed they were an inconvenience to the service; 30% of house officers and 27% of faculty (p ⬍ 0.001) believed this also. Almost all faculty and residents, however, wanted medical students on the service (⬎ 95%). Faculty believed residents did a better job teaching than either the students or residents themselves did (p ⬍ 0.001), and students thought that residents were the primary source of education in patient care. CONCLUSIONS: Considerable differences exist between faculty, surgical resident, and medical student perceptions and expectations of medical student education. Structured direct faculty contact, definition of medical student roles on the surgical team, and more consistent feedback can be rapidly improved. (J Am Coll Surg 2004;199:932–942. © 2004 by the American College of Surgeons) BACKGROUND:
A considerable decline in student interest in general surgery, but not surgical subspecialties, has occurred over the last several years.1 The reasons cited for this include lifestyle, clerkship experience, quality of mentorship, and training obligations.2-4 This could change with the new 80-hour work restrictions, but the quality of students choosing surgery might not be as high.5 A medical student’s first impression of surgery is often from the third-year clerkship experience and is frequently the only opportunity surgeons have to show medical stu-
dents the excitement and commitment that come with a surgical career.6 For medical students, a negative thirdyear educational experience may affect their decisions about whether or not to pursue a career in surgery. Contrary to many medical school third-year clerkships, the time that general surgery attendings spend directly with students is limited by operative and research responsibilities. Variable amounts of teaching occur in the operating room, depending on circumstances. Much of the onus of teaching medical students the fundamentals of managing a pre- and postoperative general surgery patient, as a result, falls on the residents, particularly with ward care.7-9 But attendings do the final evaluations of medical students, just as in other rotations. Attendings are in a position, of having to evaluate med-
Received July 7, 2004; Revised August 11, 2004; Accepted August 12, 2004. From the Department of Surgery, University of Michigan Medical Center, Ann Arbor, MI. Correspondence address: Peter K Henke, MD, 1500 East Medical Center Dr, Room 2210 Taubman Health Care Center, Ann Arbor, MI 48109-0329.
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ical students after only limited exposure, and residents may be inexperienced teachers. In addition, the tools available for judging medical students vary from attending to attending.10 Although many studies about medical student education during third-year required clerkships exist, few have dealt specifically with the general surgery clerkship11 or compared the views of medical students with their general surgery educators. We sought to better understand how each group involved in medical student education—the attendings, the house staff, and the students themselves—perceived not only their own responsibilities but each others’ in educating medical students about fundamentals of general surgery. METHODS A paper survey (Appendices A, B, C) was distributed to all Department of Surgery faculty members at the University of Michigan Medical Center; 59 (50%) responded. All members of the general surgery house staff were solicited by mail for this study, and 38 (32%) returned completed surveys. Three weeks before completion of their third year of medical school, 162 medical students received a copy of the survey. Of these, 107 (66%) were returned. The same questions appeared on all surveys except for a change in wording to correctly address the responders, questions about training level, plans for a career in surgery, and regularity of feedback. Questions in the surveys offered objective answers (eg, true/false, multiple choice, Likert scale [1–5, strongly disagree to strongly agree], and choice rank). The last two questions in each survey were subjective and open-ended, required write-in answers, and were used for internal purposes and are not reported in this article. The University of Michigan Institutional Review Board approved this study. Statistical analysis consisted of Kuskal-Wallis ANOVA on ranks with Dunn’s corrections for multiple comparisons. Categoric variables were assessed with chisquare analysis. Sigmastat 2.0 was used for all statistic analyses. RESULTS Views on surgical education time requirements
Comparison among faculty, residents, and medical students revealed different perceptions about the medical
Figure 1. (A) Desired number of instructional hours per week. Students desired significantly more hours per week of formal instruction than residents and faculty thought necessary (*p ⬍ 0.001). Median response with 25th to 75th percentile shown. (B) Procedural opportunities for students per week. Residents believed more opportunities were available for technical procedures than faculty or students (*p ⫽ 0.021).
students’ educational expectations in the surgical clerkship. There was no difference in the perception of number of instructional hours medical students received per week, with most faculty, residents, and students believing that they received 1 to 2 structured hours per week. But there was a notable difference about the number of instructional hours medical students desired, as compared with what faculty and residents believed were needed. Most medical students wanted 3 to 4 hours per week, and faculty and residents thought that 2 to 3 hours per week were sufficient (p ⬍ 0.001; Fig. 1A). There was a considerable difference in the number of hours believed necessary off service for studying; most faculty believed 6 to 10 hours per week were spent studying, and
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Table 1. Rank of Factors in Student Evaluation Rank
Faculty
Residents
Students
1 2 3 4
Questions posed to student Questions asked by student Performance in clinic Patient presentations
Knowledge of patient Questions asked by student Patient presentations Questions posed to students
Questions posed to student Questions asked by student Performance in clinic Questions asked by student
residents and students, on average, felt 11 to 20 hours per week were required (p ⫽ 0.005). Medical students viewed the number of opportunities per week to practice procedural skills to be significantly less than faculty or residents (median, 0 to 2 versus 3 to 4 procedures/week; p ⫽ 0.021) (Fig. 1B). There was marked agreement as to whom medical students should direct pre- and postoperative questions, with the majority stating that interns were the most readily available source of information. Views on medical student evaluation and team roles
Faculty were most likely to evaluate medical students by four modes; questions posed to the student, questions asked by the student, performance in clinic, and patient presentations (all ⬎ 50% of faculty responses) (Table 1). Residents tended to place more emphasis on student knowledge of the patient, followed by questions asked by the student and patient presentations. Residents were less likely to believe questions posed to the students were important for evaluation of student performance. Medical students were most likely to believe that questions posed to them were the most readily used tools to assess their progress, followed by questions asked by them or performance in clinic (all ⬎ 70% of respondents). Most students believed that writing patient orders and SOAP (subjective, objective, assessment, and plans) notes and removing staples and sutures were expected of them before their clerkship. But, more than 75% of residents and attendings thought that writing SOAP notes was all that was expected of students before they started their clerkship. Although a primary mission of a medical school is student teaching, medical students were viewed by 27% of faculty as an inconvenience to the surgical service. This percentage was slightly higher for residents, of whom 32% thought students were an inconvenience to the service. Most striking was that 51% of medical students believed themselves to be an inconvenience to the service, significantly greater than faculty and resident responses (p ⬍ 0.001). In contrast, 98% of faculty and
95% of residents stated that if offered, they would want a medical student on their team. Seventeen percent of students believed they were not wanted on the team, significantly more than faculty and residents (p ⫽ 0.007). Most faculty (84%) and residents (78%) viewed students who volunteered to stay alongside their intern or resident as a positive factor in their evaluation. Similarly, 73% of students believed this was an advantage to their evaluation. In this student cohort, 35% were planning to pursue a surgical residency in general surgery or a surgical subspecialty field. Views on faculty and house officer teaching
In response to views on ward team dynamics and how faculty mentor students, attending surgeons had a bimodal distribution; approximately 30% disagreed that attending surgeons do a good job in educating medical students, and 46% agreed. This bimodel distribution was echoed by residents and students, with no notable difference in median response. But when considering surgical resident teaching performance, most faculty thought that surgical residents did a better job of teaching than did the surgical residents themselves or medical students (p ⬍ 0.001) (Fig. 2A). In contrast, most faculty, residents, and students agreed that interns did a good job of teaching on the wards (p ⫽ NS). Similarly, the majority of students, residents, and faculty somewhat agreed or agreed strongly with the statement, “Faculty and residents play a significant role in shaping the career paths of medical students.” Interestingly, most medical students somewhat or strongly agreed that they were a good source of information about patients that they follow, but the majority of residents and faculty neither agreed nor somewhat disagreed with this statement (p ⫽ ⬍ 0.001) (Fig. 2B). Almost all faculty and residents (⬎ 80%) believed that relying on medical students to answer patients’ postoperative questions was inappropriate. Medical students and residents both thought team dynamics are very important, but faculty were less likely to believe this (p ⫽ ⬍ 0.001). Assumptions about medical student responsibilities were more commonly agreed
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trast to students, who strongly disagreed with that statement (p ⫽ ⬍ 0.001) (Fig. 3B). Faculty believed that learning sterile technique, followed by ability to present patients and identify surgical problems were the three most important skills that a medical student should learn on a surgical clerkship (Table 2). This was echoed by residents. Medical students believed that sterile technique, identifying surgical problems, and identifying complications were most important, with the ability to present patients slightly less important. Students, residents, and faculty agreed about what the medical students’ role in the operating room should be; that is, primarily watching surgeons perform
Figure 2. (A) Responses to: “Residents do a good job teaching medical students.” Faculty members were more likely to believe that residents did a good job teaching medical students than residents or students (*p ⬍ 0.001). (B) Responses to: “Medical students are a good source of information about their patients.” Most medical students strongly agreed with this statement; faculty and residents were more likely to disagree (*p ⬍ 0.001). A, agree; D, disagree; N, neutral; SA, strongly agree; SD, strongly disagree.
on by students and residents than faculty, but the difference was not notable. Most faculty were less likely than residents to believe they had made a strong effort to instruct medical students on the important technical skills essential in a surgical clerkship, as compared with residents (p ⫽ ⬍ 0.001) (Fig. 3). The majority of residents and faculty were neutral about or somewhat agreed with the statement that consistent methods were used to evaluate students in the same manner between clerkship groups. Most residents and faculty were neutral about or disagreed somewhat that students receive sufficient feedback midway through their rotation, in con-
Figure 3. (A) Importance of teaching medical students techniques. More residents believed teaching technique during the clerkship was very important as compared with most faculty (*p ⬍ 0.001). (B) Responses to: “Always give (get) feedback to students.” Students strongly disagreed that consistent feedback of their performance was given, and their response was significantly different than faculty and resident responses (*p ⬍ 0.001). A, agree; D, disagree; N, neutral; SA, strongly agree; SD, strongly disagree.
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Table 2. Rank of Skills to Be Learned in Clerkship Rank
Faculty
Residents
Students
1 2 3 4
Sterile technique Ability to present patients Identifying surgical problems Proper history and physical
Sterile technique Identifying surgical problems Ability to present patients Basic surgery anatomy
Sterile technique Identifying surgical problems Identifying complications Ability to present patients
operations, asking and answering questions posed to and by the residents and attendings, and participating in the operations with the use of instruments and retraction. But all groups agreed that students played little integral role in the operations. DISCUSSION Based on these data, important perceptions of third-year medical student clerkships differ in what faculty and residents believe is the educational experience and what students desire. This is a conclusion that is not specific to general surgery.12 The perceived lack of willingness by surgical attendings to devote time to teaching has been commonly noted in medical schools throughout the nation.13,14 Medical students expect to be taught more through didactics and other means that require personal time by the attendings and house staff. A possible fallout from less attending exposure is the decline of the number of medical students opting to choose general surgery as a specialty.7,13 In fact, this phenomenon has spurred many surgeons to wonder what can be done to halt medical students’ exodus from surgery.11,15,16 On the other hand, many processes outside of the attendings’ control act to limit these interactions—namely, greater administrative and clinical responsibilities and research commitments. This is combined with the fact that many operations are performed in an outpatient setting, so hospital admissions are fewer and the time for students to preoperatively evaluate patients and follow them postoperatively is limited. It is also doubtful that surgical subspecialty education is substantially better than general surgery, though subspecialty experience is often done in the fourth clinical year, when students have usually settled on a career choice. The most concerning data we found was the belief by many students that they are not essential to the service and may not be wanted at all. Although there is truth to this in actual day-to-day care and from a medicolegal standpoint, medical students’ primary purpose on a general surgery clerkship is to learn. That is what they are paying for. Perhaps more disturbing is that 32% of the residents and 27% of the attendings also thought that medical students were
an inconvenience to the surgical team, which is contrary to the medical school’s mission. The negative perception was borne out even more stunningly when 17% of medical students responded that they thought the faculty and house staff would rather not even have them present on their teams at all. But almost no faculty or resident believed this. One solution to this perception is to better define the medical students’ role and give them specific ward tasks to complete. Medical students are adults, and it can be frustrating to feel like an interloper with no substantive role on a clinical service. Learning ward team dynamics and the fact that that medical student involvement is appreciated by most house officers was confirmed in this study. Good surgical care very much depends on the proper function of the team, and acclimating students to this culture is as important as learning the basic pathophysiology of disease. From these data, we concluded that faculty and house staff must do a better job in communicating with medical students what they should learn and they must make time for that effort. It seems that the paucity of encounters that attendings have with medical students may have negative repercussions and underlies poor mentorship.6,15 Although not addressed specifically in this study, the negative perceptions may be one factor that has contributed to the steadily falling numbers of US graduates pursuing general surgery as a career path.15,17 The limitation of this study is the lower survey response rate from the residents, as compared with the faculty and students. But the most improvement responses with regard to improving the clerkship experience are from the students. Most responses between faculty and residents were similar, with most disagreement between these groups and students. Another limitation is that this was done within only one class and this might have been a biased population. But the number of students pursuing surgery at the University of Michigan has slowly increased over the last several years, suggesting similarity of viewpoints and the department’s addition of a medical student facilitator, as measured by ultimate career choice. Similarly, this is a single institutional study and may not be representative of other medical schools.
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Many medical schools, including the University of Michigan, have changed their first 2 years of curriculum to better acclimate students to clinical medicine earlier in their career, with positive feedback. These data suggest some areas of third-year clinical surgical education that can be improved for enhancing student experience. Because most students will not ultimately choose a surgical career, it is foremost that certain basics be taught so patients who need surgical treatment can be appropriately identified and referred for care. Several areas of improvement can be easily implemented and have been highlighted by other educators.17,18 First, well-stated goals and expectations should be presented to each incoming group of rotating third-year
medical students, including certain tasks for which they are primarily responsible. Second, dedicated ward rounds by an attending and students (perhaps nonworking rounds where residents can be freed to perform daily duties) would improve face time, quality, and personal interactions (that convey bedside teaching). Third, emphasizing the team role of a surgical service to make the student integral makes one feel useful and enthusiastic. Students who encounter enthusiastic mentors are more likely to choose that specialty, and surgery lends itself well in this regard.15 Promoting these changes seems essential not only to maintain the supply of quality surgeons but also to make sure the fundamentals of surgery are taught to all students.
Appendix A Surgery Clerkship Survey for Faculty We are asking the faculty to share their thoughts about and experiences with medical students on their third-year surgical clerkships. Please be as honest as possible when filling out this survey, and remember that all responses are completely anonymous. 1) How many hours of individual/small group instruction per week do you give medical students on their surgical clerkship? 0–1 1–2 2–3 3–4 ⬎4 2) How many hours of individual/small group instruction per week do you think you ought to be giving medical students on their surgical clerkship? 0–1 1–2 2–3 3–4 ⬎4 3) How many hours do you think medical students should expect to spend studying when they are not on duty? 0–5 6–10 11–20 21–30 ⬎30 4) How many hours of educationally unproductive work do you think a medical student should expect per week? 0–2 3–4 5–6 7–8 ⬎8 5) How many opportunities per week do you think medical students usually get to practice their procedural skills (eg, putting in Foleys, draining abscesses, suturing)? 0–2 3–4 5–6 7–8 ⬎8 6) If medical students have questions about the pre- and post-operative care of their patients, who should they consult first? Attendings Residents Interns Nurses 7) Since it is often not plausible to spend enough time with medical students to find out how well they are advancing in their education, which of the following do you use most to evaluate a medical student? (You may check more than one.) Patient presentations SOAP Notes Questions asked by student Knowledge of patient H&P skills Questions posed to student Performance in clinic Other______ 8) Which of the following do you expect medical students to be able to perform without any supervision before to their clerkship? (You may check more than one.) Write patient orders Remove staples and sutures Write SOAP notes Simple procedural skills (eg, NG tubes, Foleys) Perform noncritical parts of the surgery in the operating room Monitor noncritical aspects of recovery 9) I find teaching medical students to be somewhat of an inconvenience to my day-to-day T F responsibilities. (Please be honest.) 10) If I had a choice, I would rather not have a medical student on my team. (Please be honest.) T F 11) Though medical students are often not required or expected to be present while on call T F with their interns or residents, I am more lenient in evaluating a medical student if in fact he/she volunteers to stay alongside his/her intern or resident while on call.
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strongly disagree
J Am Coll Surg
somewhat disagree
neither agree nor disagree
somewhat agree
strongly agree
NA
12) In general, attending surgeons do a good job in educating medical students. 13) In general, surgical residents do a good job in educating medical students. 14) In general, surgical interns do a good job in educating medical students. 15) I play an important role in shaping the career paths of medical students. 16) Medical students are a good source of information about the patients they follow. 17) I feel comfortable in relying on medical students to answer the patient’s postoperative questions. 18) Team dynamics is very important in the overall educational experience on the surgery clerkship. 19) Quite a bit is assumed about the responsibilities medical students are supposed to be able to undertake. 20) I make a strong effort to make sure that the medical student has learned the technical skills I deem essential for a medical student to have learned. 21) I am very consistent with the methods that I use to evaluate students (ie, use same questions, interact in the same manner). 22) I always give feedback to students midway though their rotation, even if unsolicited. 23) What skills do you think are absolutely necessary for a medical student (especially one not going into surgery) to have learned by the end of his/her surgical clerkship? Check all that apply. Sterile technique Proper surgical H&P Identifying surgical problems Working within hierarchy Basic surgical anatomy Ability to present patients Identifying complications Ability to suture/tie surgical knots 24) Check all the boxes that you think apply to the medical students’ role in the operating room □ They watch the doctors perform the surgeries □ They ask and answer questions posed to and by the residents and attendings □ They participate in the surgeries (ie, use instruments, close wounds, retract organs) □ They play integral roles in the surgeries 25) What do you think most medical students need to do more of on their surgical clerkship? a. b. 26) What do you think are the responsibilities of medical students when they are in the clinic? a. b. 27) What do you think are the responsibilities of medical students on the surgery floor? a. b.
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Appendix B General Surgery Clerkship Survey We are asking the house officers of the department of surgery to share their thoughts about and experiences with medical students on their third-year surgical clerkships. Please be as honest as possible when filling out this survey, and remember that all responses are completely anonymous. 1) Please check the position you currently hold: Chief Resident Resident Intern 2) How many hours of individual/small group instruction per week do you give medical students on their surgical clerkship? 0–1 1–2 2–3 3–4 ⬎4 3) How many hours of individual/small group instruction per week do you think you ought to be giving medical students on their surgical clerkship? 0–1 1–2 2–3 3–4 ⬎4 4) How many hours do you think medical students should expect to spend studying when they are not on duty? 0–5 6–10 11–20 21–30 ⬎30 5) How many hours of educationally unproductive work do you think a medical student should expect per week? 0–2 3–4 5–6 7–8 ⬎8 6) How many opportunities per week do you think medical students usually get to practice their procedural skills (eg, putting in Foleys, draining abscesses, suturing)? 0–2 3–4 5–6 7–8 ⬎8 7) If medical students have questions about the pre- and post-operative care of their patients, who should they consult first? Attendings Residents Interns Nurses 8) Since it is often not plausible to spend enough time with medical students to find out how well they are advancing in their education, which of the following do you use most to evaluate a medical student? (You may check more than one.) Patient presentations SOAP notes Questions asked by student Knowledge of patient H&P skills Questions posed to student Performance in clinic Other_______ 9) Which of the following do you expect medical students to be able to perform without any supervision before to their clerkship? (You may check more than one.) Write patient orders Remove staples and sutures Write SOAP notes Simple procedural skills (eg, NG tubes, Foleys) Perform noncritical parts of the surgery in the operating room Monitor noncritical aspects of recovery 10) I find teaching medical students to be somewhat of an inconvenience to my day-to-day T F responsibilities. (Please be honest.) 11) If I had a choice, I would rather not have a medical student on my team. (Please be honest.) T F 12) Though medical students are often not required or expected to be present while on call T F with their interns or residents, I am more lenient in evaluating a medical student if in fact he/she volunteers to stay alongside his/her intern or resident while on call. strongly disagree
13) In general, attending surgeons do a good job in educating medical students. 14) In general, surgical residents do a good job in educating medical students. 15) In general, surgical interns do a good job in educating medical students. 16) I play an important role in shaping the career paths of medical students. 17) Medical students are a good source of information about the patients they follow. 18) I feel comfortable in relying on medical students to answer the patient’s postoperative questions.
somewhat disagree
neither agree nor disagree
somewhat agree
strongly agree
NA
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19) Team dynamics is very important in the overall educational experience on the surgery clerkship. 20) Quite a bit is assumed about the responsibilities medical students are supposed to be able to undertake. 21) I make a strong effort to make sure that the medical student has learned the technical skills I deem essential for a medical student to have learned. 22) I am very consistent with the methods that I use to evaluate students (ie, use same questions, interact in the same manner). 23) I always give feedback to students midway though their rotation, even if unsolicited. 24) What skills do you think are absolutely necessary for a medical student (especially one not going into surgery) to have learned by the end of his/her surgical clerkship? Check all that apply. Sterile technique Proper surgical H&P Identifying surgical problems Working within hierarchy Basic surgical anatomy Ability to present patients Identifying complications Ability to suture/tie surgical knots 25) Check all the boxes that you think apply to the medical students’ role in the operating room □ They watch the doctors perform the surgeries □ They ask and answer questions posed to and by the residents and attendings □ They participate in the surgeries (ie, use instruments, close wounds, retract organs) □ They play integral roles in the surgeries 26) What do you think most medical students need to do more of on their surgical clerkship? a. b. 27) What do you think are the responsibilities of medical students when they are in the clinic? a. b. 28) What do you think are the responsibilities of medical students on the surgery floor? a. b.
Appendix C General Surgery Clerkship Survey We are asking third-year medical students to share their thoughts and experiences about their education on the surgery clerkship. Please be as honest as possible when filling out this survey, and remember that all responses are completely anonymous. 1) How many hours of individual/small group instruction have you received/did you receive per week during your surgical clerkship? 0–1 1–2 2–3 3–4 ⬎4 2) How many hours of individual/small group instruction do you think you ought to be receiving per week during your surgical clerkship? 0–1 1–2 2–3 3–4 ⬎4 3) How many hours do you think you’re expected to spend studying when not on duty per week? 0–5 6–10 11–20 21–30 ⬎30 4) How many hours of educationally unproductive work do you think a medical student should expect per week on his surgical clerkship? 0–2 3–4 5–6 7–8 ⬎8 5) How many opportunities per week do you think medical students usually have to practice their procedural skills (eg, putting in Foleys, draining abscesses, suturing)? 0–2 3–4 5–6 7–8 ⬎8 6) If medical students have questions about the pre- and post-operative care of their patients, who should they consult first? Attendings Residents Interns Nurses
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7) Since it is often not plausible to spend enough time with medical students to find out how well they are advancing in their education, which of the following do you think attending surgeons use most to assess a medical student’s progress (You may check more than one.) Patient presentations SOAP notes Questions asked by student Knowledge of patient H&P skills Questions posed to student Performance in clinic Other______ 8) Which of the following do you think attending surgeons expect medical students to be able to perform without any supervision before their clerkship? (You may check more than one.) Write patient orders Remove staples and sutures Write SOAP notes Simple procedural skills (eg, NG tubes, Foleys) Perform noncritical parts of the surgery in the operating room Monitor noncritical aspects of recovery 9) The faculty and residents view teaching medical students as an inconvenience to their T F day-to-day responsibilities. 10) The faculty and residents would rather not have a medical student on their team. T F 11) Though medical students are often not required or expected to be present while on T F call with their interns or residents, not doing so will hurt their evaluation. 12) I am planning to pursue a residency in either general surgery or one of the surgical T F subspecialties. strongly disagree
somewhat disagree
neither agree nor disagree
somewhat agree
strongly agree
NA
13) In general, attending surgeons do a good job in educating medical students. 14) In general, surgical residents do a good job in educating medical students. 15) In general, surgical interns do a good job in educating medical students. 16) The faculty and residents play an important role in shaping the career paths of medical students. 17) Medical students are a good source of information about the patients they follow. 18) Team dynamics is very important in the overall educational experience on the surgery clerkship. 19) Quite a bit is assumed about the responsibilities medical students are supposed to be able to undertake. 20) Faculty members/residents give feedback to students midway though their rotation, even if unsolicited. 21) What skills do you think are absolutely necessary for a medical student (especially one not going into surgery) to have learned by the end of his/her surgical clerkship? Check all that apply. Sterile technique Proper surgical H&P Identifying surgical problems Working within hierarchy Basic surgical anatomy Ability to present patients Identifying complications Ability to suture/tie surgical knots 22) Check all the boxes that you think apply to the medical students’ role in the operating room □ They watch the doctors perform the surgeries □ They ask and answer questions posed to and by the residents and attendings □ They participate in the surgeries (ie, use instruments, close wounds, retract organs) □ They play integral roles in the surgeries 23) What do you think most medical students need to do more of on their surgical clerkship? a. b. c.
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24) What do you think are the responsibilities of medical students when they are in the clinic? a. b. c. 25) What do you think are the responsibilities of medical students on the surgery floor? a. b. c. REFERENCES 1. Bland KI, Isaacs G. Contemporary trends in student selection of medical specialties: the potential impact on general surgery. Arch Surg 2002;137:259–267. 2. Evans S, Sarani B. The modern medical school graduate and general surgical training: are they compatible? Arch Surg 2002; 137:274–277. 3. Henningsen JA. Why the numbers are dropping in general surgery: the answer no one wants to hear--lifestyle! Arch Surg 2002; 137:255–256. 4. Meyer AA, Weiner TM. The generation gap: perspectives of a program director. Arch Surg 2002;137:268–270. 5. Callcut R, Snow M, Lewis B, Chen H. Do the best students go into general surgery? J Surg Res 2003;115:69–73. 6. Gauvin JM. How to promote medical student interest in surgery. Surgery 2003;134:407–408. 7. Minor S, Poenaru D. The in-house education of clinical clerks in surgery and the role of housestaff. Am J Surg 2002;184:471–475. 8. Pelletier M, Belliveau P. Role of surgical residents in undergraduate surgical education. Can J Surg 1999;42:451–456. 9. Lowry SF. The role of house staff in undergraduate surgical education. Surgery 1976;80:624–628. 10. Libbin JB, Hauge LS, Myers JA, Millikan KW. Evaluation of student experience and performance in a surgical clerkship. Am Surg 2003;69:280–286; discussion 286.
11. Woolley DC, Moser SE, Davis NL, et al. Treatment of medical students during clerkships based on their stated career interests. Teach Learn Med 2003;15:156–162. 12. 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;34:292–298. 13. Claridge JA, Calland JF, Chandrasekhara V, et al. Comparing resident measurements to attending surgeon self-perceptions of surgical educators. Am J Surg 2003;185:323–327. 14. Baciewicz FA Jr, Arent L, Weaver M, et al. Influence of clerkship structure and timing on individual student performance. Am J Surg 1990;159:265–268. 15. Cochran A, Paukert JL, Neumayer LA. Does a general surgery clerkship influence student perceptions of surgeons and surgical careers? Surgery 2003;134:153–157. 16. O’Herrin JK, Lewis BJ, Rikkers LF, Chen H. Medical student operative experience correlates with a match to a categorical surgical program. Am J Surg 2003;186:125–128. 17. Bland KI. The recruitment of medical students to careers in general surgery: emphasis on the first and second years of medical education. Surgery 2003;134:409–413. 18. Polk HC Jr. The declining interest in surgical careers, the primary care mirage, and concerns about contemporary undergraduate surgical education. Am J Surg 1999;178:177– 179.
ANNOUNCEMENT Beginning September 2004 JACS editorial office will test an all electronic editorial system.
JANUARY 2005 All manuscripts will be submitted on the electronic system ONLY. WATCH FOR GUIDELINES All new electronic editorial office for JACS manuscripts.
Attending, House Officer, and Medical Student Perceptions about Teaching in the Third-Year Medical School General Surgery Clerkship Sumit K De, MD, Peter K Henke, MD, FACS, Gorav Ailawadi, MD, Justin B Dimick, MD, Lisa M Colletti, MD, FACS There has been declining interest in surgery among medical students and one reason might be the third-year clerkship experience. The aim of this study was to clarify the perceptions and expectations of attendings, residents, and medical students on the clerkship experience. STUDY DESIGN: A survey was distributed to all general surgery attendings, the entire general surgery house staff, and an entire third year medical school class inclusive of the 2001–2002 academic year at a single institution. Statistic analysis consisted of chi-square and Kruskal-Wallis-ANOVA on ranks with Dunn’s test for multiple comparisons. A p ⬍ 0.05 was significant. RESULTS: Responses were obtained from 59 attending surgeons (50%), 38 surgical residents (32%), and 107 medical students (66%). Of this student cohort, 35% were planning to choose a surgical specialty as a career. Agreement was high among faculty, students, and residents about factors considered important in evaluation, expectations of skills, and level of skills needed before the clerkship. Medical students desired more hours of instruction, believed they performed fewer procedures per week, and thought that feedback was poor compared with the opinions of faculty and residents (p ⬍ 0.002). Nearly 50% of medical students believed they were an inconvenience to the service; 30% of house officers and 27% of faculty (p ⬍ 0.001) believed this also. Almost all faculty and residents, however, wanted medical students on the service (⬎ 95%). Faculty believed residents did a better job teaching than either the students or residents themselves did (p ⬍ 0.001), and students thought that residents were the primary source of education in patient care. CONCLUSIONS: Considerable differences exist between faculty, surgical resident, and medical student perceptions and expectations of medical student education. Structured direct faculty contact, definition of medical student roles on the surgical team, and more consistent feedback can be rapidly improved. (J Am Coll Surg 2004;199:932–942. © 2004 by the American College of Surgeons) BACKGROUND:
A considerable decline in student interest in general surgery, but not surgical subspecialties, has occurred over the last several years.1 The reasons cited for this include lifestyle, clerkship experience, quality of mentorship, and training obligations.2-4 This could change with the new 80-hour work restrictions, but the quality of students choosing surgery might not be as high.5 A medical student’s first impression of surgery is often from the third-year clerkship experience and is frequently the only opportunity surgeons have to show medical stu-
dents the excitement and commitment that come with a surgical career.6 For medical students, a negative thirdyear educational experience may affect their decisions about whether or not to pursue a career in surgery. Contrary to many medical school third-year clerkships, the time that general surgery attendings spend directly with students is limited by operative and research responsibilities. Variable amounts of teaching occur in the operating room, depending on circumstances. Much of the onus of teaching medical students the fundamentals of managing a pre- and postoperative general surgery patient, as a result, falls on the residents, particularly with ward care.7-9 But attendings do the final evaluations of medical students, just as in other rotations. Attendings are in a position, of having to evaluate med-
Received July 7, 2004; Revised August 11, 2004; Accepted August 12, 2004. From the Department of Surgery, University of Michigan Medical Center, Ann Arbor, MI. Correspondence address: Peter K Henke, MD, 1500 East Medical Center Dr, Room 2210 Taubman Health Care Center, Ann Arbor, MI 48109-0329.
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ical students after only limited exposure, and residents may be inexperienced teachers. In addition, the tools available for judging medical students vary from attending to attending.10 Although many studies about medical student education during third-year required clerkships exist, few have dealt specifically with the general surgery clerkship11 or compared the views of medical students with their general surgery educators. We sought to better understand how each group involved in medical student education—the attendings, the house staff, and the students themselves—perceived not only their own responsibilities but each others’ in educating medical students about fundamentals of general surgery. METHODS A paper survey (Appendices A, B, C) was distributed to all Department of Surgery faculty members at the University of Michigan Medical Center; 59 (50%) responded. All members of the general surgery house staff were solicited by mail for this study, and 38 (32%) returned completed surveys. Three weeks before completion of their third year of medical school, 162 medical students received a copy of the survey. Of these, 107 (66%) were returned. The same questions appeared on all surveys except for a change in wording to correctly address the responders, questions about training level, plans for a career in surgery, and regularity of feedback. Questions in the surveys offered objective answers (eg, true/false, multiple choice, Likert scale [1–5, strongly disagree to strongly agree], and choice rank). The last two questions in each survey were subjective and open-ended, required write-in answers, and were used for internal purposes and are not reported in this article. The University of Michigan Institutional Review Board approved this study. Statistical analysis consisted of Kuskal-Wallis ANOVA on ranks with Dunn’s corrections for multiple comparisons. Categoric variables were assessed with chisquare analysis. Sigmastat 2.0 was used for all statistic analyses. RESULTS Views on surgical education time requirements
Comparison among faculty, residents, and medical students revealed different perceptions about the medical
Figure 1. (A) Desired number of instructional hours per week. Students desired significantly more hours per week of formal instruction than residents and faculty thought necessary (*p ⬍ 0.001). Median response with 25th to 75th percentile shown. (B) Procedural opportunities for students per week. Residents believed more opportunities were available for technical procedures than faculty or students (*p ⫽ 0.021).
students’ educational expectations in the surgical clerkship. There was no difference in the perception of number of instructional hours medical students received per week, with most faculty, residents, and students believing that they received 1 to 2 structured hours per week. But there was a notable difference about the number of instructional hours medical students desired, as compared with what faculty and residents believed were needed. Most medical students wanted 3 to 4 hours per week, and faculty and residents thought that 2 to 3 hours per week were sufficient (p ⬍ 0.001; Fig. 1A). There was a considerable difference in the number of hours believed necessary off service for studying; most faculty believed 6 to 10 hours per week were spent studying, and
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Table 1. Rank of Factors in Student Evaluation Rank
Faculty
Residents
Students
1 2 3 4
Questions posed to student Questions asked by student Performance in clinic Patient presentations
Knowledge of patient Questions asked by student Patient presentations Questions posed to students
Questions posed to student Questions asked by student Performance in clinic Questions asked by student
residents and students, on average, felt 11 to 20 hours per week were required (p ⫽ 0.005). Medical students viewed the number of opportunities per week to practice procedural skills to be significantly less than faculty or residents (median, 0 to 2 versus 3 to 4 procedures/week; p ⫽ 0.021) (Fig. 1B). There was marked agreement as to whom medical students should direct pre- and postoperative questions, with the majority stating that interns were the most readily available source of information. Views on medical student evaluation and team roles
Faculty were most likely to evaluate medical students by four modes; questions posed to the student, questions asked by the student, performance in clinic, and patient presentations (all ⬎ 50% of faculty responses) (Table 1). Residents tended to place more emphasis on student knowledge of the patient, followed by questions asked by the student and patient presentations. Residents were less likely to believe questions posed to the students were important for evaluation of student performance. Medical students were most likely to believe that questions posed to them were the most readily used tools to assess their progress, followed by questions asked by them or performance in clinic (all ⬎ 70% of respondents). Most students believed that writing patient orders and SOAP (subjective, objective, assessment, and plans) notes and removing staples and sutures were expected of them before their clerkship. But, more than 75% of residents and attendings thought that writing SOAP notes was all that was expected of students before they started their clerkship. Although a primary mission of a medical school is student teaching, medical students were viewed by 27% of faculty as an inconvenience to the surgical service. This percentage was slightly higher for residents, of whom 32% thought students were an inconvenience to the service. Most striking was that 51% of medical students believed themselves to be an inconvenience to the service, significantly greater than faculty and resident responses (p ⬍ 0.001). In contrast, 98% of faculty and
95% of residents stated that if offered, they would want a medical student on their team. Seventeen percent of students believed they were not wanted on the team, significantly more than faculty and residents (p ⫽ 0.007). Most faculty (84%) and residents (78%) viewed students who volunteered to stay alongside their intern or resident as a positive factor in their evaluation. Similarly, 73% of students believed this was an advantage to their evaluation. In this student cohort, 35% were planning to pursue a surgical residency in general surgery or a surgical subspecialty field. Views on faculty and house officer teaching
In response to views on ward team dynamics and how faculty mentor students, attending surgeons had a bimodal distribution; approximately 30% disagreed that attending surgeons do a good job in educating medical students, and 46% agreed. This bimodel distribution was echoed by residents and students, with no notable difference in median response. But when considering surgical resident teaching performance, most faculty thought that surgical residents did a better job of teaching than did the surgical residents themselves or medical students (p ⬍ 0.001) (Fig. 2A). In contrast, most faculty, residents, and students agreed that interns did a good job of teaching on the wards (p ⫽ NS). Similarly, the majority of students, residents, and faculty somewhat agreed or agreed strongly with the statement, “Faculty and residents play a significant role in shaping the career paths of medical students.” Interestingly, most medical students somewhat or strongly agreed that they were a good source of information about patients that they follow, but the majority of residents and faculty neither agreed nor somewhat disagreed with this statement (p ⫽ ⬍ 0.001) (Fig. 2B). Almost all faculty and residents (⬎ 80%) believed that relying on medical students to answer patients’ postoperative questions was inappropriate. Medical students and residents both thought team dynamics are very important, but faculty were less likely to believe this (p ⫽ ⬍ 0.001). Assumptions about medical student responsibilities were more commonly agreed
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trast to students, who strongly disagreed with that statement (p ⫽ ⬍ 0.001) (Fig. 3B). Faculty believed that learning sterile technique, followed by ability to present patients and identify surgical problems were the three most important skills that a medical student should learn on a surgical clerkship (Table 2). This was echoed by residents. Medical students believed that sterile technique, identifying surgical problems, and identifying complications were most important, with the ability to present patients slightly less important. Students, residents, and faculty agreed about what the medical students’ role in the operating room should be; that is, primarily watching surgeons perform
Figure 2. (A) Responses to: “Residents do a good job teaching medical students.” Faculty members were more likely to believe that residents did a good job teaching medical students than residents or students (*p ⬍ 0.001). (B) Responses to: “Medical students are a good source of information about their patients.” Most medical students strongly agreed with this statement; faculty and residents were more likely to disagree (*p ⬍ 0.001). A, agree; D, disagree; N, neutral; SA, strongly agree; SD, strongly disagree.
on by students and residents than faculty, but the difference was not notable. Most faculty were less likely than residents to believe they had made a strong effort to instruct medical students on the important technical skills essential in a surgical clerkship, as compared with residents (p ⫽ ⬍ 0.001) (Fig. 3). The majority of residents and faculty were neutral about or somewhat agreed with the statement that consistent methods were used to evaluate students in the same manner between clerkship groups. Most residents and faculty were neutral about or disagreed somewhat that students receive sufficient feedback midway through their rotation, in con-
Figure 3. (A) Importance of teaching medical students techniques. More residents believed teaching technique during the clerkship was very important as compared with most faculty (*p ⬍ 0.001). (B) Responses to: “Always give (get) feedback to students.” Students strongly disagreed that consistent feedback of their performance was given, and their response was significantly different than faculty and resident responses (*p ⬍ 0.001). A, agree; D, disagree; N, neutral; SA, strongly agree; SD, strongly disagree.
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Table 2. Rank of Skills to Be Learned in Clerkship Rank
Faculty
Residents
Students
1 2 3 4
Sterile technique Ability to present patients Identifying surgical problems Proper history and physical
Sterile technique Identifying surgical problems Ability to present patients Basic surgery anatomy
Sterile technique Identifying surgical problems Identifying complications Ability to present patients
operations, asking and answering questions posed to and by the residents and attendings, and participating in the operations with the use of instruments and retraction. But all groups agreed that students played little integral role in the operations. DISCUSSION Based on these data, important perceptions of third-year medical student clerkships differ in what faculty and residents believe is the educational experience and what students desire. This is a conclusion that is not specific to general surgery.12 The perceived lack of willingness by surgical attendings to devote time to teaching has been commonly noted in medical schools throughout the nation.13,14 Medical students expect to be taught more through didactics and other means that require personal time by the attendings and house staff. A possible fallout from less attending exposure is the decline of the number of medical students opting to choose general surgery as a specialty.7,13 In fact, this phenomenon has spurred many surgeons to wonder what can be done to halt medical students’ exodus from surgery.11,15,16 On the other hand, many processes outside of the attendings’ control act to limit these interactions—namely, greater administrative and clinical responsibilities and research commitments. This is combined with the fact that many operations are performed in an outpatient setting, so hospital admissions are fewer and the time for students to preoperatively evaluate patients and follow them postoperatively is limited. It is also doubtful that surgical subspecialty education is substantially better than general surgery, though subspecialty experience is often done in the fourth clinical year, when students have usually settled on a career choice. The most concerning data we found was the belief by many students that they are not essential to the service and may not be wanted at all. Although there is truth to this in actual day-to-day care and from a medicolegal standpoint, medical students’ primary purpose on a general surgery clerkship is to learn. That is what they are paying for. Perhaps more disturbing is that 32% of the residents and 27% of the attendings also thought that medical students were
an inconvenience to the surgical team, which is contrary to the medical school’s mission. The negative perception was borne out even more stunningly when 17% of medical students responded that they thought the faculty and house staff would rather not even have them present on their teams at all. But almost no faculty or resident believed this. One solution to this perception is to better define the medical students’ role and give them specific ward tasks to complete. Medical students are adults, and it can be frustrating to feel like an interloper with no substantive role on a clinical service. Learning ward team dynamics and the fact that that medical student involvement is appreciated by most house officers was confirmed in this study. Good surgical care very much depends on the proper function of the team, and acclimating students to this culture is as important as learning the basic pathophysiology of disease. From these data, we concluded that faculty and house staff must do a better job in communicating with medical students what they should learn and they must make time for that effort. It seems that the paucity of encounters that attendings have with medical students may have negative repercussions and underlies poor mentorship.6,15 Although not addressed specifically in this study, the negative perceptions may be one factor that has contributed to the steadily falling numbers of US graduates pursuing general surgery as a career path.15,17 The limitation of this study is the lower survey response rate from the residents, as compared with the faculty and students. But the most improvement responses with regard to improving the clerkship experience are from the students. Most responses between faculty and residents were similar, with most disagreement between these groups and students. Another limitation is that this was done within only one class and this might have been a biased population. But the number of students pursuing surgery at the University of Michigan has slowly increased over the last several years, suggesting similarity of viewpoints and the department’s addition of a medical student facilitator, as measured by ultimate career choice. Similarly, this is a single institutional study and may not be representative of other medical schools.
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Many medical schools, including the University of Michigan, have changed their first 2 years of curriculum to better acclimate students to clinical medicine earlier in their career, with positive feedback. These data suggest some areas of third-year clinical surgical education that can be improved for enhancing student experience. Because most students will not ultimately choose a surgical career, it is foremost that certain basics be taught so patients who need surgical treatment can be appropriately identified and referred for care. Several areas of improvement can be easily implemented and have been highlighted by other educators.17,18 First, well-stated goals and expectations should be presented to each incoming group of rotating third-year
medical students, including certain tasks for which they are primarily responsible. Second, dedicated ward rounds by an attending and students (perhaps nonworking rounds where residents can be freed to perform daily duties) would improve face time, quality, and personal interactions (that convey bedside teaching). Third, emphasizing the team role of a surgical service to make the student integral makes one feel useful and enthusiastic. Students who encounter enthusiastic mentors are more likely to choose that specialty, and surgery lends itself well in this regard.15 Promoting these changes seems essential not only to maintain the supply of quality surgeons but also to make sure the fundamentals of surgery are taught to all students.
Appendix A Surgery Clerkship Survey for Faculty We are asking the faculty to share their thoughts about and experiences with medical students on their third-year surgical clerkships. Please be as honest as possible when filling out this survey, and remember that all responses are completely anonymous. 1) How many hours of individual/small group instruction per week do you give medical students on their surgical clerkship? 0–1 1–2 2–3 3–4 ⬎4 2) How many hours of individual/small group instruction per week do you think you ought to be giving medical students on their surgical clerkship? 0–1 1–2 2–3 3–4 ⬎4 3) How many hours do you think medical students should expect to spend studying when they are not on duty? 0–5 6–10 11–20 21–30 ⬎30 4) How many hours of educationally unproductive work do you think a medical student should expect per week? 0–2 3–4 5–6 7–8 ⬎8 5) How many opportunities per week do you think medical students usually get to practice their procedural skills (eg, putting in Foleys, draining abscesses, suturing)? 0–2 3–4 5–6 7–8 ⬎8 6) If medical students have questions about the pre- and post-operative care of their patients, who should they consult first? Attendings Residents Interns Nurses 7) Since it is often not plausible to spend enough time with medical students to find out how well they are advancing in their education, which of the following do you use most to evaluate a medical student? (You may check more than one.) Patient presentations SOAP Notes Questions asked by student Knowledge of patient H&P skills Questions posed to student Performance in clinic Other______ 8) Which of the following do you expect medical students to be able to perform without any supervision before to their clerkship? (You may check more than one.) Write patient orders Remove staples and sutures Write SOAP notes Simple procedural skills (eg, NG tubes, Foleys) Perform noncritical parts of the surgery in the operating room Monitor noncritical aspects of recovery 9) I find teaching medical students to be somewhat of an inconvenience to my day-to-day T F responsibilities. (Please be honest.) 10) If I had a choice, I would rather not have a medical student on my team. (Please be honest.) T F 11) Though medical students are often not required or expected to be present while on call T F with their interns or residents, I am more lenient in evaluating a medical student if in fact he/she volunteers to stay alongside his/her intern or resident while on call.
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somewhat disagree
neither agree nor disagree
somewhat agree
strongly agree
NA
12) In general, attending surgeons do a good job in educating medical students. 13) In general, surgical residents do a good job in educating medical students. 14) In general, surgical interns do a good job in educating medical students. 15) I play an important role in shaping the career paths of medical students. 16) Medical students are a good source of information about the patients they follow. 17) I feel comfortable in relying on medical students to answer the patient’s postoperative questions. 18) Team dynamics is very important in the overall educational experience on the surgery clerkship. 19) Quite a bit is assumed about the responsibilities medical students are supposed to be able to undertake. 20) I make a strong effort to make sure that the medical student has learned the technical skills I deem essential for a medical student to have learned. 21) I am very consistent with the methods that I use to evaluate students (ie, use same questions, interact in the same manner). 22) I always give feedback to students midway though their rotation, even if unsolicited. 23) What skills do you think are absolutely necessary for a medical student (especially one not going into surgery) to have learned by the end of his/her surgical clerkship? Check all that apply. Sterile technique Proper surgical H&P Identifying surgical problems Working within hierarchy Basic surgical anatomy Ability to present patients Identifying complications Ability to suture/tie surgical knots 24) Check all the boxes that you think apply to the medical students’ role in the operating room □ They watch the doctors perform the surgeries □ They ask and answer questions posed to and by the residents and attendings □ They participate in the surgeries (ie, use instruments, close wounds, retract organs) □ They play integral roles in the surgeries 25) What do you think most medical students need to do more of on their surgical clerkship? a. b. 26) What do you think are the responsibilities of medical students when they are in the clinic? a. b. 27) What do you think are the responsibilities of medical students on the surgery floor? a. b.
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Appendix B General Surgery Clerkship Survey We are asking the house officers of the department of surgery to share their thoughts about and experiences with medical students on their third-year surgical clerkships. Please be as honest as possible when filling out this survey, and remember that all responses are completely anonymous. 1) Please check the position you currently hold: Chief Resident Resident Intern 2) How many hours of individual/small group instruction per week do you give medical students on their surgical clerkship? 0–1 1–2 2–3 3–4 ⬎4 3) How many hours of individual/small group instruction per week do you think you ought to be giving medical students on their surgical clerkship? 0–1 1–2 2–3 3–4 ⬎4 4) How many hours do you think medical students should expect to spend studying when they are not on duty? 0–5 6–10 11–20 21–30 ⬎30 5) How many hours of educationally unproductive work do you think a medical student should expect per week? 0–2 3–4 5–6 7–8 ⬎8 6) How many opportunities per week do you think medical students usually get to practice their procedural skills (eg, putting in Foleys, draining abscesses, suturing)? 0–2 3–4 5–6 7–8 ⬎8 7) If medical students have questions about the pre- and post-operative care of their patients, who should they consult first? Attendings Residents Interns Nurses 8) Since it is often not plausible to spend enough time with medical students to find out how well they are advancing in their education, which of the following do you use most to evaluate a medical student? (You may check more than one.) Patient presentations SOAP notes Questions asked by student Knowledge of patient H&P skills Questions posed to student Performance in clinic Other_______ 9) Which of the following do you expect medical students to be able to perform without any supervision before to their clerkship? (You may check more than one.) Write patient orders Remove staples and sutures Write SOAP notes Simple procedural skills (eg, NG tubes, Foleys) Perform noncritical parts of the surgery in the operating room Monitor noncritical aspects of recovery 10) I find teaching medical students to be somewhat of an inconvenience to my day-to-day T F responsibilities. (Please be honest.) 11) If I had a choice, I would rather not have a medical student on my team. (Please be honest.) T F 12) Though medical students are often not required or expected to be present while on call T F with their interns or residents, I am more lenient in evaluating a medical student if in fact he/she volunteers to stay alongside his/her intern or resident while on call. strongly disagree
13) In general, attending surgeons do a good job in educating medical students. 14) In general, surgical residents do a good job in educating medical students. 15) In general, surgical interns do a good job in educating medical students. 16) I play an important role in shaping the career paths of medical students. 17) Medical students are a good source of information about the patients they follow. 18) I feel comfortable in relying on medical students to answer the patient’s postoperative questions.
somewhat disagree
neither agree nor disagree
somewhat agree
strongly agree
NA
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19) Team dynamics is very important in the overall educational experience on the surgery clerkship. 20) Quite a bit is assumed about the responsibilities medical students are supposed to be able to undertake. 21) I make a strong effort to make sure that the medical student has learned the technical skills I deem essential for a medical student to have learned. 22) I am very consistent with the methods that I use to evaluate students (ie, use same questions, interact in the same manner). 23) I always give feedback to students midway though their rotation, even if unsolicited. 24) What skills do you think are absolutely necessary for a medical student (especially one not going into surgery) to have learned by the end of his/her surgical clerkship? Check all that apply. Sterile technique Proper surgical H&P Identifying surgical problems Working within hierarchy Basic surgical anatomy Ability to present patients Identifying complications Ability to suture/tie surgical knots 25) Check all the boxes that you think apply to the medical students’ role in the operating room □ They watch the doctors perform the surgeries □ They ask and answer questions posed to and by the residents and attendings □ They participate in the surgeries (ie, use instruments, close wounds, retract organs) □ They play integral roles in the surgeries 26) What do you think most medical students need to do more of on their surgical clerkship? a. b. 27) What do you think are the responsibilities of medical students when they are in the clinic? a. b. 28) What do you think are the responsibilities of medical students on the surgery floor? a. b.
Appendix C General Surgery Clerkship Survey We are asking third-year medical students to share their thoughts and experiences about their education on the surgery clerkship. Please be as honest as possible when filling out this survey, and remember that all responses are completely anonymous. 1) How many hours of individual/small group instruction have you received/did you receive per week during your surgical clerkship? 0–1 1–2 2–3 3–4 ⬎4 2) How many hours of individual/small group instruction do you think you ought to be receiving per week during your surgical clerkship? 0–1 1–2 2–3 3–4 ⬎4 3) How many hours do you think you’re expected to spend studying when not on duty per week? 0–5 6–10 11–20 21–30 ⬎30 4) How many hours of educationally unproductive work do you think a medical student should expect per week on his surgical clerkship? 0–2 3–4 5–6 7–8 ⬎8 5) How many opportunities per week do you think medical students usually have to practice their procedural skills (eg, putting in Foleys, draining abscesses, suturing)? 0–2 3–4 5–6 7–8 ⬎8 6) If medical students have questions about the pre- and post-operative care of their patients, who should they consult first? Attendings Residents Interns Nurses
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7) Since it is often not plausible to spend enough time with medical students to find out how well they are advancing in their education, which of the following do you think attending surgeons use most to assess a medical student’s progress (You may check more than one.) Patient presentations SOAP notes Questions asked by student Knowledge of patient H&P skills Questions posed to student Performance in clinic Other______ 8) Which of the following do you think attending surgeons expect medical students to be able to perform without any supervision before their clerkship? (You may check more than one.) Write patient orders Remove staples and sutures Write SOAP notes Simple procedural skills (eg, NG tubes, Foleys) Perform noncritical parts of the surgery in the operating room Monitor noncritical aspects of recovery 9) The faculty and residents view teaching medical students as an inconvenience to their T F day-to-day responsibilities. 10) The faculty and residents would rather not have a medical student on their team. T F 11) Though medical students are often not required or expected to be present while on T F call with their interns or residents, not doing so will hurt their evaluation. 12) I am planning to pursue a residency in either general surgery or one of the surgical T F subspecialties. strongly disagree
somewhat disagree
neither agree nor disagree
somewhat agree
strongly agree
NA
13) In general, attending surgeons do a good job in educating medical students. 14) In general, surgical residents do a good job in educating medical students. 15) In general, surgical interns do a good job in educating medical students. 16) The faculty and residents play an important role in shaping the career paths of medical students. 17) Medical students are a good source of information about the patients they follow. 18) Team dynamics is very important in the overall educational experience on the surgery clerkship. 19) Quite a bit is assumed about the responsibilities medical students are supposed to be able to undertake. 20) Faculty members/residents give feedback to students midway though their rotation, even if unsolicited. 21) What skills do you think are absolutely necessary for a medical student (especially one not going into surgery) to have learned by the end of his/her surgical clerkship? Check all that apply. Sterile technique Proper surgical H&P Identifying surgical problems Working within hierarchy Basic surgical anatomy Ability to present patients Identifying complications Ability to suture/tie surgical knots 22) Check all the boxes that you think apply to the medical students’ role in the operating room □ They watch the doctors perform the surgeries □ They ask and answer questions posed to and by the residents and attendings □ They participate in the surgeries (ie, use instruments, close wounds, retract organs) □ They play integral roles in the surgeries 23) What do you think most medical students need to do more of on their surgical clerkship? a. b. c.
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24) What do you think are the responsibilities of medical students when they are in the clinic? a. b. c. 25) What do you think are the responsibilities of medical students on the surgery floor? a. b. c. REFERENCES 1. Bland KI, Isaacs G. Contemporary trends in student selection of medical specialties: the potential impact on general surgery. Arch Surg 2002;137:259–267. 2. Evans S, Sarani B. The modern medical school graduate and general surgical training: are they compatible? Arch Surg 2002; 137:274–277. 3. Henningsen JA. Why the numbers are dropping in general surgery: the answer no one wants to hear--lifestyle! Arch Surg 2002; 137:255–256. 4. Meyer AA, Weiner TM. The generation gap: perspectives of a program director. Arch Surg 2002;137:268–270. 5. Callcut R, Snow M, Lewis B, Chen H. Do the best students go into general surgery? J Surg Res 2003;115:69–73. 6. Gauvin JM. How to promote medical student interest in surgery. Surgery 2003;134:407–408. 7. Minor S, Poenaru D. The in-house education of clinical clerks in surgery and the role of housestaff. Am J Surg 2002;184:471–475. 8. Pelletier M, Belliveau P. Role of surgical residents in undergraduate surgical education. Can J Surg 1999;42:451–456. 9. Lowry SF. The role of house staff in undergraduate surgical education. Surgery 1976;80:624–628. 10. Libbin JB, Hauge LS, Myers JA, Millikan KW. Evaluation of student experience and performance in a surgical clerkship. Am Surg 2003;69:280–286; discussion 286.
11. Woolley DC, Moser SE, Davis NL, et al. Treatment of medical students during clerkships based on their stated career interests. Teach Learn Med 2003;15:156–162. 12. 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;34:292–298. 13. Claridge JA, Calland JF, Chandrasekhara V, et al. Comparing resident measurements to attending surgeon self-perceptions of surgical educators. Am J Surg 2003;185:323–327. 14. Baciewicz FA Jr, Arent L, Weaver M, et al. Influence of clerkship structure and timing on individual student performance. Am J Surg 1990;159:265–268. 15. Cochran A, Paukert JL, Neumayer LA. Does a general surgery clerkship influence student perceptions of surgeons and surgical careers? Surgery 2003;134:153–157. 16. O’Herrin JK, Lewis BJ, Rikkers LF, Chen H. Medical student operative experience correlates with a match to a categorical surgical program. Am J Surg 2003;186:125–128. 17. Bland KI. The recruitment of medical students to careers in general surgery: emphasis on the first and second years of medical education. Surgery 2003;134:409–413. 18. Polk HC Jr. The declining interest in surgical careers, the primary care mirage, and concerns about contemporary undergraduate surgical education. Am J Surg 1999;178:177– 179.
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