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Does a general surgery clerkship influence student perceptions of surgeons and surgical careers?
Does a general surgery clerkship influence student perceptions of surgeons and surgical careers? Amalia Cochran, MD, Judy L. Paukert, PhD, and Leigh A. Neumayer, MD, Salt Lake City, Utah, and San Antonio, Tex
Background. Student perceptions of surgeons and surgical careers may influence their decision to pursue a surgical career. We evaluated the impact of a general surgery clerkship on medical student perceptions of surgeons and surgical careers and of the clerkship on student interest in surgical careers. Methods. We conducted voluntary pre- and postclerkship surveys of third-year medical students who were enrolled in their required general surgery clerkship and used 5-point Likert scale rankings to capture agreement with declarative statements (1 = strongly agree; 5 = strongly disagree). T-tests were used to evaluate both paired and individual items. Results. Students indicated that their surgical clerkship improved their opinion of surgeons (2.47; P < .001). Several perceptions changed after the clerkship. First, students agreed more strongly that surgeons were compassionate physicians (ranking, 2.87 vs 2.53; P = .003) and that patients respected surgeons (ranking, 1.84 vs 1.62; P = .026). Acknowledgment of career satisfaction by students increased (ranking, 2.57 vs 2.22; P = .008). Students more strongly disagreed that “surgeons [were] respectful of other physicians” (ranking, 3.29 vs 3.62; P = .009). Interest in surgical careers did not change significantly during the clerkship (ranking, 2.83 vs 2.68; P = .218). Conclusion. Medical student perceptions of surgeons and surgical careers generally improve during the surgical clerkship. However, student impressions of surgeons’ collegial behavior and commitment to teaching deteriorate significantly during the surgical clerkship. (Surgery 2003;134:153-7.) From the Salt Lake City Veterans Affairs Healthcare System and Department of Surgery, University of Utah Health Sciences Center, Salt Lake City, Utah; and the Office of Graduate Medical Education, University of Texas Health Science Center, San Antonio, Tex
in surgical careers is implicit in the recent National Residency Matching Program results. In 2001, 1041 categorical general surgery positions were offered through the National Residency Matching Program, but only 973 positions were filled.1 General surgery fared little better in 2002, when 1073 categorical positions were offered, and 981 positions were filled.2 The explanation for medical student diminishing interest in general surgery is clearly multifactorial.3 Lifestyle considerations are widely touted as a key element that drives medical student specialty selections.4-6 Spousal opinion may also DECLINING MEDICAL STUDENT INTEREST
Presented at the 64th Annual Meeting of the Society of University Surgeons, Houston, Texas, February 12-15, 2003. Reprint requests: Leigh A. Neumayer, MD, Department of Surgery, University of Utah Health Sciences Center, 30 North 1900 East, Room 3C410, Salt Lake City, UT 84132. © 2003 Mosby, Inc. All rights reserved. 0039-6060/2003/$30.00 + 0 doi:10.1067/msy.2003.216
influence choice of specialty, particularly when spouses disapprove of the commitment required of medical specialties with less controllable lifestyles.7 Role models, both positive and negative, strongly influence medical student selection of specialty.8-11 Thus, a key component of the apparent decreasing interest in general surgery may be the surgical profession’s failure to provide adequate role models for medical students. The common theme of these factors that are known to influence specialty selection is the student’s perception of both the specialty and its practitioners. Medical student perceptions of surgeons and surgical careers may begin before enrollment in a general surgery clerkship. However, the clerkship itself provides the most concentrated environment for these perceptions to evolve. Mutha et al8 showed that most medical students develop perceptions about specialties during their clinical clerkships. Further, most changes in medical student specialty selections occur during the third year of medical school.12 Despite these findings, SURGERY 153
154 Cochran, Paukert, and Neumayer
there has been no systematic evaluation of the impact of first-hand exposure to surgery as a discipline and to surgeons as physicians on student perceptions. The objective of this study was to examine the immediate impact of a general surgery clerkship on medical student perceptions of surgeons and surgical careers. METHODS Survey. All third-year medical students at the University of Utah are required to complete a 6week general surgery clerkship. During the 2001 through 2002 academic year, these students were asked to complete a voluntary survey at the beginning and the end of their surgery clerkship. The before and after clerkship surveys were nearly identical in content and questions. The surveys consisted largely of declarative statements followed by Likert scale rankings. One set of Likert scale rankings captured agreement with these statements: 1 indicated strong agreement, and 5 indicated strong disagreement. The other Likert scale indicated whether an item encouraged or discouraged the student from considering a surgical career, with a ranking of 1 indicating an item that strongly encouraged a student to consider a surgical career and a ranking of 5 indicating an item that strongly discouraged a student to consider a surgical career. Statistical analysis. Paired t-tests were used to compare before and after clerkship survey items. The Student t test compared items that appeared only on 1 survey only against a test value of 3. All data analysis was conducted with the use of SPSS for Windows 11.0.1 (SPSS, Inc, Chicago, Ill). The human subjects office at the University of Utah Health Sciences Center granted institutional review board approval for this project. RESULTS Of 98 students enrolled in the general surgery clerkship in 2001 through 2002, 93 students completed both surveys (response rate, 94.9%). Table I presents the significant changes in student perceptions of surgeons during the clinical clerkship. After the clerkship, students agreed more strongly that surgeons are compassionate physicians, are content with their career choice, and are respected by both other physicians and patients. Students tended to agree more strongly that surgeons provide good role models for medical students, although this item failed to attain statistical significance (mean before clerkship, 2.76; mean after clerkship, 2.71; P = .63). Students disagreed with the statement, “Surgeons lead well-balanced,
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rewarding lifestyles,” both before and after their clerkship, but tended to disagree less strongly after their clerkship (mean before clerkship, 3.91; mean after clerkship, 3.73; P = .062). Another positive finding was the shift away from students agreeing with the statement, “Surgeons are mean” (mean before clerkship, 2.21; mean after clerkship, 3.56; P < .001). Finally, students tended to agree more strongly with the statement, “I am possibly interested in a surgical career,” after their clerkship (mean before clerkship, 2.83; mean after clerkship, 2.68; P = .218). Student interest in a surgical career was encouraged more after the clerkship by the statements that appear in Table II; the significant items were identical to those from the perception Likert scale responses. Student encouragement to consider a surgical career on the basis of the statement, “Surgeons lead well-balanced, rewarding lifestyles,” was comparable to their agreement Likert scale responses. Although student discouragement to consider a surgical career was reflected in this statement both before and after the clerkship, the level of discouragement tended to decrease after the surgical clerkship (mean before clerkship, 3.87; mean after clerkship, 3.83; P = .685). Students indicated a more negative response to several survey statements after the clerkship. For example, after the clerkship, students disagreed more strongly that “Surgeons are respectful of other physicians” (mean before clerkship, 3.29; mean after clerkship, 3.62; P = .01). After the clerkship, survey respondents tended to agree less strongly with 2 statements, “Surgeons encourage medical students to consider careers in surgery” (mean before clerkship, 2.64; mean after clerkship, 2.76; P = .38), and “Surgeons actively participate in medical student education” (mean before clerkship, 2.52; mean after clerkship, 2.65; P = .29, paired Student t test). As one might expect, surgeons’ failure to promote consideration of surgical careers by medical students was 1 factor that tended to be less encouraging of student interest in a surgical career after the clerkship (mean before clerkship, 2.88 vs mean after clerkship, 2.95; P = .530). A worsened perception of surgeons’ participation in medical student education did not generate a significant shift in student encouragement to pursue a surgical career after the clerkship (mean before clerkship, 2.67 vs mean after clerkship, 2.78; P = .334). After the clerkship, students were discouraged to pursue a surgical career on the basis of their perceived disrespect of surgeons toward other clinicians, although this item narrowly failed to attain statisti-
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Table I. Factors with improved student perceptions after clerkship Statement Surgeons are compassionate physicians. Surgeons are generally content with their career choice. Surgeons are respected by other physicians. Surgeons are respected by patients.
Before clerkship (mean ± SEM)
After clerkship (mean ± SEM)
P value*
2.87 ± 0.09 2.57 ± 0.09 2.39 ± 0.10 1.84 ± 0.09
2.53 ± 0.09 2.22 ± 0.10 2.18 ± 0.09 1.62 ± 0.06
.003 .008 .047 .026
Likert scale values: 1 = strongly agree; 3= no opinion; 5= strongly disagree. t-tests, Wilcoxon rank-sum coefficients.
*Paired
Table II. Factors that are more encouraging of student interest in a surgical career after clerkship Factor Surgeons are compassionate physicians. Surgeons are generally content with their career choice. Surgeons are respected by other physicians. Surgeons are respected by patients.
Before clerkship (mean ± SEM)
After clerkship (mean ± SEM)
P value*
3.27 ± 0.09 2.90 ± 0.09 2.77 ± 0.08 2.44 ± 0.08
2.87 ± 0.11 2.59 ± 0.09 2.60 ± 0.07 2.18 ± 0.07
<.001 .004 .035 .002
Likert scale values: 1 = strongly encouraging; 3 = no impact; 5 = strongly discouraging. *Paired t-tests, Wilcoxon rank-sum coefficients.
cal significance (mean before clerkship, 3.32; mean after clerkship, 3.54; P = .054). Responses before and after the clerkship to the statement, “I am possibly interested in a surgical career,” were compared. The findings demonstrated a trend toward increased student receptivity to surgical careers after general surgery clerkships (mean before clerkship, 2.83; mean after clerkship, 2.68), although the change was not statistically significant (P = .218). Finally, in the postclerkship survey, students were asked to consider the statement, “This clerkship improved my opinion of surgeons.” Fig 1 shows the frequency distribution of student Likert scale rankings for this statement. The mean value of 2.47 was significantly different from the neutral test value of 3 (P < .001, Student t test). DISCUSSION The apparent decline in interest in general surgery as a career is clearly multifactorial. This survey explored whether student experience during a required general surgery clerkship influenced student interest in general surgery. The results indicate significant improvements in medical student perception of surgeons, particularly with regard to job satisfaction and prestige. The significant improvement in these perceptions was driven by an incremental improvement with most students, rather than extreme shifts that are generated by a few student “outliers.” However, some areas of student perceptions in the survey deteriorated markedly. Students left the clerkship dissatisfied with surgeons’ relationships with other physicians; again, this perception was widespread and was not driven by only a few students with extreme respons-
es. Students also tended to criticize the educational commitment of surgeons at the conclusion of the clerkship. Statements about mentorship and active participation in medical student education may have attained significance were a larger sample available. The indisputable reaction provided by the students is that they are receptive to the messages we communicate about our specialty, our practices, and our colleagues. The results of this study illustrate important facets in medical student perceptions of surgeons’ job satisfaction after a general surgery clerkship. In other studies, role models that were identified by students have indicated that the expression of enthusiasm for their specialty affected subsequent medical student specialty selection.13,14 Neumayer et al15 demonstrated that female medical students have a negative perception of career satisfaction in female surgeons, although the direct impact of this finding on specialty selection was not posited. Professional dissatisfaction has been described as an important attribute in negative role models and, therefore, in dissuasion from specialty selection.8,16 However, careful examination of job satisfaction among surgeons reveals that surgeons of both genders are generally content with their career choice.4 The discrepancy is that surgeons may not communicate effectively and consistently their job satisfaction to students. Job dissatisfaction has also been linked to lifestyle in many studies of medical student specialty selections by the descriptor “overworked.”3,8,17 This study’s results imply that student negative perceptions of the surgical lifestyle changed little during a surgical clerkship and that the surgical
156 Cochran, Paukert, and Neumayer
Fig 1. Frequency distribution of responses to the statement, “This clerkship improved my opinion of surgeons.” (1 = strongly agree; 5 = strongly disagree). The bars represent the number of student responses.
lifestyle was a detractor when medical students considered specialty choice. Lifestyle issues are certainly the most frequent justification given for the decrease in applicants for general surgery residencies.4-6 However, students who truly consider careers in general surgery were less likely to be discouraged from surgery on the basis of lifestyle.10 The ultimate impact of lifestyle on student selection of a career in general surgery needs more rigorous delineation. Prestige, as captured by respect for surgeons by patients and other physicians, may influence medical students to consider a surgical career. In this survey, students who noted this prestige were encouraged to consider surgical careers. However, this finding may not apply to all medical students. An inverse relationship has been documented between the selection of a primary care specialty and concern for prestige within the medical profession.18 Students who select surgical careers may view prestige as an important element of job satisfaction. If prestige is a motivating factor for medical students who seek a general surgery career, the trend in medical school curricula toward devaluing surgery and its subspecialties may affect student interest in surgical careers negatively.4 Thus, the predominant academic and political climate of the 1990s with its emphasis on primary care may have done little to encourage medical students to specialize in surgery. Another factor that may discourage medical students to specialize in surgery is the mixed message that students receive about surgeons’ professional behavior. In this survey, students more readily acknowledged after their clerkship that surgeons provided compassionate care. These respondents also indicated that professionalism toward patients positively influenced them to consider a surgical career. This finding is consistent with the identification of compassion as an important characteristic
Surgery August 2003 in good physician role models.13 However, responses to this survey revealed that medical students disapproved of surgeon behavior toward other physicians. The perceived disrespect of surgeons for other physicians in turn discouraged medical student interest in surgical careers. Rankings of the statement, “Surgeons are mean,” improved significantly after the surgical clerkship. This finding implies that the issue of respect toward other physicians is an isolated, albeit important, behavioral issue. Harmonious interpersonal relationships and a positive working environment are important elements of job satisfaction for members of the socalled “Generation X.”19 Fostering collegial relationships with other specialties is imperative if surgical educators are to reverse the decline in medical student interest in general surgery. Declining interest in general surgery may also be linked to student perceptions of surgeons as mentors and educators. Medical students often cite career guidance and encouragement as key components of mentoring.11 For both medical students and residents, teaching ability is one of the most important qualities in physicians who are role models.20,21 After their clinical clerkship in surgery, respondents felt less strongly that surgeons encouraged them to consider surgical careers. These students also seemed disappointed with surgeons’ involvement in medical student education. Several recent editorials have targeted this perception and have called for increased mentoring by surgeons as a key strategy for combating the deterioration of interest in surgical careers.22,23 Although attributes of excellent role models have been studied and specifically delineated in internal medicine, many of the criteria are rather explicit and do not extrapolate to academic surgical practice.14 Future research that specifies characteristics of outstanding surgical role models would contribute substantially to the understanding of mentoring in surgical education. Two summary statements provide insight into the overall impact of the surgical clerkship on medical student perceptions of surgeons and surgical careers. After their clerkship, our students were slightly more positive in their response to the statement, “I am possibly interested in a surgical career,” although this relationship failed to attain statistical significance. The absence of a significant negative finding in response to this statement is encouraging. In addition, most responding medical students agreed after their clerkship with the statement, “This clerkship improved my opinion of surgeons.” One explanation for their agreement with this statement may be that students simply have low opinions of surgeons before their clerk-
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ship or hold perceptions that are clouded in myth. In spite of several deficiencies that were identified through this survey, after an intense period of exposure medical students seemed to be generally more comfortable with surgeons. This study has several limitations. The survey was administered for only 1 academic year at a single institution, and there may be selection bias in the subjects. Selection bias may be real, because an unusually high number of students from the surveyed class selected general surgery or its subspecialties for their residency. A temporal bias may also exist because the surveys were administered during the last 3 days of student surgical clerkships. The results of the postclerkship survey might show some decay over time, although we did not examine this phenomenon. This study does confirm the complexity of medical student specialty selection. Recognition of the relevance of student perceptions may provide a crucial element to understanding student specialty selections. Perceptions of professionalism with patients, job satisfaction, and prestige all improved significantly in responding students after their clinical clerkship. Perceived unprofessional behavior with medical colleagues and failure to mentor and educate contributed to student negative inferences about surgery and surgeons. The varied responses to the statements in this survey illustrate the multifactorial nature of the decision-making algorithm that medical students use to select their specialty. Ongoing efforts hopefully will identify the critical factors in this decision-making process and will provide insight into the balance of positive and negative influences that are perceived by medical students in the selection of a medical specialty. REFERENCES 1. 2001 National resident matching program match data. Washington (DC): American Association of Medical Colleges; 2001. 2. 2002 National resident matching program match data. Washington (DC): American Association of Medical Colleges; 2002. 3. Richardson HC, Redfern N. Why do women reject surgical careers? Ann R Coll Surg Eng 2000;82(suppl):290-3.
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4. Richardson JD. Workforce and lifestyle issues in general surgery training and practice. Arch Surg 2002;137:515-20. 5. Henningsen JA. Why the numbers are dropping in general surgery. Arch Surg 2002;137:255-6. 6. Craven JE. The generation gap in modern surgery. Arch Surg 2002;137:257-8. 7. Valente J, Rappaport W, Neumayer L, Witzke D, Putnam CW. Influence of spousal opinions on residency selection. Am J Surg 1992;163:596-8. 8. Mutha S, Takayama JI, O’Neil EH. Insights into medical students’ career choices based on third- and fourth-year students’ focus-group discussions. Acad Med 1997;72:635-40. 9. Wright S, Wong A, Newill C. The impact of role models on medical students. J Gen Intern Med 1997;12:53-6. 10. Erzurum VZ, Obermeyer RJ, Fecher A, Thyagarajan P, Tan P, Koler AK, et al. What influences medical students’ choice of surgical careers. Surgery 2000;128:253-6. 11. Paukert JL, Richards BF. How medical students and residents describe the roles and characteristics of their influential clinical teachers. Acad Med 2000;75:843-5. 12. Katz LA, Sarnacki RE, Schimpfhauser F. The role of negative factors in changes in career selection by medical students. J Med Ed 1984;59:285-90. 13. Ambrozy DM, Irby DM, Bowen JL, Burack JH, Carline JD, Stritter FT. Role models’ perceptions of themselves and their influence on students’ specialty choices. Acad Med 1997;72:1119-21. 14. Wright SM, Kern DE, Kolodner K, Howard DM, Brancati FL. Attributes of excellent attending physician role models. N Engl J Med 1998;339:1986-93. 15. Neumayer L, Kaiser S, Anderson K, Barney L, Curet M, Jacobs D, et al. Perceptions of women medical students and their influence on career choice. Am J Surg 2002;183:146-50. 16. Evans S, Sarani B. The modern medical school graduate and general surgical training. Arch Surg 2002;137:274-7. 17. McMurray JE, Schwartz MD, Genero NP, Linzer M. The attractiveness of internal medicine: a qualitative analysis of the experiences of female and male medical students. Ann Intern Med 1993;119:812-8. 18. Newton DA, Grayson MS, Whitley TW. What predicts medical student career choice? J Gen Intern Med 1998;13:200-3. 19. Losyk B. Generation X: what they think and what they plan to do. Public Management 1997;79:4-5. 20. Ullian JA, Bland CJ, Simpson DE. An alternative approach to defining the role of the clinical teacher. Acad Med 1994;69:832-8. 21. Wright S. Examining what residents look for in their role models. Acad Med 1996;71:290-2. 22. Polk HC. The declining interest in surgical careers, the primary care mirage, and concerns about contemporary undergraduate surgical education. Am J Surg 1999;178:177-9. 23. Nussbaum MS. What influences medical students’ choice of surgical careers: a critical appraisal [editorial]. Surgery 2000;128:257-8.
Background. Student perceptions of surgeons and surgical careers may influence their decision to pursue a surgical career. We evaluated the impact of a general surgery clerkship on medical student perceptions of surgeons and surgical careers and of the clerkship on student interest in surgical careers. Methods. We conducted voluntary pre- and postclerkship surveys of third-year medical students who were enrolled in their required general surgery clerkship and used 5-point Likert scale rankings to capture agreement with declarative statements (1 = strongly agree; 5 = strongly disagree). T-tests were used to evaluate both paired and individual items. Results. Students indicated that their surgical clerkship improved their opinion of surgeons (2.47; P < .001). Several perceptions changed after the clerkship. First, students agreed more strongly that surgeons were compassionate physicians (ranking, 2.87 vs 2.53; P = .003) and that patients respected surgeons (ranking, 1.84 vs 1.62; P = .026). Acknowledgment of career satisfaction by students increased (ranking, 2.57 vs 2.22; P = .008). Students more strongly disagreed that “surgeons [were] respectful of other physicians” (ranking, 3.29 vs 3.62; P = .009). Interest in surgical careers did not change significantly during the clerkship (ranking, 2.83 vs 2.68; P = .218). Conclusion. Medical student perceptions of surgeons and surgical careers generally improve during the surgical clerkship. However, student impressions of surgeons’ collegial behavior and commitment to teaching deteriorate significantly during the surgical clerkship. (Surgery 2003;134:153-7.) From the Salt Lake City Veterans Affairs Healthcare System and Department of Surgery, University of Utah Health Sciences Center, Salt Lake City, Utah; and the Office of Graduate Medical Education, University of Texas Health Science Center, San Antonio, Tex
in surgical careers is implicit in the recent National Residency Matching Program results. In 2001, 1041 categorical general surgery positions were offered through the National Residency Matching Program, but only 973 positions were filled.1 General surgery fared little better in 2002, when 1073 categorical positions were offered, and 981 positions were filled.2 The explanation for medical student diminishing interest in general surgery is clearly multifactorial.3 Lifestyle considerations are widely touted as a key element that drives medical student specialty selections.4-6 Spousal opinion may also DECLINING MEDICAL STUDENT INTEREST
Presented at the 64th Annual Meeting of the Society of University Surgeons, Houston, Texas, February 12-15, 2003. Reprint requests: Leigh A. Neumayer, MD, Department of Surgery, University of Utah Health Sciences Center, 30 North 1900 East, Room 3C410, Salt Lake City, UT 84132. © 2003 Mosby, Inc. All rights reserved. 0039-6060/2003/$30.00 + 0 doi:10.1067/msy.2003.216
influence choice of specialty, particularly when spouses disapprove of the commitment required of medical specialties with less controllable lifestyles.7 Role models, both positive and negative, strongly influence medical student selection of specialty.8-11 Thus, a key component of the apparent decreasing interest in general surgery may be the surgical profession’s failure to provide adequate role models for medical students. The common theme of these factors that are known to influence specialty selection is the student’s perception of both the specialty and its practitioners. Medical student perceptions of surgeons and surgical careers may begin before enrollment in a general surgery clerkship. However, the clerkship itself provides the most concentrated environment for these perceptions to evolve. Mutha et al8 showed that most medical students develop perceptions about specialties during their clinical clerkships. Further, most changes in medical student specialty selections occur during the third year of medical school.12 Despite these findings, SURGERY 153
154 Cochran, Paukert, and Neumayer
there has been no systematic evaluation of the impact of first-hand exposure to surgery as a discipline and to surgeons as physicians on student perceptions. The objective of this study was to examine the immediate impact of a general surgery clerkship on medical student perceptions of surgeons and surgical careers. METHODS Survey. All third-year medical students at the University of Utah are required to complete a 6week general surgery clerkship. During the 2001 through 2002 academic year, these students were asked to complete a voluntary survey at the beginning and the end of their surgery clerkship. The before and after clerkship surveys were nearly identical in content and questions. The surveys consisted largely of declarative statements followed by Likert scale rankings. One set of Likert scale rankings captured agreement with these statements: 1 indicated strong agreement, and 5 indicated strong disagreement. The other Likert scale indicated whether an item encouraged or discouraged the student from considering a surgical career, with a ranking of 1 indicating an item that strongly encouraged a student to consider a surgical career and a ranking of 5 indicating an item that strongly discouraged a student to consider a surgical career. Statistical analysis. Paired t-tests were used to compare before and after clerkship survey items. The Student t test compared items that appeared only on 1 survey only against a test value of 3. All data analysis was conducted with the use of SPSS for Windows 11.0.1 (SPSS, Inc, Chicago, Ill). The human subjects office at the University of Utah Health Sciences Center granted institutional review board approval for this project. RESULTS Of 98 students enrolled in the general surgery clerkship in 2001 through 2002, 93 students completed both surveys (response rate, 94.9%). Table I presents the significant changes in student perceptions of surgeons during the clinical clerkship. After the clerkship, students agreed more strongly that surgeons are compassionate physicians, are content with their career choice, and are respected by both other physicians and patients. Students tended to agree more strongly that surgeons provide good role models for medical students, although this item failed to attain statistical significance (mean before clerkship, 2.76; mean after clerkship, 2.71; P = .63). Students disagreed with the statement, “Surgeons lead well-balanced,
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rewarding lifestyles,” both before and after their clerkship, but tended to disagree less strongly after their clerkship (mean before clerkship, 3.91; mean after clerkship, 3.73; P = .062). Another positive finding was the shift away from students agreeing with the statement, “Surgeons are mean” (mean before clerkship, 2.21; mean after clerkship, 3.56; P < .001). Finally, students tended to agree more strongly with the statement, “I am possibly interested in a surgical career,” after their clerkship (mean before clerkship, 2.83; mean after clerkship, 2.68; P = .218). Student interest in a surgical career was encouraged more after the clerkship by the statements that appear in Table II; the significant items were identical to those from the perception Likert scale responses. Student encouragement to consider a surgical career on the basis of the statement, “Surgeons lead well-balanced, rewarding lifestyles,” was comparable to their agreement Likert scale responses. Although student discouragement to consider a surgical career was reflected in this statement both before and after the clerkship, the level of discouragement tended to decrease after the surgical clerkship (mean before clerkship, 3.87; mean after clerkship, 3.83; P = .685). Students indicated a more negative response to several survey statements after the clerkship. For example, after the clerkship, students disagreed more strongly that “Surgeons are respectful of other physicians” (mean before clerkship, 3.29; mean after clerkship, 3.62; P = .01). After the clerkship, survey respondents tended to agree less strongly with 2 statements, “Surgeons encourage medical students to consider careers in surgery” (mean before clerkship, 2.64; mean after clerkship, 2.76; P = .38), and “Surgeons actively participate in medical student education” (mean before clerkship, 2.52; mean after clerkship, 2.65; P = .29, paired Student t test). As one might expect, surgeons’ failure to promote consideration of surgical careers by medical students was 1 factor that tended to be less encouraging of student interest in a surgical career after the clerkship (mean before clerkship, 2.88 vs mean after clerkship, 2.95; P = .530). A worsened perception of surgeons’ participation in medical student education did not generate a significant shift in student encouragement to pursue a surgical career after the clerkship (mean before clerkship, 2.67 vs mean after clerkship, 2.78; P = .334). After the clerkship, students were discouraged to pursue a surgical career on the basis of their perceived disrespect of surgeons toward other clinicians, although this item narrowly failed to attain statisti-
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Table I. Factors with improved student perceptions after clerkship Statement Surgeons are compassionate physicians. Surgeons are generally content with their career choice. Surgeons are respected by other physicians. Surgeons are respected by patients.
Before clerkship (mean ± SEM)
After clerkship (mean ± SEM)
P value*
2.87 ± 0.09 2.57 ± 0.09 2.39 ± 0.10 1.84 ± 0.09
2.53 ± 0.09 2.22 ± 0.10 2.18 ± 0.09 1.62 ± 0.06
.003 .008 .047 .026
Likert scale values: 1 = strongly agree; 3= no opinion; 5= strongly disagree. t-tests, Wilcoxon rank-sum coefficients.
*Paired
Table II. Factors that are more encouraging of student interest in a surgical career after clerkship Factor Surgeons are compassionate physicians. Surgeons are generally content with their career choice. Surgeons are respected by other physicians. Surgeons are respected by patients.
Before clerkship (mean ± SEM)
After clerkship (mean ± SEM)
P value*
3.27 ± 0.09 2.90 ± 0.09 2.77 ± 0.08 2.44 ± 0.08
2.87 ± 0.11 2.59 ± 0.09 2.60 ± 0.07 2.18 ± 0.07
<.001 .004 .035 .002
Likert scale values: 1 = strongly encouraging; 3 = no impact; 5 = strongly discouraging. *Paired t-tests, Wilcoxon rank-sum coefficients.
cal significance (mean before clerkship, 3.32; mean after clerkship, 3.54; P = .054). Responses before and after the clerkship to the statement, “I am possibly interested in a surgical career,” were compared. The findings demonstrated a trend toward increased student receptivity to surgical careers after general surgery clerkships (mean before clerkship, 2.83; mean after clerkship, 2.68), although the change was not statistically significant (P = .218). Finally, in the postclerkship survey, students were asked to consider the statement, “This clerkship improved my opinion of surgeons.” Fig 1 shows the frequency distribution of student Likert scale rankings for this statement. The mean value of 2.47 was significantly different from the neutral test value of 3 (P < .001, Student t test). DISCUSSION The apparent decline in interest in general surgery as a career is clearly multifactorial. This survey explored whether student experience during a required general surgery clerkship influenced student interest in general surgery. The results indicate significant improvements in medical student perception of surgeons, particularly with regard to job satisfaction and prestige. The significant improvement in these perceptions was driven by an incremental improvement with most students, rather than extreme shifts that are generated by a few student “outliers.” However, some areas of student perceptions in the survey deteriorated markedly. Students left the clerkship dissatisfied with surgeons’ relationships with other physicians; again, this perception was widespread and was not driven by only a few students with extreme respons-
es. Students also tended to criticize the educational commitment of surgeons at the conclusion of the clerkship. Statements about mentorship and active participation in medical student education may have attained significance were a larger sample available. The indisputable reaction provided by the students is that they are receptive to the messages we communicate about our specialty, our practices, and our colleagues. The results of this study illustrate important facets in medical student perceptions of surgeons’ job satisfaction after a general surgery clerkship. In other studies, role models that were identified by students have indicated that the expression of enthusiasm for their specialty affected subsequent medical student specialty selection.13,14 Neumayer et al15 demonstrated that female medical students have a negative perception of career satisfaction in female surgeons, although the direct impact of this finding on specialty selection was not posited. Professional dissatisfaction has been described as an important attribute in negative role models and, therefore, in dissuasion from specialty selection.8,16 However, careful examination of job satisfaction among surgeons reveals that surgeons of both genders are generally content with their career choice.4 The discrepancy is that surgeons may not communicate effectively and consistently their job satisfaction to students. Job dissatisfaction has also been linked to lifestyle in many studies of medical student specialty selections by the descriptor “overworked.”3,8,17 This study’s results imply that student negative perceptions of the surgical lifestyle changed little during a surgical clerkship and that the surgical
156 Cochran, Paukert, and Neumayer
Fig 1. Frequency distribution of responses to the statement, “This clerkship improved my opinion of surgeons.” (1 = strongly agree; 5 = strongly disagree). The bars represent the number of student responses.
lifestyle was a detractor when medical students considered specialty choice. Lifestyle issues are certainly the most frequent justification given for the decrease in applicants for general surgery residencies.4-6 However, students who truly consider careers in general surgery were less likely to be discouraged from surgery on the basis of lifestyle.10 The ultimate impact of lifestyle on student selection of a career in general surgery needs more rigorous delineation. Prestige, as captured by respect for surgeons by patients and other physicians, may influence medical students to consider a surgical career. In this survey, students who noted this prestige were encouraged to consider surgical careers. However, this finding may not apply to all medical students. An inverse relationship has been documented between the selection of a primary care specialty and concern for prestige within the medical profession.18 Students who select surgical careers may view prestige as an important element of job satisfaction. If prestige is a motivating factor for medical students who seek a general surgery career, the trend in medical school curricula toward devaluing surgery and its subspecialties may affect student interest in surgical careers negatively.4 Thus, the predominant academic and political climate of the 1990s with its emphasis on primary care may have done little to encourage medical students to specialize in surgery. Another factor that may discourage medical students to specialize in surgery is the mixed message that students receive about surgeons’ professional behavior. In this survey, students more readily acknowledged after their clerkship that surgeons provided compassionate care. These respondents also indicated that professionalism toward patients positively influenced them to consider a surgical career. This finding is consistent with the identification of compassion as an important characteristic
Surgery August 2003 in good physician role models.13 However, responses to this survey revealed that medical students disapproved of surgeon behavior toward other physicians. The perceived disrespect of surgeons for other physicians in turn discouraged medical student interest in surgical careers. Rankings of the statement, “Surgeons are mean,” improved significantly after the surgical clerkship. This finding implies that the issue of respect toward other physicians is an isolated, albeit important, behavioral issue. Harmonious interpersonal relationships and a positive working environment are important elements of job satisfaction for members of the socalled “Generation X.”19 Fostering collegial relationships with other specialties is imperative if surgical educators are to reverse the decline in medical student interest in general surgery. Declining interest in general surgery may also be linked to student perceptions of surgeons as mentors and educators. Medical students often cite career guidance and encouragement as key components of mentoring.11 For both medical students and residents, teaching ability is one of the most important qualities in physicians who are role models.20,21 After their clinical clerkship in surgery, respondents felt less strongly that surgeons encouraged them to consider surgical careers. These students also seemed disappointed with surgeons’ involvement in medical student education. Several recent editorials have targeted this perception and have called for increased mentoring by surgeons as a key strategy for combating the deterioration of interest in surgical careers.22,23 Although attributes of excellent role models have been studied and specifically delineated in internal medicine, many of the criteria are rather explicit and do not extrapolate to academic surgical practice.14 Future research that specifies characteristics of outstanding surgical role models would contribute substantially to the understanding of mentoring in surgical education. Two summary statements provide insight into the overall impact of the surgical clerkship on medical student perceptions of surgeons and surgical careers. After their clerkship, our students were slightly more positive in their response to the statement, “I am possibly interested in a surgical career,” although this relationship failed to attain statistical significance. The absence of a significant negative finding in response to this statement is encouraging. In addition, most responding medical students agreed after their clerkship with the statement, “This clerkship improved my opinion of surgeons.” One explanation for their agreement with this statement may be that students simply have low opinions of surgeons before their clerk-
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ship or hold perceptions that are clouded in myth. In spite of several deficiencies that were identified through this survey, after an intense period of exposure medical students seemed to be generally more comfortable with surgeons. This study has several limitations. The survey was administered for only 1 academic year at a single institution, and there may be selection bias in the subjects. Selection bias may be real, because an unusually high number of students from the surveyed class selected general surgery or its subspecialties for their residency. A temporal bias may also exist because the surveys were administered during the last 3 days of student surgical clerkships. The results of the postclerkship survey might show some decay over time, although we did not examine this phenomenon. This study does confirm the complexity of medical student specialty selection. Recognition of the relevance of student perceptions may provide a crucial element to understanding student specialty selections. Perceptions of professionalism with patients, job satisfaction, and prestige all improved significantly in responding students after their clinical clerkship. Perceived unprofessional behavior with medical colleagues and failure to mentor and educate contributed to student negative inferences about surgery and surgeons. The varied responses to the statements in this survey illustrate the multifactorial nature of the decision-making algorithm that medical students use to select their specialty. Ongoing efforts hopefully will identify the critical factors in this decision-making process and will provide insight into the balance of positive and negative influences that are perceived by medical students in the selection of a medical specialty. REFERENCES 1. 2001 National resident matching program match data. Washington (DC): American Association of Medical Colleges; 2001. 2. 2002 National resident matching program match data. Washington (DC): American Association of Medical Colleges; 2002. 3. Richardson HC, Redfern N. Why do women reject surgical careers? Ann R Coll Surg Eng 2000;82(suppl):290-3.
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