Surgery service learning in preclinical years improves medical student attitudes toward surgery, clinical confidence, and social determinants of health screening

The American Journal of Surgery xxx (xxxx) xxx

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Surgery service learning in preclinical years improves medical student attitudes toward surgery, clinical confidence, and social determinants of health screening Megan G. Janeway a, Su Yeon Lee c, Elisa Caron b, Isabel K. Sausjord b, Lisa Allee a, b, Sabrina E. Sanchez a, b, Tracey A. Dechert a, b, * a b c

Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA Boston University School of Medicine, Boston, MA, USA Department of Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, The Bronx, NY, USA

a r t i c l e i n f o

a b s t r a c t

Article history: Received 11 May 2019 Received in revised form 27 September 2019 Accepted 6 November 2019

Introduction: Patient health literacy is paramount for optimal outcomes. The Service Learning Project (SLP) aims to merge the need for patient education with the desire of medical students for early clinical experience. Methods: This pretest-posttest study examined the effect of the SLP on medical students. First-year students spent 8 h each month educating inpatients and screening for social determinants of health (SDH). Students completed a 30-question survey pre- and post-SLP, and longitudinally throughout medical school. We used t-tests to assess changes in attitudes towards surgery, clinical confidence, and SDH screening. Results: Student self-perceived value on surgical teams increased significantly (2.49 vs 3.63 post-SLP, p < 0.001), as did their confidence interacting with patients (3.66e4.14, p ¼ 0.002) and confidence assessing for SDH (3.13e4.75, p ¼ 0.002). 100% of students continued to assess for SDH on clerkships. Conclusions: The SLP model improves medical students’ skills and confidence working with patients and addressing SDH. © 2019 Elsevier Inc. All rights reserved.

Keywords: Medical student education Social determinants of health Service learning

Introduction The Boston University School of Medicine (BUSM) and its associated teaching hospital, Boston Medical Center (BMC), have a longstanding commitment to caring for an underserved patient population. This comes with significant challenges that are compounded by inadequate health literacy,1 language barriers,2 and mistrust of the healthcare system,3 all of which are known to contribute to poorer patient outcomes.4e6 The surgery Service Learning Project (SLP) model was developed to address some of these challenges by engaging surgical patients and medical students in a unique and mutually beneficial education and health literacy initiative.

* Corresponding author. Associate Professor of Surgery Department of Trauma and Acute Care Surgery Boston University Medical Center 840, Harrison Avenue Dowling 2, South Boston, MA, 02118, USA. E-mail address: [email protected] (T.A. Dechert).

Service learning as a model began in order to make classroom learning more meaningful by providing experiential learning with the added benefit of creating community connections. This model has been remarkably effective7 and has spread to fields of public health and medicine.8 Recognizing this benefit, the Liaison Committee on Medical Education revised its accreditation process in 2008 to require medical schools to provide opportunities for and give credit to service learning.9 Medical students often have a paucity of clinical experience in their two first years of education, and little to no formal training in screening patients for social determinants of health (SDH).10 By being cognizant of and screening patients for social barriers to health, health practitioners can strengthen the therapeutic relationship, formulate appropriate discharge plans, and identify opportunities to refer and assist patients in need.11,12 Students increasingly value service experiences and early clinical experience in medical school. A majority of matriculating students consider community-based medicine experience an important factor in selecting a medical school, ranking it equally to

https://doi.org/10.1016/j.amjsurg.2019.11.010 0002-9610/© 2019 Elsevier Inc. All rights reserved.

Please cite this article as: Janeway MG et al., Surgery service learning in preclinical years improves medical student attitudes toward surgery, clinical confidence, and social determinants of health screening, The American Journal of Surgery, https://doi.org/10.1016/j.amjsurg.2019.11.010

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research opportunity, and a further majority aspire to work for social change.13 While BUSM students are fortunate to learn about SDH in the classroom and practice interacting with patients in their first two years in school, the preclinical curriculum does not include merging these experiences to directly impact SDH with patients in the hospital. Furthermore, of the published prior efforts to involve medical students in improving patient health literacy,14,15 none have been specific to the discipline of surgery. Additionally, most of these programs were aimed at students during their clinical years and projects involving preclinical students were carried out in community-based settings rather than inpatient hospitalizations.16,17 From clinical experience, many faculty and resident providers at BMC have perceived multiple barriers to the optimal care of patients, including low health literacy and distrust of medical providers who have less time to spend with patients on a high turnover acute care surgery service. Given the importance of SDH in achieving good health outcomes and the perceived barriers to care identified by BMC’s surgical providers, we devised the SLP as an opportunity to improve care for our patients while providing interested students a chance to enrich their preclinical medical education with experiential learning. Our specific goals were to improve our student’s understanding of surgical care, increase their confidence in clinical settings, and train them to recognize SDH barriers to care. We hypothesized that students participating in the SLP would be empowered with this new knowledge, leading to increased confidence with patient communication and consideration of socioeconomic disparities in their future clinical practice. Methods Study population This was a longitudinal study of all medical students enrolled in the BUSM SLP from 2015 to 2019. Students who were enrolled but did not complete both the pre-intervention and post-intervention questionnaires were excluded. The BMC/BUSM Institutional Review Board (IRB) deemed this study exempt from review. Enrollment and intervention Starting in 2015 all incoming first-year medical students at BUSM are invited to apply for the SLP. The application consists of a brief explanation of interest in the program and any past experiences overcoming communication challenges. The SLP leadership team selects a subset of these applicants to participate in the SLP. Once enrolled an orientation is conducted for all participants by volunteer faculty, residents, and medical students. The orientation includes a standardized education session about three common surgical diseases (appendicitis, cholecystitis, and inguinal hernia), their associated surgical procedures, surgical complications, and important postoperative care including the iCOUGH protocol,18 postoperative ambulation, and adequate postoperative pain control. Students are also trained in the “teach-back method,” which has been shown to be an effective form of patient communication to improve retention of medical information19,20 Students are provided a low-cost pocket guide with validated questions to screen patients for social barriers of care and resources at BMC to address such barriers (Appendix A). Following the initial orientation all participants complete eight months in the SLP with a minimum of 8 h per month spent in the hospital educating patients on their surgical conditions and postoperative care. During these hospital sessions students report to the acute care surgery workroom and identify appropriate patients with the help of a clinical surgical provider, who explains briefly to

the student any specific postoperative needs or concerns for each patient prior to the student approach. In addition, students participate in monthly didactic sessions led by volunteer faculty from a variety of specialties familiarizing them with specific social health care barriers faced by BMC patients and emphasizing practical skills to screen patients for these barriers and address their needs. After completion of the first year SLP students have the option to stay involved in the SLP during their second through fourth years in MS by becoming SLP leaders, helping train future students of the program, or taking part in related service or research projects under the mentorship of participating faculty and residents.

Survey development A novel survey instrument was developed to quantify students’ self-assessed knowledge and attitudes toward surgery and SDH and to gather students’ feedback of the SLP. The survey assesses three key domains: (1) self-assessed knowledge and exposure to the field of surgery; (2) self-assessed knowledge and behavioral intentions regarding SDH; and (3) medical student confidence in clinical practice and self-perceived value. There are five questionnaires in total; pre-SLP and post-SLP (first MS year), second MS year, third MS year, and fourth MS year. The pre-SLP survey establishes a baseline, and each follow-up survey contains reflection and follow-up questions tailored to the specific MS year, leading to each questionnaire having a slightly different question set. The questions used for each of the surveys are depicted in Tables 1 and 2. A member of the research team who was not involved in survey development screened the questionnaires for ambiguous questions, which were then modified as appropriate.

Data collection and follow-up Participants were given a brief pre-SLP survey at the beginning of the SLP orientation. Post-intervention surveys were administered upon completion of the SLP at the end of the first MS year. Students were then given additional surveys at the end of their second, third, and fourth MS years in order to track changes in selfassessed knowledge, attitudes, and practice longitudinally. At each follow-up point, each student received an email with a survey invitation link. Students who did not initially respond and complete the questionnaire received up to two email reminders to complete each of the surveys. All surveys were completed voluntarily.

Study endpoints and statistical analysis Our primary outcome was changes in scores in these three domains over the first MS year, comparing self-assessed knowledge and attitudes before and after the SLP experience. Our secondary outcomes were students’ self-assessed knowledge, attitudes, and behavioral intentions over the course of second, third and fourth MS years and satisfaction with the SLP reflected both in quantitative and qualitative data. We used paired sample t-tests to assess changes in self-assessed knowledge and attitudes between their first year pre- and post-intervention surveys. We also used paired sample t-tests to compare students’ responses to question 20 and question 21 on the first year post-SLP survey to determine whether they attributed their skills in screening patients for SDH more to the MS curriculum or to the SLP. Analysis was performed using IBM SPSS statistical software, version 25. A p-value of <0.05 was considered statistically significant.

Please cite this article as: Janeway MG et al., Surgery service learning in preclinical years improves medical student attitudes toward surgery, clinical confidence, and social determinants of health screening, The American Journal of Surgery, https://doi.org/10.1016/j.amjsurg.2019.11.010

M.G. Janeway et al. / The American Journal of Surgery xxx (xxxx) xxx Table 1 Questionnaire items: Common questionsa. 15 core questions (included in pre-SLP, post-SLP, 2nd year, and 3rd year surveys) Perceptions of Surgery and Educational Experience 1. What is your current attitude about going into general surgery?c 2. I am considering surgery as a future career path. 3. I have useful clinical knowledge about common emergent surgical procedures. 4. My medical education thus far is providing me with meaningful exposure to the discipline of surgery. 5. My medical education is adequately preparing me to become a physician who can educate my patients.b Social Determinants of Health 6. I understand what social determinants of health are. 7. I understand how social determinants of health can affect patient care. 8. I have a good understanding of how surgery and public health relate. 9. I have a good understanding of the underserved patient population. 10. I feel confident assessing patients for social determinants of health.b 11. I feel it is important to screen patients for social determinants of health. Medical Student Confidence in Clinical Practice and Self Perceived Value 12. I feel confident working on the wards. 13. I feel confident interacting with patients. 14. When I am on the wards, I am a valuable member of the care team. 15. What I do on the wards makes a positive difference in patient care. 16A: I have valuable knowledge about the care of surgery patients, both preand post-op. (pre- and post-SLP) 16B: I gained valuable knowledge about the care of surgery patients in the SLP. (2nd, 3rd, 4th year) 17: I am learning useful patient education skills in my medical education. (preSLP, post-SLP, 2nd year) General reflection questions (included in post-SLP, 2nd year, 3rd year, 4th year surveys) 18. The Service Learning Project training helped me with my patient interaction skills. 19. I learned useful patient education skills in the Service Learning Project. 20. The medical school curriculum taught me how to effectively screen patients for SDH 21. The service learning project taught me how to effectively screen my patients for SDH. 22. The service learning project adequately prepared me to become a physician who can educate my patients. Feedback questions regarding the SLP Post-SLP and 2nd year: 23. The training provided at the start of the project was helpful. 24. The floor team on the trauma service was helpful and friendly. 25. The residents and advanced practitioners gave me adequate guidance in completing my tasks. 26. Any concerns that I had were adequately addressed by the SRS leadership. Post-SLP, 2nd, 3rd, 4th year: 27. I would recommend that future first-year students participate in this project. 28. Please provide any comments about your experience in the SLP.d SRS ¼ Socially Responsible Surgery. a All responses on 5-point Likert scale (Strongly Disagree/Disagree/Neutral/ Agree/Strongly Agree) except as noted. b Also asked on the 4th year survey. c Rated on a 0e100 scale. d Free response.

Results Baseline characteristics of students Baseline characteristics of study participants are shown in Table 3. A total of 47 students were enrolled in the SLP between 2015 and 2019, 35 of which completed both the pre-and postintervention surveys (74.4%). The majority of the study population was female (60.0%) and white (45.7%). Slightly less than half (48.6%) expressed interest in a career in a surgical specialty. Most participants had a positive attitude towards general surgery but low selfreported knowledge about it. Improving patient health literacy was the most common motivation for joining the SLP (Table 3). Review of the logs tracking self-reported student presence in the wards for

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Table 2 Questionnaire items: Survey/year-specific questionsa. First year (pre-SLP survey):  How much do you know about general surgery?b First year (post-SLP survey):  The Service Learning Project made me more confident in ICM.  The Service Learning Project helped prepare me for 2 nd year of medical school.  I feel better prepared than my peers for 2 nd year because of my experience in the SLP. Second year:  The Service Learning Project made me more confident going into 2nd year ICM.  The Service Learning Project helped prepare me for 2 nd year of medical school. Third year:  The Service Learning Project made me more confident on the wards as I started 3rd year clerkships.  The Service Learning Project helped prepare me for 3rd year clerkships.  I feel better prepared than my peers for 3rd year clerkships because of my experience in the SLP.  I assess patients for social determinants of health on my clerkships. Fourth year:  The service learning project has influenced my specialty choice.  Overall, the service learning project has been valuable regardless of my specialty choice.  I will continue to screen for SDH moving forward. ICM ¼ Introduction to Clinical Medicine. a All responses on 5-point Likert scale (Strongly Disagree/Disagree/Neutral/ Agree/Strongly Agree) except as noted. b Rated on a 0e100 scale.

the SLP showed students spent an average of eight to 12 h per month on the project. Of note, 25.6% of participants were excluded from the study due to not completing the first year post-SLP survey and additional students failed to complete the follow-up studies in their second, third, and fourth MS years (Table 3). Student knowledge of and exposure to surgery Students reported higher self-assessed knowledge of surgical procedures (2.34e4.09, p < 0.001) and how to care for surgical patients (2.46e4.49, p < 0.001) after their time in the SLP. When asked whether their medical education thus far was providing them with meaningful exposure to the discipline of surgery, there was a significant difference in the scores pre- and post-SLP (2.69e3.97, p < 0.001). Additionally, students were more likely to consider surgery as a future career path after the SLP (4.23e4.63, p ¼ 0.011) (Table 4). When we evaluated the responses of SLP students as they progressed through MS, we found that their increase in self-assessed knowledge of surgical procedures persisted and their interest in pursuing surgery as a career, while decreasing in their second year, increased again in their third and fourth year (Fig. 1). Social determinants of health knowledge and screening Over the course of the SLP, self-assessed knowledge of SDH and how SDH affects patients both increased significantly (3.89e4.83 and 3.60 to 4.83 respectively, p < 0.001), as did self-perceived understanding of underserved patient populations (3.69e4.71, p < 0.001). Self-reported confidence assessing for SDH increased from 3.13 to 4.75 (p ¼ 0.002). (Table 3). The gains in self-assessed knowledge of SDH, how SDH affects patients, and underserved populations were sustained over the follow-up period in the second (4.75, 4.83, and 4.33, respectively)

Please cite this article as: Janeway MG et al., Surgery service learning in preclinical years improves medical student attitudes toward surgery, clinical confidence, and social determinants of health screening, The American Journal of Surgery, https://doi.org/10.1016/j.amjsurg.2019.11.010

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M.G. Janeway et al. / The American Journal of Surgery xxx (xxxx) xxx

Table 3 Baseline characteristics of medical student participants in the service learning project from 2015 to 2019. Total (n ¼ 35) Year Enrolled, n (%) 2015e2016 (fourth year student, 8 total participants)a 2016e2017 (third year student, 11 total participants) 2017e2018 (second year student, 13 total participants) 2018e2019 (first year student, 15 total participants) Sex, n (%) Male Female Race, n (%)b Black White Asian Hispanic Other Specialty Planning to Pursue, n (%)c Surgery Surgical Subspecialty Undecided: (Areas of interest listed below)d Internal Medicine Emergency Medicine Neurology Pediatrics Other Primary Motivation for Joining SLP, n (%)e Early exposure to patient interaction/wards Improving patient health literacy Exposure to surgery Getting involved with patient advocacy

6 (17.1%) 8 (22.9%) 8 (22.9%) 13 (37.1%) 14 (40.0%) 21 (60.0%) 2 (5.7%) 16 (45.7%) 7 (20.0%) 7 (20.0%) 2 (5.7%) 10 (28.6%) 7 (20.0%) 18 (51.4%) 6 (33.3%) 9 (50.0%) 3 (16.6%) 2 (11.1%) 4 (22.2%) 3 5 3 2

(23.1%) (38.5%) (23.1%) (15.4%)

a

Current year in medical school at writing of this manuscript. Missing 1 response. c Optional response, n ¼ 26, could select more than one answer. d Students who were undecided could list up to 3 specialties of interest. e Optional response, not included on the survey for year 2015e2016, missing 22 responses. b

and third MS years (4.85, 4.85, and 4.77, respectively). Students’ confidence in screening for SDH trended downward in their second MS year but increased again in their third year and fourth years (Fig. 2). Importantly, students reported durable behavioral practices and intentions; 100% of students surveyed in their third MS year endorsed continuing to assess patients for SDH on clerkships, and 100% of fourth MS year students endorsed planning to make SDH a regular part of their patient assessments when they started

residency. Confidence on the Wards and Self-Perceived Value. Prior to the SLP, medical students had low self-perceived value on the clinical wards. Students’ perceptions of their value on the care team increased significantly after participating in the SLP (2.49e3.63, p < 0.001) as did their perceptions of making a positive difference in patient care (3.14e4.29, p < 0.001). Confidence interacting with patients (3.66e4.14, p ¼ 0.002) also increased over the course of the SLP. Confidence working on the wards also trended upward, however this result did not reach statistical significance (Table 4). In the follow-up period, self-perceived value on the care team and perceptions of making a positive difference in patient care both decreased in second year, however, they increased again in third year. Confidence with patients continued to increase in the participants’ second and third MS year (Table 4).

Valuation of the service learning experience At the end of their first MS year, participants felt the SLP was significantly more effective than the formal MS curriculum in teaching them to screen patients for SDH (4.46 vs 3.63, p < 0.001) Of the total responses collected over the longitudinal follow-up period, 96% of respondents over the four years agreed or strongly agreed that the SLP helped with their patient interaction skills. Students unanimously agreed or strongly agreed that they learned useful patient education skills in the SLP (Fig. 3). With respect to the formal curriculum, 86% of first year students and 100% of second year students felt that the SLP made them more confident in their Introduction to Clinical Medicine (ICM) course, while 85% of third year students felt the SLP made them more confident on their clerkships. A strong majority of second (83%) and third years (77%) felt that the SLP prepared them for their current year in MS. Lastly, 96% of students agreed or strongly agreed that they would recommend the SLP to other students.

Qualitative analysis of project The main impact areas of the SLP as noted by our results and supported by student freehand feedback are summarized in Table 5.

Table 4 Comparison of medical student participants’ first year Pre-SLP and Post-SLP, second year, and third year questionnaire answersa.

QUESTION 2. Considering Career in Surgery 3. Knowledge of Surgical Procedures 4. Exposure to Surgery 16A Knowledge of Care Surgical Patientsb 6 Knowledge of SDH 7 How SDH Affect Patients 8 How Surgery and Public Health Relate 9 Knowledge of Underserved Patients 10 Confidence Screening for SDHc 11. Important to Screen For SDHc 12 Confidence on Wards 13. Confidence with Patients 14. Valuable Member of Team 15. Positive Difference in Patient Care

FIRST YEAR PRE-SLP POST-SLP N M 35 4.23 35 2.34 35 2.69 35 2.46 35 3.89 35 3.60 35 3.14 35 3.69 8 3.13 8 4.75 35 3.31 35 3.66 35 2.49 35 3.14

SD 0.69 0.80 1.07 0.74 0.63 0.78 0.81 0.80 0.64 0.46 0.72 0.68 1.01 1.19

M 4.63 4.09 3.97 4.49 4.83 4.83 4.63 4.71 4.75 4.88 3.63 4.14 3.63 4.29

SD 0.55 0.61 0.89 0.74 0.38 0.38 0.55 0.52 0.46 0.35 0.84 0.60 0.84 0.62

P 0.011 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 0.002 0.351 0.155 0.002 <0.001 <0.001

SECOND YEAR (N ¼ 12) M SD 4.00 1.21 4.00 0.85 4.08 1.08 4.75 0.45 4.83 0.39 4.67 0.49 4.33 0.49 4.42 0.52 4.75 0.45 3.33 0.78 4.42 0.52 3.33 0.89 3.83 1.27

THIRD YEAR (N ¼ 13) M SD 4.62 0.65 4.46 0.88 4.15 0.69 4.85 0.38 4.85 0.38 4.69 0.48 4.77 0.44 4.62 0.65 4.85 0.38 4.46 0.66 4.77 0.44 4.15 0.56 4.31 0.48

Key: M ¼ mean value of Likert responses (1 ¼ strongly disagree to 5 ¼ strongly agree). SD ¼ standard deviation. Bold signifies where the comparison pre-SLP and post-SLP is statistically significant. a Fourth year students excluded from table as only one question overlaps with this table (Question 10: M ¼ 4.66). b Question 16A was not on the follow-up surveys from second year onward (replaced by question 16B). c New question added to pre-SLP survey in 2018, n ¼ 8 students filled this out on their baseline pre-SLP survey.

Please cite this article as: Janeway MG et al., Surgery service learning in preclinical years improves medical student attitudes toward surgery, clinical confidence, and social determinants of health screening, The American Journal of Surgery, https://doi.org/10.1016/j.amjsurg.2019.11.010

M.G. Janeway et al. / The American Journal of Surgery xxx (xxxx) xxx

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Fig. 1. Medical Student Participants’ Response to Question 2: “I am considering surgery as a future career path” by Year in Medical School.

Fig. 2. Question 10: Confidence in screening patients for SDH, medical school participants by year.

Discussion Prior to the SLP, preclinical students at our institution had clinical exposure limited to structured shadowing and medical history and physical exam practice, lacking training in SDH and patient education skills. This study demonstrates that preclinical exposure through surgical patient education opportunities can increase medical students’ self-perceived knowledge of SDH as well as their confidence in clinical settings. In addition, this confidence is sustained throughout clinical years and matched by continued selfreported SDH screening practices. Early clinical exposure for first year medical students has been shown to increase satisfaction with their medical education21 help them gain confidence in clinical settings22 and lead to measurable gains in overall clinical skills.23,24 At our institution, all students interact with patients in the ICM courses in first and second year: 20 h in the fall working in small groups with patients to learn the medical interview, 10 clinical sessions with a preceptor, and six clinical sessions practicing the history and physical exam. Students who participated in the SLP, in contrast, spent an additional

64 þ hours in the hospital over the course of their first year. The increased confidence SLP students reported interacting with patients could be in part attributable to their formal MS curriculum, but SLP students overwhelmingly credited the SLP for their improved confidence with patient interaction skills. In addition, participants universally reported learning useful patient education skills in the SLP, a unique benefit from this experience. Students’ responses also suggest a synergistic effect between the SLP and the formal MS curriculum, as the majority of first and second year respondents indicated that the SLP made them more confident in their ICM courses. This effect persisted into the clinical years, as the majority of third year students reported that the SLP prepared them for their clerkships, further attesting to the benefits afforded through early clinical exposure through this program. Somewhat surprising was the discrepancy between the strong majority of third year students who felt the SLP prepared them for clinical clerkships and the fact that only about half stated they felt better prepared than their peers. This is likely related to the fact that being prepared for clerkships requires a wide variety of abilities beyond the interpersonal skills taught by the SLP. Further

Please cite this article as: Janeway MG et al., Surgery service learning in preclinical years improves medical student attitudes toward surgery, clinical confidence, and social determinants of health screening, The American Journal of Surgery, https://doi.org/10.1016/j.amjsurg.2019.11.010

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Fig. 3. Medical Student Participants’ Response to “I learned useful patient education skills in the Service Learning Project” by Year in Medical School.

Table 5 Impact of service learning project. SLP Target Impact

Results

Anonymous Student Feedback of SLP Experience

“I had a biased view of surgery before starting this SLP. I was a public health major with only exposure to primary care. I didn’t know ANY surgeons and only knew what I had heard about surgery. In contrast, I’ve found through my experience with this SLP that surgery is a field that cares about and surrounds itself with the SDH. I’ve learned that practicing surgery without tackling SDH in your surgical patients means poorer outcomes.” Self-perceived Value Increased value on the surgical team (2.49 “This was an incredibly valuable experience during first year, as it provided far more e3.63, p < 0.001) meaningful patient contact than the medical school clinical medicine curriculum. I felt as though I was making a difference in patient care as a first year, in some ways that I couldn’t even as a third or fourth year given my clinical responsibilities. Educating patients about nutrition and their surgical pathology was fulfilling for me as a student, and undoubtedly for the patients as well.” Prevention of Burnout Making positive difference in patient care “SLP makes me feel valued and makes me feel like I am making a different in patients’ (3.14e4.29, p < 0.001) lives. It reminds me of why I went into medicine in the first place and fuels my passion for advocating.” “So much more valuable to my medical education than I could have imagined. I also felt like I was helping our patients more than I thought a first-year med student would be able to.” SLP more effective in teaching screening “This was great and taught me more skills than the Med school curriculum itself.” Value of Service Learning as an patients for SDH (4.46e3.63, p < 0.001) “I found it to be a rewarding and extremely valuable component of my first two years at Addition to Medical School BUSM. While the school’s education about SDH was useful, learning directly from medical Curriculum professionals about how to communicate with patients about SDH and then practically applying those skills was an amazing experience.” “It was probably the best experience of my medical school career.” “I felt much more useful, independent and able to practice my patient interaction skills Experiential learning of while participating in the SLP.” communication and patient “SLP was a great way to get clinical experience talking to patients and giving education in education skills a health literacy sensitive manner.” “This was one of the highlights of my first year and was an essential component in learning to interact and educate patients.” Preclinical exposure to surgery and Self-reported knowledge of care of “Worthwhile to learn about emergent surgeries and help patients understand their patient care surgical patients (2.46e4.49, p < 0.001) hospital course.” “Great early exposure to surgical disease management and patient education in general.” “It was a great experience that taught me a lot about postoperative care and interacting with surgical patients.” Mentorship “I think that the gradual progression of training (working with 2 nd years, then with other first years, sometimes alone) was very helpful for me.” “Helping to orient the first years when I was a second year was also a great experience.” Students Perceptions of Surgery

More likely to consider going into surgery. (4.23e4.63, p ¼ 0.011)

qualitative feedback on the SLP curriculum may help elucidate why our students felt this way. Most SDH curriculums in medical schools, including BUSM, are

learned through case presentations outside of clinical settings10 or not until students are in their clinical years.25e27 Through the SLP model students have the unique opportunity to both learn about

Please cite this article as: Janeway MG et al., Surgery service learning in preclinical years improves medical student attitudes toward surgery, clinical confidence, and social determinants of health screening, The American Journal of Surgery, https://doi.org/10.1016/j.amjsurg.2019.11.010

M.G. Janeway et al. / The American Journal of Surgery xxx (xxxx) xxx

SDH and put that knowledge into practice in their first MS year. Students not only reported increased knowledge of health disparities and how they affect surgical patients, but also improved confidence in their skills to effectively screen for SDH. In fact, students felt the SLP was more effective at teaching them to screen for SDH than their MS curriculum. This may be due to the practical experience of screening patients themselves, as this type of experiential learning has been shown to increase confidence, motivation and sense of professional identity in medical students.28 This is further suggested by freehand survey responses, which credit experiential learning as a key factor in skills gained during the SLP. During their second year, students reported maintaining their knowledge of SDH, which likely represents enduring impact, as they were not exposed to SDH in the formal curriculum during that time. At the same time, their confidence in screening patients for SDH trended downward, which may be due to feeling out of practice in the clinical dimension. The fact that confidence in screening for SDH increased again in their third year likely indicates that students either took the opportunity during their clerkships to refresh their skills from the SLP or that they benefited from a formal SDH clerkship curriculum. During the study period, SDH teaching in clinical clerkships was limited to a handful of specialties, including general surgery and obstetrics/gynecology, and consisted of guest lectures, home visits, and the provision of resource cards similar to those given to SLP participants. Additionally, our findings suggest enduring behavioral patterns, as students endorsed that they continued to regularly screen patients in their clerkships in third and fourth year of medical school. Another important finding of this study was the increase in selfperceived value in clinical care. With burnout prevalent in medical students of all years,29 it is critical to keep students engaged. Notably, self-perceived value and making a positive difference in patient care increased significantly over the first year in the program, while students actively participated in patient education and SDH screening through the SLP but dropped in the second year. This is unsurprising considering that during the second year of MS students who did not opt to participate in SLP leadership or other related enrichment opportunities interacted with patients only through the formal curriculum, which prioritizes development of students’ interview and physical exam skills rather than patient education or service. In third year, as students started their clinical rotations and again had the opportunity to care for patients as part of a clinical hospital team, their self-perceived value increased. An unanticipated outcome of this study was the increase in the positive perception of surgery as a career. While we expected participation in the SLP to be skewed towards students interested in surgery at baseline, we also saw an increase in the level of interest in pursuing surgery as a career between the pre-intervention and post-intervention survey. A minority of students at our institution have surgeons as their clinical preceptor in the first and second MS years, but other than that, the formal curriculum does not include exposure to surgery until the third year clerkship. Meanwhile, the SLP provides students the opportunity to interact with surgical faculty and residents both early on and on a regular basis. Therefore, the SLP is a very likely contributor to students becoming more interested in surgery as a career after their first year. Qualitative feedback from students after the SLP also indicates its effectiveness in inspiring an interest in a surgical career. We also noted that students’ interest in a career in surgery dropped in the second year before returning to post-SLP levels in the third year. The decrease in the second year could be due to multiple reasons, such as limited exposure to surgery in the formal curriculum, in addition to the timing of the survey in close proximity to the students’ USMLE Step 1 exam, when they are likely to be focused on studying rather than future career goals. By reviewing Match data,

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we found that half of our original cohort of eight participants ended up entering a general surgery or surgical specialty residency after graduation in 2019. On average, only 8% of students entering MS in the United States have an interest in pursuing a surgical specialty,13 and only 6% actually pursue general surgery.30 Meanwhile, there is an expected surgical specialist shortage of 14,300 to 23,400 providers by 2032.31 Therefore, it is vital that we inspire more students to pursue surgical specialties in order to fulfill this need. Additionally, with the growing number of students interested in integrating public health and care of underserved patient populations into their career, it is important to highlight that mentorship in these areas of interest exists in surgical specialties. This is especially important considering that ‘role model influence’ and ‘fit with personality, interests, and skills’ were among the leading reasons for specialty choice among medical students on the 2018 graduate questionnaire.30 This study has multiple limitations. First, our study lacks a control group. At our institution, student response rates to surveys are quite low, to the point that enforcement mechanisms have been instituted to increase students’ completion of mandatory course evaluations. This knowledge, combined with our lack of funding to provide incentives for survey completion, led to our perception that we would not be able to obtain control data of any reasonable quality and thus, our decision to forego a control group. Without a control group it is difficult to establish a definitive relationship between the SLP intervention and the outcomes of interest. However, the inclusion of both qualitative and quantitative student evaluations of the SLP is a strength that helps support our hypothesis of the SLP being a useful educational program to increase confidence in patient communication and consideration of SDH in their clinical practice. A closely related limitation is the relatively high rate of nonresponse and loss to follow-up. Although we made the survey as short as possible to decrease attrition and reached out multiple times to encourage survey completion, we were unable to mandate or incentivize survey completion and overcome “survey fatigue”32,33 amongst all the competing priorities of medical students. This attrition may bias our sample towards students who had a positive experience in the SLP, as these students might find the survey more salient and be more willing to complete it.33 Another limitation is our reliance on self-assessed knowledge, confidence, and self-reported behaviors, rather than objective measures of the same. Although self-assessed knowledge has been widely used as a proxy for cognitive learning, this correlation is moderate at best and self-assessed knowledge may be more reflective of a learners’ motivation and satisfaction with a training programs.34 Furthermore, studies of medical trainees confirm that self-assessed knowledge and skills may be inaccurate, meaning that confidence does not necessarily correlate with competence35 Based on the Kirkpatrick model of training evaluation36 we have evaluated learners’ reactions (Level 1) and changes in attitude (Level 2A) over the course of the training and used self-report as a proxy to analyze behavioral impact (Level 3) which is more accessible but less reliable than observed behaviors due to potential response bias. We have not yet evaluated the impact of this educational program on patients (Level 4B), although we are currently in the process of collecting data to determine whether the SLP directly benefits patients in the form of measurable increased knowledge, improved patient experience, and improved clinical outcomes. Results from the patient arm of the study are forthcoming. Another limitation was the lack of an existing validated survey applicable to our population and study questions. Thus, we developed our questionnaire using basic principles and screened questions for confusing or ambiguous wording by running them by a member of the SLP team not involved in survey development.

Please cite this article as: Janeway MG et al., Surgery service learning in preclinical years improves medical student attitudes toward surgery, clinical confidence, and social determinants of health screening, The American Journal of Surgery, https://doi.org/10.1016/j.amjsurg.2019.11.010

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M.G. Janeway et al. / The American Journal of Surgery xxx (xxxx) xxx

However, the fact that our survey was not validated is a limitation to our study. We also had a small number of participants that were self-selected. This puts into question the generalizability of our findings to the entire BUSM student body or the wider MS population as a whole. With regards to the BUSM population, however, the gender and racial makeup of our sample is similar to the demographics of the BUSM student body, as a recent entering class included about 50% women and 19% underrepresented racial minorities.37 Studies of this model at other medical schools should help establish reproducibility of this program’s value at institutions with different demographics. A final limitation is that students’ attendance at the shifts they signed up for was not monitored and was taken in good faith, and therefore we cannot verify the number of hours that each participant worked in the hospital, and the variation between students might be greater than our records suggest. In conclusion, a modest and low-cost service learning model delivered during the preclinical years of MS can provide valuable experience in surgical patient education and health disparities as evidenced by higher self-assessed knowledge of these topics and students’ perception of the SLP as a valuable learning experience. Furthermore, service learning can positively affect student attitudes and confidence in clinical settings. Students indicate continued confidence in and commitment to screening patients for SDH in their clinical years, suggesting an enduring impact of this educational initiative. We are continuing data collection of the patient experience with the SLP to demonstrate its impact on patients’ knowledge, attitudes, and health outcomes. We are looking into expanding this program to other institutions and look forward to further research of its impact on students’ abilities in patient education and addressing health disparities.

 Understand the importance of postoperative care practices to prevent postoperative complications  Communicate effectively with patients from diverse cultural, socioeconomic, and linguistic backgrounds  Integrate as an actively contributing member of a surgical team  Join a community of faculty, residents, and students dedicated to surgical health equity

Schedule by Month August:  Tabling at student activities fair by SLP leadership and recently graduated SLP students  Email to all first-year students inviting them to apply to the program  Review of applications and enrollment of new medical students into the program September:  Introduction to the Trauma and Acute Care Surgery service team, including advanced care practitioners  Education on appendectomy, cholecystectomy, inguinal hernia repair  Post-operative care overview: incentive spirometry, pain control, ambulation, diet  Training on effective patient education skills, including TeachBack  Overview of resource card/pocket guide October:

Previous communication None. Funding This work was supported by T32 grant [2T32GM086308-06A1]. Acknowledgements We would like to acknowledge Socially Responsible Surgery and the T32 grant (2T32GM086308-06A1) for supporting this research project.

 Newly enrolled students are scheduled for two shifts with experienced SLP students. In the first visit the experienced students lead the visit, in the second visit, the new students lead the visit and receive critical feedback from the on the experienced student NovembereJune:  SLP participants visit patients a minimum of 8 h per month each month

Didactic sessions September:

Appendix A. Supplementary data Supplementary data to this article can be found online at https://doi.org/10.1016/j.amjsurg.2019.11.010.

“Introduction to social determinants of health and their impact on surgical patients and their recovery” Presenters- SLP leadership

Appendix B

December:

Service Learning Project Syllabus

“Food insecurity as a social determinant of health” Tour of the hospital’s Preventative Food Pantry and Teaching Kitchen Presenters: Latchman Hiralall and Tracey Burg, RD, LDN

Learning Objectives  Understand how social determinants of health impact underserved populations  Screen patients for social barriers to health and identify appropriate hospital and community resources to address these challenges  Understand basic postoperative care and teach patients in a health-literacy sensitive manner

February: “Housing insecurity and health” Presenter- Megan Sandel, MD MPH March:

Please cite this article as: Janeway MG et al., Surgery service learning in preclinical years improves medical student attitudes toward surgery, clinical confidence, and social determinants of health screening, The American Journal of Surgery, https://doi.org/10.1016/j.amjsurg.2019.11.010

M.G. Janeway et al. / The American Journal of Surgery xxx (xxxx) xxx

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Please cite this article as: Janeway MG et al., Surgery service learning in preclinical years improves medical student attitudes toward surgery, clinical confidence, and social determinants of health screening, The American Journal of Surgery, https://doi.org/10.1016/j.amjsurg.2019.11.010