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Medical student contact with patients on a surgery clerkship: is there a chance to learn?
Medical Student Contact with Patients on a Surgery Clerkship: Is There a Chance to Learn? Margaret L Boehler, RN, MS, Cathy J Schwind, RN, MS, Gary Dunnington, MD, FACS, David A Rogers, MD, FACS, Roland Folse, MD, FACS Earlier studies of medical students on nonsurgical rotations have shown that clinical clerks usually first interact with their patients late in the clinical course. This would seem disadvantageous to the student’s learning because they would have less opportunity to generate diagnoses or a management plan. STUDY DESIGN: A questionnaire designed to assess the nature of medical student-patient interactions in all potential clinical sites was administered to third year medical students during their surgical clerkship. Students received questionnaires each day to evaluate their clinical experiences from the previous day. RESULTS: The results from 311 student-patient encounters were collected and analyzed by clinical site as follows: outpatient clinics, outpatient surgery, inpatient surgery, day of surgery admission, inpatient consults, or emergency room consults. Students reported significantly more opportunities to elicit chief complaint, generate potential diagnosis, develop or suggest a management plan, and perform the initial examination when in the clinic setting. CONCLUSIONS: Overall, students were given relatively few opportunities to be the first to interact with any patient in any setting. They infrequently had an opportunity to independently generate a hypothesis or generate a management plan. Currently, the clinic offers the best opportunity for the student to complete these processes. (J Am Coll Surg 2002;195:539–542. © 2002 by the American College of Surgeons) BACKGROUND:
A major goal of surgical medical student education is to provide the student with opportunities for developing an understanding of common surgical presentations along with common principles of patient management.1-3 Changes in health care delivery have changed the way surgical patients and students interact. Outpatient surgery has become predominant, and the elimination or reduction of preoperative hospitalizations diminishes opportunities to engage in the assessment and management of surgical patients.2 Because of the emphasis on decreased hospital stays, students see patients only after an extensive process of referrals that provides answers to questions the students have not even
asked.2 These and other changes inhibit the student’s development of critical thinking skills4,5 because the student cannot help but be influenced by the given diagnoses. Others have shown that medical students have limited opportunities to develop the clinical skills of hypothesis generation, problem solving, and investigation and management in nonsurgical environments.6 Given the changing environment of health care delivery,7,8 we became interested in determining if this was also true for students in a surgical clerkship. We were specifically interested in assessing the point at which students entered the evaluation process with a patient and if they had an opportunity to independently assess the patient and generate a plan.
No competing interests declared.
Presented at the moderated poster session of the Association for Surgical Education, 2001, Boston, MA.
METHODS A questionnaire designed to assess the nature of medical student-patient interactions in all potential clinical sites was administered to 20 third year medical students during their 10-week surgical clerkship. The questionnaires were designed to capture the opportunities that the stu-
Received February 7, 2002; Revised April 26, 2002; accepted June 3, 2002. From the Department of Surgery, Southern Illinois University School of Medicine, Springfield, IL. Correspondence address: Margaret L Boehler, RN, MS, Southern Illinois University School of Medicine, Department of Surgery, PO Box 19655, Springfield, IL 62794-9655.
© 2002 by the American College of Surgeons Published by Elsevier Science Inc.
539
ISSN 1072-7515/02/$21.00 PII S1072-7515(02)01326-1
540
Boehler et al
Patient Contact on a Surgery Clerkship
J Am Coll Surg
Table 1. Questionnaire Results
Student responses
First to elicit history of chief complaint Performed the initial surgical physical exam Asked to generate the initial hypotheses Opportunity was given to develop management plan Knew the diagnosis before workup Had access to and reviewed previous medical records
Clinic (%) n ⴝ 104
Day of surgery admission (%) n ⴝ 60
Inpatient surgery (%) n ⴝ 46
Outpatient surgery (%) n ⴝ 86
Overall (%) n ⴝ 311
59.6*
5.0
4.3
0.0
25.1
70.2*
25.0
8.7
17.4
36.3
29.8*
8.3
2.2
4.7
14.8
23.1*
8.3
0.0
3.5
11.6
75.0*
91.7
93.5
91.9
85.2
76.0
86.7
87
80.2
80.1
*Statistically significant by chi-square tests of independence at p ⬍ 0.05.
dent had to generate diagnoses and patient management plans. The questionnaire, composed of eight questions, elicited information to determine at what point the student first interacted in the patient’s care. For example, students were asked such questions as, “Were you the first to elicit the history of the chief complaint? Did you have access to and review any previous medical records? Were you asked to generate the hypotheses? Were you given the opportunity to suggest what initial investigations should be ordered?” Students received questionnaires each day in order to evaluate all of their clinical experiences from the previous day including outpatient clinics, outpatient surgery, inpatient consults, emergency room consults, day of surgery admission, and inpatient surgery. Students recorded all patient contacts in logbooks that were reviewed on a weekly basis by surgery department nurse instructors to ensure accuracy. Collection of surveys continued until further data input no longer influenced statistical trends. Chi-square tests of independence were used to determine any significant differences between the clinical sites. RESULTS Results from 311 student-patient encounters were categorized by clinical site. These 311 questionnaires represented 80% of all student-patient encounters that occurred during this time frame as determined by reviewing the student’s daily logbooks. Inpatient and emergency room consults occurred so infrequently (9 inpatient consults and 6 emergency room consults) that
they were not included in the final analysis. Frequency data did reveal that 67% of the patient interactions in the emergency room did give the student the opportunity to generate potential diagnoses and formulate management plans. Students reported considerably more opportunities to elicit chief complaint, generate potential diagnoses, develop or suggest a management plan, and perform the initial examination when in the clinic setting (Table 1). Inpatient surgery encounters least often offered students opportunities to develop their critical thinking skills. Outside of clinics, students interact most often with patients after pertinent data acquisition by others has occurred. DISCUSSION Our results demonstrate that in most learning settings on the surgical clerkship, students rarely have the opportunity to be the initial investigator. These results are very similar to the results reported by McLeod and Meagher,6 in which medicine clerks were initial investigator in less than 5% of the total patient encounters included in their study. This has been shown to limit the opportunity for students to independently generate a diagnosis and management plan, fundamental skills that they should be developing at this point in their education.1,6,9,10 In contrast to other sites, our results illustrated that students are more often able to engage in critical thinking in the clinic. Although this was the best setting, it is important to recognize that even in the clinic, students were given the opportunity to generate a diagnosis or
Vol. 195, No. 4, October 2002
plan in less than 30% of the cases. This might be occurring as a result of several issues, such as lack of faculty time because of rushed clinic schedules or student assignment to patients already late in their course of therapy. Microskills teaching is a five-step model of clinical teaching that uses distinct steps that provide a supportive learning environment. We believe that by introducing faculty to the concept of microskills teaching, we will provide them with skills necessary to take advantage of the time available in clinic for optimal student learning while minimizing interference in cost-effective clinical practice.11-13 We also believe that the educational experience for the medical students could be substantially improved in the clinic by training the clinic staff to identify the most suitable patients for student’s evaluation (eg, new patients). With this change, students would be more likely to generate diagnosis and management plans. Several published articles3,5,9,14-16 have presented the expanding role and training implications of teaching in ambulatory settings. As many of these publications point out, not only are overall patient interactions increasing in this arena, there are existing opportunities for valuable student-patient interactions. As seen in our study, other clinical sites do not offer students the opportunity to develop initial diagnoses or management plans. Opportunities to see patients throughout the perioperative process, in the same day, are unique to the ambulatory surgical setting. This educational opportunity is often lost because of the pressure to push the patient through the system efficiently. O’Driscoll and colleagues14 have offered a number of possible suggestions for improving student education in this setting. Students followed patients that they had previously seen in the preadmission clinic and were responsible for writing up the preoperative surgical history and physical, determining the provisional diagnosis, and assessing the patient’s suitability for ambulatory surgery. On the day of surgery the student would assist in surgery, assess the patient during the recovery process, determine appropriateness for discharge, and provide discharge instructions. Because postoperative care is most likely to be the responsibility of the patient’s general health care provider, they complete this process by making a followup phone call to their patients to assess any potential postoperative complications. Even though there were statistically insignificant
Boehler et al
Patient Contact on a Surgery Clerkship
541
numbers of both inpatient and emergency room consults that students performed, it appeared that students allowed to participate in any patient consult were almost always given the opportunity to develop initial diagnoses and management plans. One way to ensure student exposure to patient consults would be to assign students for daily consulting responsibilities on a rotational basis. It can be assumed that this would provide potentially one of the most educationally rich opportunities for students to formulate diagnoses and develop management skills on a diverse population of patients. Our medical school has recently undergone a curriculum revision that has increased the frequency of clinical encounters in the first 2 years of medical school. Previously, patient contact was generally limited to the second year, when students were given the requirement to complete a history and physical on only a few hospitalized patients. Even though the amount of patient contact has increased to an average of 3 hours per week, there is no evidence that the quality of these encounters will provide students the types of experience that will most likely allow them to develop their diagnostic and management skills. We cannot expect that the surgery clerkship can or should provide all the tools that students need in order to provide optimal health care. What we should be concerned about is providing efficient and appropriate use of a medical student’s educational opportunities. More studies are needed to establish exactly when and where medical students are given these crucial opportunities to develop these necessary skills. This would allow us to develop a coordinated curriculum throughout all 4 years that would ensure that each student is given ample opportunity to develop the necessary skills of diagnosis and development of a management plan. In conclusion, the goal of medical education, starting with the first year of medical school and continuing through residency, is for students to attain a level of competence that will satisfy the health care needs of their patients. It has been revealed in the literature that expert skills are not developed by simply more experience.17 So we cannot expect that this will be accomplished as an automatic consequence of simply more clinical experience but rather through structured learning in appropriate settings. Author Contributions
Study conception and design: Boehler, Schwind, Dunnington Acquisition of data: Boehler, Schwind
542
Boehler et al
Patient Contact on a Surgery Clerkship
Analysis and interpretation of data: Boehler Drafting of manuscript: Boehler Critical revision: Schwind, Dunnington, Rogers, Folse REFERENCES 1. DaRosa DA, Prystowsky JB, Nahrwold DL. Evaluating a clerkship curriculum: description and results. Teach Learn Med 2000;13:1–26. 2. Barrows HS. The scope of clinical education. J Med Educ 1986; 61:3–33. 3. Prideaux DJ, Marshall VR. A “common” surgery curriculum: health care delivery and undergraduate surgical education in Australian teaching hospitals. World J Surg 1994;18:657–661. 4. Moskowitz AJ, Kuipers BJ, Kassirer JP. Dealing with uncertainty, risks, and tradeoffs in clinical decisions. Ann Intern Med 1988;108:435–449. 5. Kassirer JP. Teaching problem solving. How are we doing? N Engl J Med 1995;332:1507–1509. 6. McLeod PJ, Meagher TW. Internal medicine clinical teaching unit: is it an inappropriate site for student learning? Teach Learn Med 1999;11:92–195. 7. Berman JB, Bergen MR, Skeff KM. Feasibility of incorporating alternative teaching methods into clinical clerkships. Teach Learn Med 1990;2:98–103.
J Am Coll Surg
8. Maddern GJ. The changing pattern of surgery. J Surg 1996;83: 145–146. 9. McLeod PJ, Snell L. Casemix in an internal medicine clerkship: educational value of the clinical problems seen. J Gen Intern Med 1991;6:455–459. 10. Benbassat J, Cohen R. Clinical instruction and cognitive development of medical students. Lancet 1982;1:195–97. 11. Neher JO, Gordon KC, Meyer B, Stevens N. A five-step “Microskills” model of clinical teaching. J Am Board Fam Pract 1992;5:419–424. 12. Ferenchick G, Simpson D, Blackman J, et al. Strategies for efficient and effective teaching in ambulatory care settings. Acad Med 1997;72:277–280. 13. Dunnington G, DaRosa D. A prospective randomized trial of a residents-as-teachers training program. Acad Med 1998;73: 696–700. 14. O’Driscoll MCE, Rudkin GE, Carty VM. Day surgery: teaching the next generation. Med Educ 1998;32:390–395. 15. Sharp RJ, Wellwood J. The training implications of day-case surgery. Br J Hosp Med 1996;55:472–475. 16. Irby DM. Teaching and learning in ambulatory care settings: A thematic review of the literature. Acad Med 1995;70:898– 931. 17. Ericsson KA, Charness N. Expert performance: its structure and acquisition. Am Psychol 1994;9:725–747.
A major goal of surgical medical student education is to provide the student with opportunities for developing an understanding of common surgical presentations along with common principles of patient management.1-3 Changes in health care delivery have changed the way surgical patients and students interact. Outpatient surgery has become predominant, and the elimination or reduction of preoperative hospitalizations diminishes opportunities to engage in the assessment and management of surgical patients.2 Because of the emphasis on decreased hospital stays, students see patients only after an extensive process of referrals that provides answers to questions the students have not even
asked.2 These and other changes inhibit the student’s development of critical thinking skills4,5 because the student cannot help but be influenced by the given diagnoses. Others have shown that medical students have limited opportunities to develop the clinical skills of hypothesis generation, problem solving, and investigation and management in nonsurgical environments.6 Given the changing environment of health care delivery,7,8 we became interested in determining if this was also true for students in a surgical clerkship. We were specifically interested in assessing the point at which students entered the evaluation process with a patient and if they had an opportunity to independently assess the patient and generate a plan.
No competing interests declared.
Presented at the moderated poster session of the Association for Surgical Education, 2001, Boston, MA.
METHODS A questionnaire designed to assess the nature of medical student-patient interactions in all potential clinical sites was administered to 20 third year medical students during their 10-week surgical clerkship. The questionnaires were designed to capture the opportunities that the stu-
Received February 7, 2002; Revised April 26, 2002; accepted June 3, 2002. From the Department of Surgery, Southern Illinois University School of Medicine, Springfield, IL. Correspondence address: Margaret L Boehler, RN, MS, Southern Illinois University School of Medicine, Department of Surgery, PO Box 19655, Springfield, IL 62794-9655.
© 2002 by the American College of Surgeons Published by Elsevier Science Inc.
539
ISSN 1072-7515/02/$21.00 PII S1072-7515(02)01326-1
540
Boehler et al
Patient Contact on a Surgery Clerkship
J Am Coll Surg
Table 1. Questionnaire Results
Student responses
First to elicit history of chief complaint Performed the initial surgical physical exam Asked to generate the initial hypotheses Opportunity was given to develop management plan Knew the diagnosis before workup Had access to and reviewed previous medical records
Clinic (%) n ⴝ 104
Day of surgery admission (%) n ⴝ 60
Inpatient surgery (%) n ⴝ 46
Outpatient surgery (%) n ⴝ 86
Overall (%) n ⴝ 311
59.6*
5.0
4.3
0.0
25.1
70.2*
25.0
8.7
17.4
36.3
29.8*
8.3
2.2
4.7
14.8
23.1*
8.3
0.0
3.5
11.6
75.0*
91.7
93.5
91.9
85.2
76.0
86.7
87
80.2
80.1
*Statistically significant by chi-square tests of independence at p ⬍ 0.05.
dent had to generate diagnoses and patient management plans. The questionnaire, composed of eight questions, elicited information to determine at what point the student first interacted in the patient’s care. For example, students were asked such questions as, “Were you the first to elicit the history of the chief complaint? Did you have access to and review any previous medical records? Were you asked to generate the hypotheses? Were you given the opportunity to suggest what initial investigations should be ordered?” Students received questionnaires each day in order to evaluate all of their clinical experiences from the previous day including outpatient clinics, outpatient surgery, inpatient consults, emergency room consults, day of surgery admission, and inpatient surgery. Students recorded all patient contacts in logbooks that were reviewed on a weekly basis by surgery department nurse instructors to ensure accuracy. Collection of surveys continued until further data input no longer influenced statistical trends. Chi-square tests of independence were used to determine any significant differences between the clinical sites. RESULTS Results from 311 student-patient encounters were categorized by clinical site. These 311 questionnaires represented 80% of all student-patient encounters that occurred during this time frame as determined by reviewing the student’s daily logbooks. Inpatient and emergency room consults occurred so infrequently (9 inpatient consults and 6 emergency room consults) that
they were not included in the final analysis. Frequency data did reveal that 67% of the patient interactions in the emergency room did give the student the opportunity to generate potential diagnoses and formulate management plans. Students reported considerably more opportunities to elicit chief complaint, generate potential diagnoses, develop or suggest a management plan, and perform the initial examination when in the clinic setting (Table 1). Inpatient surgery encounters least often offered students opportunities to develop their critical thinking skills. Outside of clinics, students interact most often with patients after pertinent data acquisition by others has occurred. DISCUSSION Our results demonstrate that in most learning settings on the surgical clerkship, students rarely have the opportunity to be the initial investigator. These results are very similar to the results reported by McLeod and Meagher,6 in which medicine clerks were initial investigator in less than 5% of the total patient encounters included in their study. This has been shown to limit the opportunity for students to independently generate a diagnosis and management plan, fundamental skills that they should be developing at this point in their education.1,6,9,10 In contrast to other sites, our results illustrated that students are more often able to engage in critical thinking in the clinic. Although this was the best setting, it is important to recognize that even in the clinic, students were given the opportunity to generate a diagnosis or
Vol. 195, No. 4, October 2002
plan in less than 30% of the cases. This might be occurring as a result of several issues, such as lack of faculty time because of rushed clinic schedules or student assignment to patients already late in their course of therapy. Microskills teaching is a five-step model of clinical teaching that uses distinct steps that provide a supportive learning environment. We believe that by introducing faculty to the concept of microskills teaching, we will provide them with skills necessary to take advantage of the time available in clinic for optimal student learning while minimizing interference in cost-effective clinical practice.11-13 We also believe that the educational experience for the medical students could be substantially improved in the clinic by training the clinic staff to identify the most suitable patients for student’s evaluation (eg, new patients). With this change, students would be more likely to generate diagnosis and management plans. Several published articles3,5,9,14-16 have presented the expanding role and training implications of teaching in ambulatory settings. As many of these publications point out, not only are overall patient interactions increasing in this arena, there are existing opportunities for valuable student-patient interactions. As seen in our study, other clinical sites do not offer students the opportunity to develop initial diagnoses or management plans. Opportunities to see patients throughout the perioperative process, in the same day, are unique to the ambulatory surgical setting. This educational opportunity is often lost because of the pressure to push the patient through the system efficiently. O’Driscoll and colleagues14 have offered a number of possible suggestions for improving student education in this setting. Students followed patients that they had previously seen in the preadmission clinic and were responsible for writing up the preoperative surgical history and physical, determining the provisional diagnosis, and assessing the patient’s suitability for ambulatory surgery. On the day of surgery the student would assist in surgery, assess the patient during the recovery process, determine appropriateness for discharge, and provide discharge instructions. Because postoperative care is most likely to be the responsibility of the patient’s general health care provider, they complete this process by making a followup phone call to their patients to assess any potential postoperative complications. Even though there were statistically insignificant
Boehler et al
Patient Contact on a Surgery Clerkship
541
numbers of both inpatient and emergency room consults that students performed, it appeared that students allowed to participate in any patient consult were almost always given the opportunity to develop initial diagnoses and management plans. One way to ensure student exposure to patient consults would be to assign students for daily consulting responsibilities on a rotational basis. It can be assumed that this would provide potentially one of the most educationally rich opportunities for students to formulate diagnoses and develop management skills on a diverse population of patients. Our medical school has recently undergone a curriculum revision that has increased the frequency of clinical encounters in the first 2 years of medical school. Previously, patient contact was generally limited to the second year, when students were given the requirement to complete a history and physical on only a few hospitalized patients. Even though the amount of patient contact has increased to an average of 3 hours per week, there is no evidence that the quality of these encounters will provide students the types of experience that will most likely allow them to develop their diagnostic and management skills. We cannot expect that the surgery clerkship can or should provide all the tools that students need in order to provide optimal health care. What we should be concerned about is providing efficient and appropriate use of a medical student’s educational opportunities. More studies are needed to establish exactly when and where medical students are given these crucial opportunities to develop these necessary skills. This would allow us to develop a coordinated curriculum throughout all 4 years that would ensure that each student is given ample opportunity to develop the necessary skills of diagnosis and development of a management plan. In conclusion, the goal of medical education, starting with the first year of medical school and continuing through residency, is for students to attain a level of competence that will satisfy the health care needs of their patients. It has been revealed in the literature that expert skills are not developed by simply more experience.17 So we cannot expect that this will be accomplished as an automatic consequence of simply more clinical experience but rather through structured learning in appropriate settings. Author Contributions
Study conception and design: Boehler, Schwind, Dunnington Acquisition of data: Boehler, Schwind
542
Boehler et al
Patient Contact on a Surgery Clerkship
Analysis and interpretation of data: Boehler Drafting of manuscript: Boehler Critical revision: Schwind, Dunnington, Rogers, Folse REFERENCES 1. DaRosa DA, Prystowsky JB, Nahrwold DL. Evaluating a clerkship curriculum: description and results. Teach Learn Med 2000;13:1–26. 2. Barrows HS. The scope of clinical education. J Med Educ 1986; 61:3–33. 3. Prideaux DJ, Marshall VR. A “common” surgery curriculum: health care delivery and undergraduate surgical education in Australian teaching hospitals. World J Surg 1994;18:657–661. 4. Moskowitz AJ, Kuipers BJ, Kassirer JP. Dealing with uncertainty, risks, and tradeoffs in clinical decisions. Ann Intern Med 1988;108:435–449. 5. Kassirer JP. Teaching problem solving. How are we doing? N Engl J Med 1995;332:1507–1509. 6. McLeod PJ, Meagher TW. Internal medicine clinical teaching unit: is it an inappropriate site for student learning? Teach Learn Med 1999;11:92–195. 7. Berman JB, Bergen MR, Skeff KM. Feasibility of incorporating alternative teaching methods into clinical clerkships. Teach Learn Med 1990;2:98–103.
J Am Coll Surg
8. Maddern GJ. The changing pattern of surgery. J Surg 1996;83: 145–146. 9. McLeod PJ, Snell L. Casemix in an internal medicine clerkship: educational value of the clinical problems seen. J Gen Intern Med 1991;6:455–459. 10. Benbassat J, Cohen R. Clinical instruction and cognitive development of medical students. Lancet 1982;1:195–97. 11. Neher JO, Gordon KC, Meyer B, Stevens N. A five-step “Microskills” model of clinical teaching. J Am Board Fam Pract 1992;5:419–424. 12. Ferenchick G, Simpson D, Blackman J, et al. Strategies for efficient and effective teaching in ambulatory care settings. Acad Med 1997;72:277–280. 13. Dunnington G, DaRosa D. A prospective randomized trial of a residents-as-teachers training program. Acad Med 1998;73: 696–700. 14. O’Driscoll MCE, Rudkin GE, Carty VM. Day surgery: teaching the next generation. Med Educ 1998;32:390–395. 15. Sharp RJ, Wellwood J. The training implications of day-case surgery. Br J Hosp Med 1996;55:472–475. 16. Irby DM. Teaching and learning in ambulatory care settings: A thematic review of the literature. Acad Med 1995;70:898– 931. 17. Ericsson KA, Charness N. Expert performance: its structure and acquisition. Am Psychol 1994;9:725–747.