Exploring Medical Students’ Perceptions of Organ Procurement: Need for a Formalized Medical Student Curriculum

ARTICLE IN PRESS ORIGINAL REPORTS

Exploring Medical Students’ Perceptions of Organ Procurement: Need for a Formalized Medical Student Curriculum Leah K. Winer, MD,* Matthew P. Vivero, MD,† Brendan F. Scully, MD,‡ Alexander R. Cortez, MD,* Al-Faraaz Kassam, MD,* Roman Nowygrod, MD,‡ Adam D. Griesemer, MD,x Jean C. Emond, MD,x and Ralph C. Quillin III, MD* *

Cincinnati Research on Education in Surgical Training (CREST), Department of Surgery, University of Cincinnati, Cincinnati, Ohio; †Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts; ‡Department of Surgery, Columbia University, New York, New York; and §Center for Liver Disease and Transplantation, Columbia University, New York, New York

OBJECTIVE: We evaluated the medical student experi-

CONCLUSIONS: Adding a structured curriculum may

ence with a deceased-donor multiorgan procurement program at a single center. The program provided the opportunity to assist with organ procurement, but no formal curriculum was offered.

turn medical students from passive observers into active learners, maximizing the educational value of procurement and better equipping future providers to promote organ donation. ( J Surg Ed 000:18. Ó 2019 Published by Elsevier Inc. on behalf of Association of Program Directors in Surgery.)

DESIGN, SETTING, PARTICIPANTS: In 2018, medical

students who registered for the program between 2014 and 2017 completed a voluntary survey about the experience and its impact on surgery interest and organ donation knowledge and advocacy. RESULTS: Of 139 respondents, 53.3% (N = 74) of stu-

dents participated in at least one procurement. The experience was resoundingly positive: 81.7% (N = 58) believed it exceeded expectations, with less than onethird missing class and only 4.3% (N = 3) reporting a negative impact on academics. Although 60.6% (N = 43) students studied prior to procurement, 57.8% (N = 41) expressed the need for increased preparation. Preferred learning modalities included videos, discussion with the transplant fellows, and focused anatomy overview. Following participation, 53.5% (N = 38) of students had increased interest in pursuing an acting internship and career in surgery. However, participation was not associated with improved familiarity with organ donation concepts or advocacy.

Presented at the 2019 American Transplant Congress and being submitted as an original manuscript to Journal of Surgical Education. Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Correspondence: Inquiries to R. Cutler Quillin III, MD, Cincinnati Research on Education in Surgical Training, Section of Transplantation, Department of Surgery, University of Cincinnati, 231 Albert Sabin Way, ML 0558, Cincinnati, OH; fax: (513) 558-8689; e-mail: [email protected]

KEY WORDS: Organ procurement, Organ donation,

Medical student education, Surgery interest COMPETENCIES: Patient Care, Medical Knowledge,

Practice-Based Learning and Improvement, Communication and interpersonal skills

INTRODUCTION Given the organ donor shortage in the United States, the importance of expanding the donor pool cannot be understated. Traditionally, efforts to combat organ shortage have focused on transplantation advocacy, policy, and public education. Health care professionals play a crucial role in addressing this problem, and their knowledge about and attitudes toward organ donation are essential for increasing donor rates.1 Communication with patients and families regarding donor eligibility, brain death, and the organ procurement process, particularly in the setting of end-of-life care, requires empathy, and cultural sensitivity.2,3 However difficult, the ability to hold such conversations is valuable, as greater communication between families and health care providers or organ procurement organization staff is associated with a higher probability of donation.4

Journal of Surgical Education  © 2019 Published by Elsevier Inc. on behalf of Association of Program Directors in 1931-7204/$30.00 Surgery. https://doi.org/10.1016/j.jsurg.2019.10.005

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ARTICLE IN PRESS Unfortunately, undergraduate medical education inadequately prepares students to advocate for organ donation. A 2006 study found that only 22% of medical students received education about organ donation and transplantation and were less knowledgeable about brain death than the general population.5 Prior work has found a significant gap in physicians’ understanding of medical and legal definitions of brain death and donor eligibility criteria.6 Among the few nursing and medical schools that do incorporate organ donation education into their curriculum, many fail to include pertinent topics or assess students’ retention.7 Deceased-donor multiorgan procurement shadowing programs may provide an opportunity for medical students to expand their knowledge of organ donation and transplantation early in training, with benefits ranging from professional development, confidence-building, and stress-reduction in the clinical setting.8 Despite some inherent limitations, including safety, liability, and unpredictable timing with frequent overnight travel and resultant fatigue, participation in procurement offers students a unique chance for surgical immersion.9 Over the past decade, the Allen O. Whipple Surgical Society, the medical student surgery interest group at Columbia University’s College of Physicians and Surgeons, has collaborated with the Center for Liver Disease and Transplantation to offer the Transplant Procurement Program. This program allows medical students to accompany the procurement team on deceased-donor multiorgan procurements. In this study, we set out to review students’ perceptions of this experience. We also assessed how participation in this program shaped medical students’ attitudes toward and knowledge about the organ procurement process, as well as their interest in pursuing further surgical training.

MATERIALS AND METHODS The Allen O. Whipple Surgical Society’s Transplant Procurement Program provides both preclinical and clinical medical students the opportunity to accompany the transplant procurement team on organ procurements. Registered students sign up for a voluntary call schedule, which is managed by a second-year medical student coordinator, providing a leadership opportunity within the surgical interest group. No formal education or orientation was provided to the students to participate in the program. When an organ becomes available, the procuring transplant surgeon notifies the student coordinator, who then arranges the participation of the on-call student. Typical composition of the procurement team includes a transplant surgery fellow, a surgical resident (either Columbia University or outside rotator), and a

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medical student. Students travel with the team, both locally and on fly-outs, assisting in the procurement, and sometimes, also the transplantation. Prior to going on procurement, students were not provided formal instruction about organ donation, procurement, or transplantation topics through the program. During the procurement experience itself, varying degrees of formal and informal education were provided by the procuring surgeon. Given the popularity of the program and sporadic nature of organ procurements, not all registered students could go on a procurement. To assess the procurement experience and its influence on organ transplant attitudes and knowledge, a voluntary and anonymous 28-question survey was administered to all students registered for the Transplant Procurement Program between the Fall of 2014 and 2017. Surveys were administered online using Survey Monkey (www.surveymonkey.com) in the Spring of 2018. Survey questions were all multiple-choice and included single-best answer and a 5-point Likert scale. Variables of interest included demographics, factors related to participation on procurement (i.e., number of runs, type of grafts procured, impact on academic performance, etc.), subjective measures of understanding about organ donation concepts, and attitudes toward organ donation. After survey collection, the student data was retrospectively analyzed. Primary outcomes included knowledge and attitudes toward organ donation and transplantation. Statistical analyses were performed using JMP Pro Version 14.0 (SAS Institute, Cary, NC). Descriptive statistics were reported as frequencies (n) and percentages (%) for categorical variables and medians and interquartile ranges for continuous variables. Pearson’s and Fisher’s exact tests were used to compare categorical variables, and p-values < 0.05 were considered statistically significant. The study was approved by the Columbia University Institutional Review Board (Protocol AAR6258).

RESULTS Procurement call coverage and participation data was available from September 2015 to December 2017. Over this time span, 75.1% (635 days) of potential call days were covered by 297 individual medical students. In total, students participated in 146 procurements, accounting for 58% of all procurements performed by Columbia’s Center for Liver Disease and Transplantation during that period of time. Surveys were completed by 139 medical students registered for the Transplant Procurement Program for an overall response rate of 46.8%. Table 1 details the demographics of the participant cohort. The majority of

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TABLE 1. Demographic Data of Medical Student Cohort Demographics

N (%) N = 139

Sex Male Female Age (median, IQR) Academic Year MS1 MS2 MS3 MS4 Member of Whipple Surgical Society? Interest in surgery? Registered organ donor prior to procurement? Most common reasons for signing up: Earlier exposure to surgery and operating room Learn about organ donation/allocation system Improve knowledge of anatomy Students had prior experience with: Being in the operating room Scrubbing Transplant related lectures Students had prior familiarity with: Thoracic anatomy Abdominal anatomy Tangible sights and sounds of OR Working and communication within hierarchy Sterile technique Basic surgical skills Procurement steps

54 (43.2%) 71 (56.8%) 24 (22-25) 36 (28.5%) 28 (22.2%) 29 (23.0%) 32 (25.4%) 43 (34.1%) 72 (51.8%) 93 (75.6%) 56 (47.1%) 27 (22.7%) 15 (12.6%) 99 (76.2%) 40 (30.8%) 19 (14.5%) 70 (54.7%) 66 (51.6%) 56 (43.8%) 37 (28.9%) 26 (20.5%) 7 (5.5%) 3 (2.3%)

Data expressed as N and percentage (%) or as median and interquartile range (IQR). MS, indicates medical school year.

respondents were female (n = 71, 56.8%) with a median age of 24 (22-25) years old. There was a near equal representation among all medical school classes participating in the procurement experience. Although only 34.1% (n = 43) were members of the surgical interest group, 51.8% (n = 72) of the respondents reported a preexisting interest in surgery and 75.6% (n = 93) were registered organ donors. The primary motivation for enrollment was earlier exposure to the operating room, followed by desire to learn about the organ donation and allocation systems. Table 2 outlines student perceptions of their participation in the Transplant Procurement Program. In total, 53.2% (n = 74) of registered survey respondents participated in at least one organ procurement while in medical school. Of the 65 respondents that did not go on an organ procurement, 72.3% (n = 47) did not go because a procurement did not occur on their call day. Among those who went on a procurement, there was equal participation by students in each medical school class, but a

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TABLE 2. Experience of Medical Students Who Participated in a Deceased-Donor Organ Procurement (N = 74) Procurement Variable Number of deceased-donor procurement runs 0 1 2 3 Organs procured Liver Kidney Liver/Kidney Multiple organs Quality of experience Greatly exceeded expectations Exceeded expectations Equaled expectations Fell short of expectations Fell far short of expectations Satisfied with organization of system Participant increased interest in: Surgical anatomy Eagerness toward surgery clerkship Pursuit of AI/elective in surgery Career in surgery Career in transplant surgery Career in transplant medicine Amount of time spent preparing None <30 min 30 min to 1 h 1 to 2 h Needed increased preparation Preferred preparatory tools (N = 59 respondents) COACH video detailing procurement procedure Discussing/briefing with transplant fellows Focused anatomy study materials Missed class School performance affected negatively Program best exemplified (N = 68 respondents) Tangible sights and sounds of OR Procurement steps Sterile technique Anatomy Working and communication within hierarchy Basic surgical skills

N (%) 65 (46.8%) 58 (41.7%) 11 (7.9%) 5 (3.6%) 32 (45.7%) 1 (1.4%) 19 (27.1%) 18 (25.7%) 37 (52.1%) 21 (29.6%) 10 (14.1%) 2 (2.8%) 1 (1.4%) 76 (61.3%) 57 (80.3%) 57 (83.8%) 38 (53.5%) 38 (53.5%) 25 (35.7%) 26 (37.1%) 28 (39.4%) 17 (23.9%) 20 (28.2%) 6 (8.5%) 41 (57.8%) 40 (68.0%) 29 (49.2%) 28 (47.5%) 22 (31.4%) 3 (4.3%) 42 (61.8%) 41 (60.3%) 40 (58.8%) 39 (57.4%) 18 (26.5%) 13 (19.1%)

AI, Acting internship; COACH, Columbia University Online Education Platform for Department of Surgery, contains operative guides, surgical videos, etc.

greater percentage of woman than men participated in the procurement experience (67.2% vs 32.8%, p = 0.03). The majority of procured grafts were livers. The procurement experience exceeded expectations in 81.7% (n = 58) of cases, and the program was considered wellorganized by 61.3% (n = 76) of students. Fewer than one-third missed class due to procurement, and only

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TABLE 3. Organ Donation Knowledge and Advocacy Outcomes of the Transplant Procurement Program Experience Outcomes of the Procurement Experience More likely to be organ donor More likely to encourage family and friends to be organ donor Discussion of experience has led others to become organ donor Familiarity with organ donation concepts: Severity of the organ shortage in the United States OPTN and UNOS Becoming listed for transplant (requirements, exclusions, etc.) Histocompatibility and medical factors involved in the matching and allocation Logistical factors involved in matching and allocation

No Procurement (N = 65)

Procurement (N = 74)

p Value

9 (21.4%) 32 (78.1%) 3 (7.1%)

4 (14.3%) 14 (50%) 2 (7.1%)

0.6675 0.0203 1.0000

41 (63.1%) 18 (28.6%) 28 (43.1%) 48 (73.9%)

40 (62.5%) 19 (29.7%) 21 (32.8%) 51 (79.7%)

0.9460 0.8899 0.2298 0.4323

22 (33.9%)

15 (23.4%)

0.1912

OPTN, Organ Procurement and Transplantation Network; UNOS, United Network for Organ Sharing.

4.3% (n = 3) believed their academic performance was compromised by procurement participation. Prior to the procurement experience, 39.4% (n = 28) did no preparation while another 52.1% (n = 37) studied for less than one hour. Only 8.5% (n = 6) studied for greater than one hour, and 57.8% (n = 41) felt that increased preparation was needed. Preferred learning modalities included a video detailing the procurement procedure, in-person discussion with the transplant fellows prior to the procurement, and a focused anatomy overview. Participants felt the procurement program best highlighted the sensory experience of the operating room, the procurement steps, and principles of sterile technique. Finally, 38 (53.5%) students reported increased interest in pursuing an acting internship and career in surgery after their procurement experience. Lastly, we analyzed whether participation in the Transplant Procurement Program was associated with enhanced organ donation advocacy or knowledge (Table 3). Organ procurement participation was not associated with greater likelihood of becoming an organ donor (p = 0.67). In fact, students who did not attend a procurement felt more inclined to encourage family and friends to become organ donors (78.1 % vs 50%, p = 0.02). Subjective understanding of organ shortage, listing requirements, immunology, or allocation was independent of exposure to organ procurement.

DISCUSSION In this survey-based study, we examined medical student participation in an organ procurement program as a means of improving transplantation knowledge and advocacy and encouraging interest in surgery. Overall, participants enjoyed their experience and found the program well-organized, with no significant negative ramifications on academic performance. However, participation was

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not associated with enhanced organ donation advocacy or knowledge, perhaps reflecting both the students’ failure to independently prepare and the lack of structured education prior to and during the procurement. Ultimately, this study reveals both strengths and areas for improvement that require optimization for greater educational impact. Given the substantial national organ shortage, the most important aim of this study was to determine whether organ procurement participation impacted donor registration and attitudes among students and/or their family and friends. We found no association between going on a procurement and organ donation status. However, this may be due to the study population’s high baseline of registered organ donors compared with the general population (76% vs 54%, respectively).10 With such a high rate of donor registration, organ donor status may not be a useful endpoint because there is a low ceiling for improvement and organ donor willingness is already associated with increased levels of medical training.1,11,12 Rather, the ubiquity of registered organ donors in our sample may reflect a selection bias, meaning that compared to nondonors, donors were more inclined to partake in both the program and survey. Concerningly, students who went on a procurement were less likely to encourage family and friends to become organ donors, which is similar to the findings of previous studies.1,12 This outcome may suggest that participants negatively perceived the program; however this is not supported by our data indicating that students largely enjoyed their experience. Rather, the deceaseddonor multiorgan procurement experience is an emotionally, physically, and ethically taxing procedure. Without appropriate context and preparation, students may potentially form a negative association with organ procurement, the process creating more detractors than supporters, regardless of students’ interest in surgery.

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TABLE 4. Review of Student Organ Procurement Education Literature Senior Author

Year Country

Intervention

Procurement Subjects Experience

Outcome measure

Effect

Vincent, DE

2008 U.S.A.

No

Medical students

Donation knowledge and willingness

+

Garcia, VD

2008 Brazil

Reading, didactic, standardized patients, case discussions Didactic (25 hours)

No

Donation knowledge and attitude

+

Roberts, J

2012 U.S.A.

Didactic

Yes

Medical, biomedical and nursing students Medical students

+/-

Gupta, A

2014 India

Interactive session

No

Medical students

Fukuhara, S

2015 Japan

Pamphlets, didactic

No

Donation knowledge and attitude Donation knowledge, willingness, and attitude Signing donor card

Van de Weil, 2017 Netherlands Didactic HBM Kulkarni, S 2018 India Didactic

No

First and third year medical students who were nondonors Primary school students Dental students

Orandi, BJ

Yes

Medical students

2019 U.S.A.

Didactic (3 months)

No

This assertion is supported by our findings that the majority of students prepared for less than one hour and did not report an improved understanding of organ donation concepts after the procurement experience. Taken together, the lack of both independent preparation and a structured curriculum may relegate medical students to passive observers, minimizing educational and altruistic benefits. Insufficient medical knowledge may serve to bolster mistrust, deterring students from encouraging their loved ones to become organ donors and ultimately blunting full appreciation of the experience.13 For the procurement experience to have a positive impact on transplantation knowledge and advocacy, the addition of a formalized curriculum may be valuable. This is also consistent with the 60% of survey respondents who felt they would have benefited from further preparation. Various educational programs have been piloted internationally with mostly promising results (Table 4).8,14-20 Two recent U.S. studies examined how didactic sessions and organ procurement together affected medical student knowledge and attitudes toward the field of transplantation. Zheng et al. explored the additive impact of procurement plus a semester-long didactic course compared with nonparticipation or lecture attendance alone.8 While the interventions significantly increased subjective perceptions of transplant knowledge, they did not improve objective assessment or

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Family discussions Donation knowledge, attitude, and practices Perceptions of field, diversity

+

+

+ + +/-

professed attitudes toward transplantation or organ donation. Another study from Feinstein et al. examined the impact of didactics and organ procurement on perceptions of a career in transplantation.14 Similar to the previous study, participants reported improved transplant knowledge but were no more likely to consider it as a career. These programs’ lack of success in achieving their primary outcomes does not suggest futility but rather highlights the difficulty of designing an effective organ procurement curriculum. Perhaps surprisingly, programs targeting health care professions students without the experiential component of procurement have been successful at meeting their endpoints and may provide a starting point for curriculum design. Feeley et al. implemented a one-hour lecture covering donor eligibility, brain death, consent, and matching; this was preceded by a required independent reading assignment and followed by small group discussion and cases with trained standardized patients.16 Objective transplant knowledge and attitudes toward discussing organ donation improved significantly in the 4-month period following the intervention. This program’s effectiveness may be a credit to its “flipped classroom” approach, a blended learning paradigm whereby students prepare before lecture and then reinforce the information.21,22 Previous studies demonstrate that interface with organ recipients positively influences donation attitudes and registration, so working with standardized

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ARTICLE IN PRESS patients may also illustrate the clinical importance of organ donation.13,15 Barriers to implementing these programs include both limited time in the medical school curriculum and funding, so digital media strategies and incorporation of teaching into existing modules are prudent. Deliberate intraoperative teaching may also optimize the procurement experience. Proposed by Roberts et al. in 2009, the “Briefing, Intraoperative teaching, Debriefing” (BID) model actively involves the learner in creating learning objectives within the constraints of the operating room.23 In the setting of procurement, briefing would involve a “needs assessment” during transit to the donor center or at the scrub sink. Intraoperative teaching would focus on these objectives, and debriefing would require participants to reflect on whether they met learning objectives. The BID model is a zero-cost method that could improve the educational value of procurement without jeopardizing resident education or patient safety while asking little effort from the procuring surgeon. With repeated practice, procuring transplant surgeons would develop scripts based on common learning needs, automating intraoperative teaching and mitigating some inertia of fatigue. This approach is also consistent with learner needs identified in our study; when asked to evaluate the most helpful modalities to prepare for procurement, nearly 50% of respondents preferred in-person discussion with the procuring transplant fellow. Whereas the number of general surgery residency applications has been mostly stable between 1999 and 2014, U.S. transplant surgery fellowships only fill 75% of their positions.24,25 Thus, a secondary objective of involving medical students in organ procurement experience is promotion of general and/or transplant surgery careers. Such efforts to include medical students are important because career interest may be most impressionable early in training.26-28 Previous studies have demonstrated that medical students on the surgery clerkship prefer active learning,29 and the acquisition and practice of technical skills influence student decisions to enter the surgical field.30-33 In the current study, 84% of participants expressed increased eagerness toward their thirdyear surgery clerkship, and greater than 50% had an increased interest in an acting internship and/or a career in surgery after procurement. Although the present study did not directly address perceptions of the technical elements of procurement, allowing participants to hold retractors, suction, apply energy devices, or suture the abdominal wall may have encouraged surgical career interest, consistent with these previous data. There are several limitations to this study. First, it is retrospective so conclusions about causation cannot be made. Second, any survey-based study is inherently susceptible to selection bias, as well as differences among

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respondents and non-respondents. However, perceptions of procurement experience quality were not correlated with students’ preexisting interest in surgery, mitigating some concern about respondent partiality. In addition, the survey was administered at variable times relative to participation in the procurement experience, varying from several months to years. This likely introduced some recency bias. Third, because surveys generate only self-reported data, future studies should examine translational outcomes, such as actual donor registration and residency match results among students who participated in transplant-related education programs and/or procurement. Finally, broad implementation of such a program, as suggested, may be limited by individual program policies regarding student travel and safety in the event of an accident. One potential solution is to have participating students sign a Release of Liability, should they not be covered under a center’s insurance policy. Student participation in deceased-donor multiorgan procurement provides early exposure to the operating room and is associated with interest in surgery. However, we identified several shortcomings that need attention to optimize the program’s educational and altruistic potential. The addition of a structured curriculum incorporating didactics and personal contact with actual organ recipients, as well as deliberate intraoperative teaching, may maximize the educational experience and better equip future providers to discuss and promote organ donation. Efforts to develop, evaluate, refine, and broadly implement such a curriculum at any U.S. medical school with a transplantation program may empower thousands of rising physicians to become advocates for organ donation.

ACKNOWLEDGMENTS The authors would like to thank all of the surgical transplant fellows at Columbia University and the medical student coordinators within the Allen O. Whipple Surgical Society who worked to involve medical students in the deceased donor procurement experience over the years.

REFERENCES 1. Hobeika MJ, Simon R, Malik R, et al. U.S. surgeon

and medical student attitudes toward organ donation. J Trauma. 2009;67:372–375. 2. Aulisio MP, Devita M, Luebke D. Taking values seri-

ously: ethical challenges in organ donation and transplantation for critical care professionals. Crit Care Med. 2007;35:S95–101.

Journal of Surgical Education  Volume 00 /Number 00  Month 2019

ARTICLE IN PRESS 3. Siminoff LA, Lawrence RH, Arnold RM. Comparison

15. Murakami M, Fukuma S, Ikezoe M, et al. Effect of an

of black and white families’ experiences and perceptions regarding organ donation requests. Crit Care Med. 2003;31:146–151.

educational program on attitudes towards deceased organ donation. Ann Transplant. 2015;20:269–278.

4. Siminoff LA, Gordon N, Hewlett J, Arnold RM. Factors

influencing families’ consent for donation of solid organs for transplantation. JAMA. 2001;286:71–77. 5. Essman C, Thornton J. Assessing medical student

16. Feeley TH, Tamburlin J, Vincent DE. An educational

intervention on organ and tissue donation for first-year medical students. Prog Transplant. 2008;18:103–108. 17. Ramadurg UY, Gupta A. Impact of an educational

knowledge, attitudes, and behaviors regarding organ donation. Transplant Proc. 2006;38: 2745–2750.

intervention on increasing the knowledge and changing the attitude and beliefs towards organ donation among medical students. J Clin Diagn Res. 2014;8:JC05–JC07.

6. Siminoff LA, Arnold RM, Caplan AL. Health care pro-

18. Srinivasula S, Srilatha A, Doshi D, Reddy BS, Kulkarni

fessional attitudes toward donation: effect on practice and procurement. J Trauma. 1995;39:553–559.

S. Influence of health education on knowledge, attitude, and practices toward organ donation among dental students. J Educ Health Promot. 2018;7:157.

7. Anker AE, Feeley TH, Friedman E, Kruegler J. Teach-

ing organ and tissue donation in medical and nursing education: a needs assessment. Prog Transplant. 2009;19:343–348. 8. Zheng P, Sammann A, Qiu M, Lee R, O’Sullivan P,

Roberts J. Impact of preclinical exposure to organ donation on knowledge and attitudes of medical students. Prog Transplant. 2012;22:79–85. 109. 9. Englesbe MJ, Merion RM. The riskiest job in medi-

cine: transplant surgeons and organ procurement travel. Am J Transplant. 2009;9:2406–2415. 10. Organ Donation Statistics. Health Resources and Serv-

ices Administration; 2019. https://www.organdonor. gov/statistics-stories/statistics.html. Accessed 5 March 2019. 11. Schaeffner ES, Windisch W, Freidel K, Breitenfeldt K,

Winkelmayer WC. Knowledge and attitude regarding organ donation among medical students and physicians. Transplantation. 2004;77:1714–1718. 12. Green C, Bowden D, Molony D, Burke N, Felle P,

Dudeney S. Attitudes of the medical profession to whole body and organ donation. Surgeon. 2014;12:73–77. 13. Atamanuk AN, Ortiz Fragola JP, Giorgi M, et al. Medi-

cal students’ attitude toward organ donation: understanding reasons for refusal in order to increase transplantation rates. Transplant Proc. 2018;50: 2976–2980. 14. Feinstein MA, Marcus SG, Amara DP, Durcanova B,

Roll GR, Orandi BJ. The effect of an organ procurement experience on preclinical medical student perceptions of transplant surgery. Clin Transplant. 2019;33:e13505.

Journal of Surgical Education  Volume 00 /Number 00  Month 2019

19. Garcia CD, Barboza AP, Goldani JC, et al. Educa-

tional program of organ donation and transplantation at medical school. Transplant Proc. 2008;40:1068–1069. 20. Siebelink MJ, Verhagen AAE, Roodbol PF, Albers M,

Van de Wiel HBM. Education on organ donation and transplantation in primary school; teachers’ support and the first results of a teaching module. PLoS One. 2017;12:e0178128. 21. Jensen JL, Kummer TA, dM Godoy PD. Improvements

from a flipped classroom may simply be the fruits of active learning. CBE Life Sci Educ. 2015;14. ar5. 22. Prober CG, Khan S. Medical education reimagined: a

call to action. Acad Med. 2013;88:1407–1410. 23. Roberts NK, Williams RG, Kim MJ, Dunnington GL.

The briefing, intraoperative teaching, debriefing model for teaching in the operating room. J Am Coll Surg. 2009;208:299–303. 24. Are C, Stoddard H, Carpenter LA, O’Holleran B,

Thompson JS. Trends in the match rate and composition of candidates matching into categorical general surgery residency positions in the United States. Am J Surg. 2017;213:187–194. 25. Reich DJ, Magee JC, Gifford K, et al. Transplant sur-

gery fellow perceptions about training and the ensuing job market-are the right number of surgeons being trained? Am J Transplant. 2011;11:253–260. 26. Berger AP, Giacalone JC, Barlow P, Kapadia MR,

Keith JN. Choosing surgery as a career: early results of a longitudinal study of medical students. Surgery. 2017;161:1683–1689.

7

ARTICLE IN PRESS 27. Branstetter BFt, Faix LE, Humphrey AL, Schumann

JB. Preclinical medical student training in radiology: the effect of early exposure. AJR Am J Roentgenol. 2007;188:W9–14. 28. Erzurum VZ, Obermeyer RJ, Fecher A, et al. What

influences medical students’ choice of surgical careers. Surgery. 2000;128:253–256. 29. Cortez AR, Winer LK, Kim Y, Hanseman DJ, Athota

KP, Quillin RC 3rd.. Predictors of medical student success on the surgery clerkship. Am J Surg. 2019;217:169–174.

the operating room. J Am Coll Surg. 2008;207: 793–800. e791-792. 31. 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. 32. O’Neill R, Shapiro M, Merchant A. The role of the

operating room in medical student education: differing perspectives of learners and educators. J Surg Educ. 2018;75:14–28.

30. Berman L, Rosenthal MS, Curry LA, Evans LV, Gus-

33. Schmidt LE, Cooper CA, Guo WA. Factors influenc-

berg RJ. Attracting surgical clerks to surgical careers: role models, mentoring, and engagement in

ing US medical students’ decision to pursue surgery. J Surg Res. 2016;203:64–74.

SUPPLEMENTARY INFORMATION Supplementary material associated with this article can be found in the online version at doi:10.1016/j. jsurg.2019.10.005.

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