- Email: [email protected]
The Trauma Research Associates Program (T-RAP) for Undergraduate Students: Shaping Future Academic Surgeons
ORIGINAL REPORTS
The Trauma Research Associates Program (T-RAP) for Undergraduate Students: Shaping Future Academic Surgeons Galinos Barmparas, MD, Nicole Fierro, BS, Debora Lee, BS, Beatrice J. Sun, BS and Eric J. Ley, MD Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California OBJECTIVE: Offering undergraduate students research
opportunities may enhance their interest in pursuing a surgical career and lead to increased academic productivity. We characterize the benefits of participating in the Trauma Research Associates Program. DESIGN: A 19-point Web-based survey. SETTING: Academic Level I Trauma Center. PARTICIPANTS: A total of 29 active and former members of the Trauma Research Associates Program.
participant (adjusted odds ratio: 13.00; 95% CI: 1.27, 133.29; p ¼ 0.03). CONCLUSIONS AND RELEVANCE: Development of a
structured research program for undergraduate students is beneficial to both the participants and sponsoring institution. Undergraduate exposure to academic surgery enhances interest in pursuing a surgical specialty and leads to C 2014 Assoacademic productivity. ( J Surg 72:338-344. J ciation of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)
MAIN OUTCOME MEASURE(S): Academic activities and predictors associated with interest in a surgical career and research productivity.
KEY WORDS: undergraduate, student, research, volunteer,
RESULTS: Surveys were completed on 26 of 29 (90%)
ment, Interpersonal and Communication Skills, SystemsBased Practice
participants. Clinical experience was the most highly ranked motivation to join the program (65%), followed by pursuing a research experience (46%). During their involvement, 73% of participants observed surgical intensive care unit rounds, 65% observed acute care surgery rounds, and 35% observed a surgical procedure in the operating room. In addition, 46% submitted at least one abstract to a surgical meeting coauthored with the Division’s faculty. Furthermore, 58% reported that they enrolled in a medical school, whereas 17% pursued a full-time research job. The program influenced the interest in a surgical career in 39% of all members, and 73% reported that they would incorporate research in their medical career. Observing a surgical procedure was independently associated with development of a high interest in a surgical career (adjusted odds ratio: 6.50; 95% CI: 1.09, 38.63; p ¼ 0.04), whereas volunteering for more than 15 hours per week predicted submission of at least 1 abstract to a surgical conference by the
Correspondence: Inquiries to Eric J. Ley, MD, FACS, Department of Surgery, CedarsSinai Medical Center, 8700 Beverly Blvd, Suite 8215N, Los Angeles, CA 90048; fax: (310) 423-0139; E-mail: [email protected], [email protected]
338
academics, surgical career, shortage COMPETENCIES: Practice-Based Learning and Improve-
INTRODUCTION The shortage of general surgeons available to serve the nation’s increasing and aging population is undoubtedly a major challenge that the American College of Surgeons and the United States face today. Staggering statistics estimate that by the year 2020, there will be a shortage of 18,990 surgeons, of which 1875 will be general surgeons.1 By 2030, a shortage of 9% for general surgeons is predicted.2 The Balanced Budget Act of 1997 has capped the available medical and surgical resident positions and remains unrevised. The Division of Advocacy and Health Policy of the American College of Surgeons is seeking potential solutions to the problem by placing foreign medical graduates who have done their specializations in the United States in rural areas and by advocating for legislation to increase the available residency training positions by almost 15%.3 To add to the problem of this workforce shortage, a decline in interest in surgical specialties by medical graduates has been observed in the past decades, leading to concerns that less female applicants4 and even less
Journal of Surgical Education & 2014 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2014.08.012
competitive students5 are now being attracted to a surgical career. The focus has traditionally been on the third-year surgical clerkship, and several factors have been studied as possibly enhancing interest in surgical specialties, including exposure to the operating room early during medical school, mentoring, and interactions with residents.4,6-8 However, it appears that interest in a surgical career largely develops before this clerkship,9 possibly even before starting medical school, during undergraduate years. Various opportunities exist for undergraduate students to be exposed to clinical practice and participate in clinical and translational research.10-12 The value and effect of these programs on career development, admission to a medical school, and career choice is largely unknown. The Department of Surgery—Division of Acute Care Surgery (ACS) and Surgical Critical Care at the Cedars-Sinai Medical Center has developed the Trauma Research Associates Program (T-RAP), an integrated program that allows for undergraduate medical students seeking a career in medicine to participate in research opportunities, shadow staff surgeons, and be mentored by leaders in the field. We conducted a survey of participants in this program to assess its early effect on career choices and plans by examining academic activities and identifying predictors associated with interest in a surgical career and research productivity.
MATERIALS AND METHODS Description of the Program T-RAP is a research program geared for undergraduates pursuing careers in the areas of health care and research. The program was launched in July 2011 by recruiting undergraduate students from the University of California, Los Angeles. Every year, 12 to 15 students are included. The role of recruiting other interested volunteers once a year is taken up by 2 student coordinators by sending a notice to different LISTSERV’s at University of California, Los Angeles and by asking the departments to send the link for the application to the students. Minimum requirements for enrollment include a minimum grade point average of 3.2, a 1-year commitment including summer and other breaks, attendance of weekly mandatory meetings, and commitment to 3-hour data collection shifts twice a week. Before starting any activities, students enroll in a general laboratory safety course. All participants are expected to follow the rules and regulations of the Cedars-Sinai Medical Center Health Insurance Portability and Accountability Act requirements as they are granted access to the medical records of study subjects. Using shift assignments, students are expected to spend a total of at least 6 hours a week divided into 2 shifts in collecting predefined data for ongoing research projects. Data collection is supervised by the coordinators and faculty members to ensure accuracy and accountability.
Attendance at a weekly 1-hour meeting of all participants headed by the program coordinators in the presence of faculty members is mandatory for all participating students. These meetings serve to discuss issues that might arise during research activities, report on the progress of data collection, and ensure satisfactory and sufficient communication between participants. During these meetings, 2 students present medically related topics that are discussed under the supervision of faculty members. Optional opportunities include shadowing a trauma surgeon, attending the surgical intensive care unit (ICU) or the ACS rounds, observing procedures in the operating room, and attending the morbidity and mortality conference. Students can also pursue separate projects with faculty members and can either be mentored to develop their own research study or help with an already ongoing research activity. For these opportunities, priority is usually given by the coordinators to the most reliable and committed students. All students are mentored by faculty members in their research endeavors and in their future enrollment into a medical school. In addition to receiving class credit through their school, students are given letters of recommendation on request and a certificate of participation in the program. Students can only volunteer and no financial compensation is given for their work. Study Design After approval by the institutional review board, all current and former participants in the program were surveyed to determine the factors that drove them into participating in this program and the potential benefits they gained and interests they developed through their participation. The survey was completed within 2 weeks after an initial electronic mail was sent to all current and former participants explaining the purpose of the survey and providing a link to a website for completion of the Web-based survey. Additionally, 2 reminder emails were sent 7 and 10 days later. Completion of the survey was voluntary and responders’ anonymity was maintained at all phases of the study. Survey Instrument A 19-point Web-based survey was utilized for the purposes of this study. The questions focused on demographics related to the students’ school year and previous research experience, the amount of time they spent per week on their research activities, the degree of various motivations for joining the program, the number of abstracts they submitted to national surgical conferences because of their participation, their optional activities including observing surgical procedures, and details regarding whether their future plans include incorporating research into their medical career. Separate questions focused on the students’
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current interest in a surgical career because of their involvement in this program. Statistical Analysis The primary outcomes of this survey were development of an interest in a surgical career and research productivity, which was defined as submission of an abstract to a national surgical conference. Descriptive statistics were used, mostly as frequency distributions for the questionnaire responses. A forward logistic regression model was developed to identify factors that were independently associated with development of very high or high interest in a surgical career and factors independently associated with submission of an abstract to a national surgical conference. The adjusted odds ratio (AOR) and 95% CI were calculated, as was the area under the curve (AUC) for both models. All statistical analyses were performed using the IBM SPSS Statistics for Windows, Version 20.0 (IBM Corp., Armonk, NY).
RESULTS Of 29 eligible students, 26 (90.0%) completed the Webbased survey; among them, 14 (53.8%) were active members and 12 were (46.2%) former members (Table). Most participants (64.0%) were involved with the program for 2 or more years. Only 3 students (11.5%) had previous clinical research experience. Almost 3 of 10 participants (26.9%) spent 16 hours or more per week performing research. TABLE. Basic Demographics Participants Active members Former members Years involved with program 1 2þ School year when started participation First/second Thirdþ Previous clinical research experience Working hours per week 6 to 15 hours 16þ hours Activities while in program Full-time school Part-time school Full-time job Part-time job “How did you learn about the program?” Internet search Department mail list School counselor From a member of the program Other 340
53.8% (14/26) 46.2% (12/26) 36.0% (9/25) 64.0% (16/25) 34.6% (9/26) 65.4% (17/26) 11.5% (3/26)
Motivations to join the program that were ranked as “high” or “highest” included clinical experience (65.4%), research experience (46.2%), interest in surgery (38.5%), course credit (26.9%), and networking (23.1%). Most students attended surgical ICU rounds (73.1%) and ACS rounds (65.4%), whereas 65.4% participated in an individual research project and 46.2% submitted an abstract to a national surgical conference. Surgical procedure was observed by 34.6%, while 23.1% attended a morbidity and mortality conference. The plurality (58.3%) of former members enrolled into a medical school and 16.7% pursued full-time research (Fig. 1). Clinical exposure was the most commonly perceived true benefit of the program (96.2%), followed by learning research methodology (88.5%) and networking (73.1%) (Fig. 2). High and highest rank was given for the program by 84.6% of participants, while 88.5% thought that they consider their involvement with the program as extremely or very helpful with their future goals (Fig. 3). In a question on how much the program has influenced the students’ interest in a surgical career, 34.6% answered moderately, 30.8% much, and 7.7% very much (Fig. 4). Most participants (73.1%) answered that they would incorporate research into their future medical career. In a forward logistic regression model incorporating all available covariates (school year [o3 vs Z3]; previous clinical research experience [yes vs no]; working hours per week [o16 vs Z16]; attended surgical ICU rounds [yes vs no]; attended ACS rounds [yes vs no]; individual research project [yes vs no]; submission of abstract [yes vs no]; and very high or high motivation to join the program for clinical experience [yes vs no], for networking [yes vs no], for course credit [yes vs no], and for surgical interest [yes vs no]), observing a surgical procedure was independently associated with development of a high or very high interest in a surgical career (AOR [95% CI]: 6.50 [1.09, 38.63], adjusted p ¼ 0.04). The AUC for this model was 0.706. In a separate forward logistic regression model incorporating the same variables mentioned previously, spending 16 hours or more on research activities per week was independently associated with submission of an abstract to a national surgical conference (AOR [95% CI]: 13.00 [1.27, 133.29], adjusted p ¼ 0.03). The AUC for this model was 0.444.
73.1% (19/26) 26.9% (7/26) 84.6% (22/26) 7.7% (2/26) 30.8% (8/26) 15.4% 38.5% 3.8% 34.6% 7.7%
(4/26) (10/26) (1/26) (9/26) (2/26)
DISCUSSION The results from this survey indicate that almost 60% of participants in the T-RAP enrolled into a medical school, and approximately 17% pursued a full-time research position. The program had a moderate to high influence on the interest in a surgical career of more than 70% of participants. Observing a surgical procedure was independently associated with enhancement of interest in a surgical career, whereas spending more hours on research projects was
Journal of Surgical Education Volume 72/Number 2 March/April 2015
Active Members
Former Members
78.6%
58.3%
35.7% 21.4%
16.7%
16.7%
16.7%
0.0% Undergraduate Coursework
Medical School
Full Time Research
Other
FIGURE 1. Current activities of active and former members of the program.
associated with academic productivity and submission of at least 1 abstract to a national surgical conference. Several programs across the nation are available through medical schools and universities for undergraduate students interested in pursuing a medical career. These programs vary in their focus. Some provide opportunities for translational research,10 whereas others provide participation in clinical research and interaction with patients.11,12 Our Web search identified several similar programs, but none targeted a surgical specialty, and most were available to participants for a limited period of time, i.e., summer break and so on. The value of these programs is largely unknown and no peer-reviewed publications addressing their efficacy are available to date. This survey serves as qualitative and quantitative measure of outcomes associated with participation in an integrated research program for undergraduates interested in a medical and potentially a surgical career. The decreasing interest in certain surgical subspecialties has lead several programs to develop workshops and research
opportunities for medical students early during medical school with the purpose of increasing the number of applicants to those same subspecialties.6,13 This is in line with the findings by Goldin et al.9 suggesting that surgical interest at baseline, i.e., before the surgical clerkship, is the most important predictor of matching into a surgical specialty or subspecialty. In this survey of T-RAP students, almost 39% enrolled into the program owing to their interest in surgery and the program had a moderate to high influence on the interest in a surgical career of more than 70% of participants. In an era where the focus and relevance of undergraduate education is being questioned and changes are being sought,14-16 the T-RAP offers an early involvement of future physicians and potentially surgeons in relevant activities to enhance their academic interests and productivity and more specifically, their interest in a medical specialty. Research involvement and productivity along with extracurricular activities are considered integral parts of a
96.2% 88.5% 73.1% 57.7%
Clinical Exposure
Research Methodology
Networking
Course Credit
53.8%
Patient Interaction
FIGURE 2. Perceived true benefits of the program by participating students. Journal of Surgical Education Volume 72/Number 2 March/April 2015
341
FIGURE 3. Popularity of the program and likelihood of recommendation to others. All 3 questions were answered using a scale from 1 to 5, with 5 being the highest rank.
competitive medical school application, although few data exist to support this idea.16 Nonetheless, most medical students consider research to be important for their career development,17,18 offering the necessary tools during medical school that can lead to academic interest and productivity, and even shaping their final path to their specialty.19-21 T-RAP offers an early exposure to the principals of clinical research, and the results from our survey show that more than 65% participated in an individual research project and that more than 45% submitted an abstract to a national surgical conference. T-RAP students can use this experience to develop their academic productivity faster during medical school and even during their residency and later on in their career. In addition, the benefits for the sponsoring institution are obvious with increasing research productivity and submission of abstracts to national surgical conferences. Engagement in the operating room has been shown to attract surgical clerks to surgical careers.6,7,22 Mentoring is another factor that has a vital effect on career choices and has been shown to affect decisions to pursue surgical specialties.23-25 Passionate, experienced, highly committed, and readily available mentors who allow students to think
critically and independently can especially influence career choice.20,23-26 These factors were studied in T-RAP students. Observing a surgical procedure was independently associated with development of a high or very high interest in a surgical career. Additionally, more than 88% of participants considered their involvement with the program as extremely or very helpful with their future goals, likely as a result of networking, shadowing staff physicians, and receiving guidance for individualized research activities. Although T-RAP is primarily a research-oriented program, optional opportunities such as observing staff surgeons’ activities and surgical procedures are fundamental elements that appear to have a major effect on how these students perceive surgical specialties and how they integrate these experiences into their future career plans. This study is not without its inherit limitations. Associating increased interest in a surgical specialty with T-RAP potentially involves selection bias, as participants could be interested in a surgical career at baseline and are therefore more likely to pursue involvement in such a program. In addition, although more than 70% of participants reported interest in a surgical career, this could not be followed for potential future matching into a surgical specialty. Students applying to the T-RAP are highly motivated. One of the requirements is a grade point average above 3.2 and this requirement by itself introduces a selection bias. However, minimum selection criteria are helpful in this setting to ensure participation of candidates who are willing to invest the time and effort required to make this experience beneficial for themselves and the sponsoring institution. Owing to the relatively recent launch of the program, whether the submitted abstract resulted in peer-reviewed publications could not be examined along with the data from this survey, as peer-reviewed publications require a significant period to be completed, and it was thought that this question could introduce bias and underestimate such productivity. Additionally, only a relatively small number of
FIGURE 4. “How much has the program influenced your interest in a surgical career?” 342
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participants could be surveyed as only 2 groups of students have completed the program thus far. Lastly, although several markers of benefit to the participants and our institution are seen, such as the high percentage of enrollment in a medical school and a high percentage of submission of abstracts to national surgical conferences, the direct effect of this program on these outcomes cannot be determined and future studies with a comparison group will be required. Despite these limitations, the T-RAP appears to be mutually beneficial for both the participants and the sponsoring institution. Undergraduate exposure to academic surgery enhances interest in pursuing a surgical specialty and leads to academic productivity. Assessment of the benefits and the associated academic productivity will be constant, to ensure improvement, advancement, and growth of the program. Development of similar programs is encouraged by institutions affiliated with universities to encourage and assist undergraduate students to pursue a career in medicine and potentially in surgery.
4. Glynn RW, Kerin MJ. Factors influencing medical
students and junior doctors in choosing a career in surgery. Surgeon. 2010;8(4):187-191. http://dx.doi. org/10.1016/j.surge.2009.11.005. 5. Bland KI, Isaacs G. Contemporary trends in student
selection of medical specialties: the potential impact on general surgery. Arch Surg. 2002;137(3):259-267 Available at: http://www.ncbi.nlm.nih.gov/pubmed/ 11888445; (Accessed 04.04.2014). 6. Allen JG, Weiss ES, Patel ND, et al. Inspiring medical
students to pursue surgical careers: outcomes from our cardiothoracic surgery research program. Ann Thorac Surg. 2009;87(6):1816-1819. http://dx.doi.org/10. 1016/j.athoracsur.2009.03.007. 7. Berman L, Rosenthal MS, Curry LA, Evans LV,
Gusberg RJ. Attracting surgical clerks to surgical careers: role models, mentoring, and engagement in the operating room. J Am Coll Surg. 2008;207(6):793-800. http://dx. doi.org/10.1016/j.jamcollsurg.2008.08.003 [800.e1-2]. 8. Al-Heeti KNM, Nassar AK, Decorby K, Winch J, Reid
AUTHOR CONTRIBUTIONS Galinos Barmparas, MD; Nicole Fierro, BS; and Eric J. Ley, MD, contributed to the study conception and design. Galinos Barmparas, MD; Nicole Fierro, BS; Debora Lee, BS; and Beatrice J. Sun, BS, contributed to the acquisition of data. Galinos Barmparas, MD; Nicole Fierro, BS; Debora Lee, BS; and Beatrice J. Sun, BS, contributed to analysis and interpretation of data. Galinos Barmparas, MD, and Nicole Fierro, BS, contributed to the literature review. Galinos Barmparas, MD, and Nicole Fierro, BS, contributed to the drafting of manuscript. Eric J. Ley. MD, and Galinos Barmparas, MD, contributed to the critical revision of the manuscript.
S. The effect of general surgery clerkship rotation on the attitude of medical students towards general surgery as a future career. J Surg Educ. 2012;69(4):544-549. http: //dx.doi.org/10.1016/j.jsurg.2012.04.005. 9. Goldin SB, Schnaus MJ, Horn G, et al. Surgical
interest and surgical match for third-year students: results of a prospective multivariate longitudinal cohort study. J Am Coll Surg. 2012;215(5):599-606. http: //dx.doi.org/10.1016/j.jamcollsurg.2012.06.416. 10. Import WT. Summer Research Internship Program—
SRIP. Available at: 〈http://www.medicine.virginia.edu/edu cation/phd/gpo/srip/home-page〉; Accessed 05.04.2014.
11. RA Program at St. Vincent’s Medical Center—
Research. Available at: 〈http://raprogram.org/research〉; Accessed 05.04.2014.
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employment of part-time surgeons on the expected surgeon shortage. J Am Coll Surg. 2011;213(3): 345-351. http://dx.doi.org/10.1016/j.jamcollsurg.2011. 05.011. 2. Williams TE, Satiani B, Thomas A, Ellison EC. The
impending shortage and the estimated cost of training the future surgical workforce. Ann Surg. 2009;250 (4):590-597. http://dx.doi.org/10.1097/SLA.0b013e 3181b6c90b. 3. Workforce Legislation | American College of Surgeons.
Available at: 〈http://www.facs.org/ahp/workforce/〉; Accessed 04.05.2014.
12. Index | Department of Emergency Medicine | School
of Medicine | University of California, Irvine. Available at: 〈http://www.emergencymed.uci.edu/emrap/〉; Accessed 05.04.2014.
13. Khatib M, Soukup B, Boughton O, Amin K, Davis
CR, Evans DM. Plastic surgery undergraduate training: how a single local event can inspire and educate medical students. Ann Plast Surg. 2014. http://dx.doi. org/10.1097/SAP.0000000000000058. 14. Emanuel EJ. Changing premed requirements and the
medical curriculum. J Am Med Assoc. 2006;296(9): 1128-1131. 15. Dienstag JL. Relevance and rigor in premedical edu-
cation. N Engl J Med. 2008;359(3):221-224.
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16. Gross JP, Mommaerts CD, Earl D, De Vries RG.
21. Metcalfe D. Involving medical students in research. J R
Perspective: after a century of criticizing premedical education, are we missing the point? Acad Med. 2008;83(5):516-520.
Soc Med. 2008;101(3):102-103. http://dx.doi.org/ 10.1258/jrsm.2008.070393.
17. Sutton PA, Mason J, Vimalachandran D, McNally S.
Attitudes, motivators, and barriers to a career in surgery: a national study of UK undergraduate medical students. J Surg Educ. 2014. http://dx.doi.org/ 10.1016/j.jsurg.2014.03.005. 18. Alghamdi KM, Moussa Na, Alessa DS, Alothimeen N,
Al-Saud AS. Perceptions, attitudes and practices toward research among senior medical students. Saudi Pharm J. 2014;22(2):113-117. http://dx.doi.org/ 10.1016/j.jsps.2013.02.006. 19. Cohen BL, Friedman E, Zier K. Publications by
students doing a year of full-time research: what are realistic expectations? Am J Med. 2008;121(6):545-548. http://dx.doi.org/10.1016/j.amjmed.2008.03.006. 20. Dyrbye LN, Lindor KD, LaRusso NF, Cook DA.
Research productivity of graduates from 3 physicianscientist training programs. Am J Med. 2008;121(12): 1107-1113. http://dx.doi.org/10.1016/j.amjmed.2008. 08.015.
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22. O’Herrin JK, Lewis BJ, Rikkers LF, Chen H. Why do
students choose careers in surgery? J Surg Res. 2004;119(2):124-129. http://dx.doi.org/10.1016/j.jss. 2004.03.009. 23. Reed CE, Vaporciyan Aa, Erikson C, et al. Factors
dominating choice of surgical specialty. J Am Coll Surg. 2010;210(3):319-324. http://dx.doi.org/10.1016/j. jamcollsurg.2009.11.016. 24. McCord JH, McDonald R, Sippel RS, Leverson G,
Mahvi DM, Weber SM. Surgical career choices: the vital impact of mentoring. J Surg Res. 2009;155(1):136-141. http://dx.doi.org/10.1016/j.jss.2008.06.048. 25. Poteat LF, Shockley KM, Allen TD. Mentor-protégé
commitment fit and relationship satisfaction in academic mentoring. J Vocational Behav. 2009;74(2009): 332-337. 26. Gusic ME, Zenni EA, Ludwig S, First LR. Strategies
to design an effective mentoring program. J Pediatr. 2010;156(2):173-174 [e1].
Journal of Surgical Education Volume 72/Number 2 March/April 2015
The Trauma Research Associates Program (T-RAP) for Undergraduate Students: Shaping Future Academic Surgeons Galinos Barmparas, MD, Nicole Fierro, BS, Debora Lee, BS, Beatrice J. Sun, BS and Eric J. Ley, MD Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California OBJECTIVE: Offering undergraduate students research
opportunities may enhance their interest in pursuing a surgical career and lead to increased academic productivity. We characterize the benefits of participating in the Trauma Research Associates Program. DESIGN: A 19-point Web-based survey. SETTING: Academic Level I Trauma Center. PARTICIPANTS: A total of 29 active and former members of the Trauma Research Associates Program.
participant (adjusted odds ratio: 13.00; 95% CI: 1.27, 133.29; p ¼ 0.03). CONCLUSIONS AND RELEVANCE: Development of a
structured research program for undergraduate students is beneficial to both the participants and sponsoring institution. Undergraduate exposure to academic surgery enhances interest in pursuing a surgical specialty and leads to C 2014 Assoacademic productivity. ( J Surg 72:338-344. J ciation of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)
MAIN OUTCOME MEASURE(S): Academic activities and predictors associated with interest in a surgical career and research productivity.
KEY WORDS: undergraduate, student, research, volunteer,
RESULTS: Surveys were completed on 26 of 29 (90%)
ment, Interpersonal and Communication Skills, SystemsBased Practice
participants. Clinical experience was the most highly ranked motivation to join the program (65%), followed by pursuing a research experience (46%). During their involvement, 73% of participants observed surgical intensive care unit rounds, 65% observed acute care surgery rounds, and 35% observed a surgical procedure in the operating room. In addition, 46% submitted at least one abstract to a surgical meeting coauthored with the Division’s faculty. Furthermore, 58% reported that they enrolled in a medical school, whereas 17% pursued a full-time research job. The program influenced the interest in a surgical career in 39% of all members, and 73% reported that they would incorporate research in their medical career. Observing a surgical procedure was independently associated with development of a high interest in a surgical career (adjusted odds ratio: 6.50; 95% CI: 1.09, 38.63; p ¼ 0.04), whereas volunteering for more than 15 hours per week predicted submission of at least 1 abstract to a surgical conference by the
Correspondence: Inquiries to Eric J. Ley, MD, FACS, Department of Surgery, CedarsSinai Medical Center, 8700 Beverly Blvd, Suite 8215N, Los Angeles, CA 90048; fax: (310) 423-0139; E-mail: [email protected], [email protected]
338
academics, surgical career, shortage COMPETENCIES: Practice-Based Learning and Improve-
INTRODUCTION The shortage of general surgeons available to serve the nation’s increasing and aging population is undoubtedly a major challenge that the American College of Surgeons and the United States face today. Staggering statistics estimate that by the year 2020, there will be a shortage of 18,990 surgeons, of which 1875 will be general surgeons.1 By 2030, a shortage of 9% for general surgeons is predicted.2 The Balanced Budget Act of 1997 has capped the available medical and surgical resident positions and remains unrevised. The Division of Advocacy and Health Policy of the American College of Surgeons is seeking potential solutions to the problem by placing foreign medical graduates who have done their specializations in the United States in rural areas and by advocating for legislation to increase the available residency training positions by almost 15%.3 To add to the problem of this workforce shortage, a decline in interest in surgical specialties by medical graduates has been observed in the past decades, leading to concerns that less female applicants4 and even less
Journal of Surgical Education & 2014 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2014.08.012
competitive students5 are now being attracted to a surgical career. The focus has traditionally been on the third-year surgical clerkship, and several factors have been studied as possibly enhancing interest in surgical specialties, including exposure to the operating room early during medical school, mentoring, and interactions with residents.4,6-8 However, it appears that interest in a surgical career largely develops before this clerkship,9 possibly even before starting medical school, during undergraduate years. Various opportunities exist for undergraduate students to be exposed to clinical practice and participate in clinical and translational research.10-12 The value and effect of these programs on career development, admission to a medical school, and career choice is largely unknown. The Department of Surgery—Division of Acute Care Surgery (ACS) and Surgical Critical Care at the Cedars-Sinai Medical Center has developed the Trauma Research Associates Program (T-RAP), an integrated program that allows for undergraduate medical students seeking a career in medicine to participate in research opportunities, shadow staff surgeons, and be mentored by leaders in the field. We conducted a survey of participants in this program to assess its early effect on career choices and plans by examining academic activities and identifying predictors associated with interest in a surgical career and research productivity.
MATERIALS AND METHODS Description of the Program T-RAP is a research program geared for undergraduates pursuing careers in the areas of health care and research. The program was launched in July 2011 by recruiting undergraduate students from the University of California, Los Angeles. Every year, 12 to 15 students are included. The role of recruiting other interested volunteers once a year is taken up by 2 student coordinators by sending a notice to different LISTSERV’s at University of California, Los Angeles and by asking the departments to send the link for the application to the students. Minimum requirements for enrollment include a minimum grade point average of 3.2, a 1-year commitment including summer and other breaks, attendance of weekly mandatory meetings, and commitment to 3-hour data collection shifts twice a week. Before starting any activities, students enroll in a general laboratory safety course. All participants are expected to follow the rules and regulations of the Cedars-Sinai Medical Center Health Insurance Portability and Accountability Act requirements as they are granted access to the medical records of study subjects. Using shift assignments, students are expected to spend a total of at least 6 hours a week divided into 2 shifts in collecting predefined data for ongoing research projects. Data collection is supervised by the coordinators and faculty members to ensure accuracy and accountability.
Attendance at a weekly 1-hour meeting of all participants headed by the program coordinators in the presence of faculty members is mandatory for all participating students. These meetings serve to discuss issues that might arise during research activities, report on the progress of data collection, and ensure satisfactory and sufficient communication between participants. During these meetings, 2 students present medically related topics that are discussed under the supervision of faculty members. Optional opportunities include shadowing a trauma surgeon, attending the surgical intensive care unit (ICU) or the ACS rounds, observing procedures in the operating room, and attending the morbidity and mortality conference. Students can also pursue separate projects with faculty members and can either be mentored to develop their own research study or help with an already ongoing research activity. For these opportunities, priority is usually given by the coordinators to the most reliable and committed students. All students are mentored by faculty members in their research endeavors and in their future enrollment into a medical school. In addition to receiving class credit through their school, students are given letters of recommendation on request and a certificate of participation in the program. Students can only volunteer and no financial compensation is given for their work. Study Design After approval by the institutional review board, all current and former participants in the program were surveyed to determine the factors that drove them into participating in this program and the potential benefits they gained and interests they developed through their participation. The survey was completed within 2 weeks after an initial electronic mail was sent to all current and former participants explaining the purpose of the survey and providing a link to a website for completion of the Web-based survey. Additionally, 2 reminder emails were sent 7 and 10 days later. Completion of the survey was voluntary and responders’ anonymity was maintained at all phases of the study. Survey Instrument A 19-point Web-based survey was utilized for the purposes of this study. The questions focused on demographics related to the students’ school year and previous research experience, the amount of time they spent per week on their research activities, the degree of various motivations for joining the program, the number of abstracts they submitted to national surgical conferences because of their participation, their optional activities including observing surgical procedures, and details regarding whether their future plans include incorporating research into their medical career. Separate questions focused on the students’
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current interest in a surgical career because of their involvement in this program. Statistical Analysis The primary outcomes of this survey were development of an interest in a surgical career and research productivity, which was defined as submission of an abstract to a national surgical conference. Descriptive statistics were used, mostly as frequency distributions for the questionnaire responses. A forward logistic regression model was developed to identify factors that were independently associated with development of very high or high interest in a surgical career and factors independently associated with submission of an abstract to a national surgical conference. The adjusted odds ratio (AOR) and 95% CI were calculated, as was the area under the curve (AUC) for both models. All statistical analyses were performed using the IBM SPSS Statistics for Windows, Version 20.0 (IBM Corp., Armonk, NY).
RESULTS Of 29 eligible students, 26 (90.0%) completed the Webbased survey; among them, 14 (53.8%) were active members and 12 were (46.2%) former members (Table). Most participants (64.0%) were involved with the program for 2 or more years. Only 3 students (11.5%) had previous clinical research experience. Almost 3 of 10 participants (26.9%) spent 16 hours or more per week performing research. TABLE. Basic Demographics Participants Active members Former members Years involved with program 1 2þ School year when started participation First/second Thirdþ Previous clinical research experience Working hours per week 6 to 15 hours 16þ hours Activities while in program Full-time school Part-time school Full-time job Part-time job “How did you learn about the program?” Internet search Department mail list School counselor From a member of the program Other 340
53.8% (14/26) 46.2% (12/26) 36.0% (9/25) 64.0% (16/25) 34.6% (9/26) 65.4% (17/26) 11.5% (3/26)
Motivations to join the program that were ranked as “high” or “highest” included clinical experience (65.4%), research experience (46.2%), interest in surgery (38.5%), course credit (26.9%), and networking (23.1%). Most students attended surgical ICU rounds (73.1%) and ACS rounds (65.4%), whereas 65.4% participated in an individual research project and 46.2% submitted an abstract to a national surgical conference. Surgical procedure was observed by 34.6%, while 23.1% attended a morbidity and mortality conference. The plurality (58.3%) of former members enrolled into a medical school and 16.7% pursued full-time research (Fig. 1). Clinical exposure was the most commonly perceived true benefit of the program (96.2%), followed by learning research methodology (88.5%) and networking (73.1%) (Fig. 2). High and highest rank was given for the program by 84.6% of participants, while 88.5% thought that they consider their involvement with the program as extremely or very helpful with their future goals (Fig. 3). In a question on how much the program has influenced the students’ interest in a surgical career, 34.6% answered moderately, 30.8% much, and 7.7% very much (Fig. 4). Most participants (73.1%) answered that they would incorporate research into their future medical career. In a forward logistic regression model incorporating all available covariates (school year [o3 vs Z3]; previous clinical research experience [yes vs no]; working hours per week [o16 vs Z16]; attended surgical ICU rounds [yes vs no]; attended ACS rounds [yes vs no]; individual research project [yes vs no]; submission of abstract [yes vs no]; and very high or high motivation to join the program for clinical experience [yes vs no], for networking [yes vs no], for course credit [yes vs no], and for surgical interest [yes vs no]), observing a surgical procedure was independently associated with development of a high or very high interest in a surgical career (AOR [95% CI]: 6.50 [1.09, 38.63], adjusted p ¼ 0.04). The AUC for this model was 0.706. In a separate forward logistic regression model incorporating the same variables mentioned previously, spending 16 hours or more on research activities per week was independently associated with submission of an abstract to a national surgical conference (AOR [95% CI]: 13.00 [1.27, 133.29], adjusted p ¼ 0.03). The AUC for this model was 0.444.
73.1% (19/26) 26.9% (7/26) 84.6% (22/26) 7.7% (2/26) 30.8% (8/26) 15.4% 38.5% 3.8% 34.6% 7.7%
(4/26) (10/26) (1/26) (9/26) (2/26)
DISCUSSION The results from this survey indicate that almost 60% of participants in the T-RAP enrolled into a medical school, and approximately 17% pursued a full-time research position. The program had a moderate to high influence on the interest in a surgical career of more than 70% of participants. Observing a surgical procedure was independently associated with enhancement of interest in a surgical career, whereas spending more hours on research projects was
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Active Members
Former Members
78.6%
58.3%
35.7% 21.4%
16.7%
16.7%
16.7%
0.0% Undergraduate Coursework
Medical School
Full Time Research
Other
FIGURE 1. Current activities of active and former members of the program.
associated with academic productivity and submission of at least 1 abstract to a national surgical conference. Several programs across the nation are available through medical schools and universities for undergraduate students interested in pursuing a medical career. These programs vary in their focus. Some provide opportunities for translational research,10 whereas others provide participation in clinical research and interaction with patients.11,12 Our Web search identified several similar programs, but none targeted a surgical specialty, and most were available to participants for a limited period of time, i.e., summer break and so on. The value of these programs is largely unknown and no peer-reviewed publications addressing their efficacy are available to date. This survey serves as qualitative and quantitative measure of outcomes associated with participation in an integrated research program for undergraduates interested in a medical and potentially a surgical career. The decreasing interest in certain surgical subspecialties has lead several programs to develop workshops and research
opportunities for medical students early during medical school with the purpose of increasing the number of applicants to those same subspecialties.6,13 This is in line with the findings by Goldin et al.9 suggesting that surgical interest at baseline, i.e., before the surgical clerkship, is the most important predictor of matching into a surgical specialty or subspecialty. In this survey of T-RAP students, almost 39% enrolled into the program owing to their interest in surgery and the program had a moderate to high influence on the interest in a surgical career of more than 70% of participants. In an era where the focus and relevance of undergraduate education is being questioned and changes are being sought,14-16 the T-RAP offers an early involvement of future physicians and potentially surgeons in relevant activities to enhance their academic interests and productivity and more specifically, their interest in a medical specialty. Research involvement and productivity along with extracurricular activities are considered integral parts of a
96.2% 88.5% 73.1% 57.7%
Clinical Exposure
Research Methodology
Networking
Course Credit
53.8%
Patient Interaction
FIGURE 2. Perceived true benefits of the program by participating students. Journal of Surgical Education Volume 72/Number 2 March/April 2015
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FIGURE 3. Popularity of the program and likelihood of recommendation to others. All 3 questions were answered using a scale from 1 to 5, with 5 being the highest rank.
competitive medical school application, although few data exist to support this idea.16 Nonetheless, most medical students consider research to be important for their career development,17,18 offering the necessary tools during medical school that can lead to academic interest and productivity, and even shaping their final path to their specialty.19-21 T-RAP offers an early exposure to the principals of clinical research, and the results from our survey show that more than 65% participated in an individual research project and that more than 45% submitted an abstract to a national surgical conference. T-RAP students can use this experience to develop their academic productivity faster during medical school and even during their residency and later on in their career. In addition, the benefits for the sponsoring institution are obvious with increasing research productivity and submission of abstracts to national surgical conferences. Engagement in the operating room has been shown to attract surgical clerks to surgical careers.6,7,22 Mentoring is another factor that has a vital effect on career choices and has been shown to affect decisions to pursue surgical specialties.23-25 Passionate, experienced, highly committed, and readily available mentors who allow students to think
critically and independently can especially influence career choice.20,23-26 These factors were studied in T-RAP students. Observing a surgical procedure was independently associated with development of a high or very high interest in a surgical career. Additionally, more than 88% of participants considered their involvement with the program as extremely or very helpful with their future goals, likely as a result of networking, shadowing staff physicians, and receiving guidance for individualized research activities. Although T-RAP is primarily a research-oriented program, optional opportunities such as observing staff surgeons’ activities and surgical procedures are fundamental elements that appear to have a major effect on how these students perceive surgical specialties and how they integrate these experiences into their future career plans. This study is not without its inherit limitations. Associating increased interest in a surgical specialty with T-RAP potentially involves selection bias, as participants could be interested in a surgical career at baseline and are therefore more likely to pursue involvement in such a program. In addition, although more than 70% of participants reported interest in a surgical career, this could not be followed for potential future matching into a surgical specialty. Students applying to the T-RAP are highly motivated. One of the requirements is a grade point average above 3.2 and this requirement by itself introduces a selection bias. However, minimum selection criteria are helpful in this setting to ensure participation of candidates who are willing to invest the time and effort required to make this experience beneficial for themselves and the sponsoring institution. Owing to the relatively recent launch of the program, whether the submitted abstract resulted in peer-reviewed publications could not be examined along with the data from this survey, as peer-reviewed publications require a significant period to be completed, and it was thought that this question could introduce bias and underestimate such productivity. Additionally, only a relatively small number of
FIGURE 4. “How much has the program influenced your interest in a surgical career?” 342
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participants could be surveyed as only 2 groups of students have completed the program thus far. Lastly, although several markers of benefit to the participants and our institution are seen, such as the high percentage of enrollment in a medical school and a high percentage of submission of abstracts to national surgical conferences, the direct effect of this program on these outcomes cannot be determined and future studies with a comparison group will be required. Despite these limitations, the T-RAP appears to be mutually beneficial for both the participants and the sponsoring institution. Undergraduate exposure to academic surgery enhances interest in pursuing a surgical specialty and leads to academic productivity. Assessment of the benefits and the associated academic productivity will be constant, to ensure improvement, advancement, and growth of the program. Development of similar programs is encouraged by institutions affiliated with universities to encourage and assist undergraduate students to pursue a career in medicine and potentially in surgery.
4. Glynn RW, Kerin MJ. Factors influencing medical
students and junior doctors in choosing a career in surgery. Surgeon. 2010;8(4):187-191. http://dx.doi. org/10.1016/j.surge.2009.11.005. 5. Bland KI, Isaacs G. Contemporary trends in student
selection of medical specialties: the potential impact on general surgery. Arch Surg. 2002;137(3):259-267 Available at: http://www.ncbi.nlm.nih.gov/pubmed/ 11888445; (Accessed 04.04.2014). 6. Allen JG, Weiss ES, Patel ND, et al. Inspiring medical
students to pursue surgical careers: outcomes from our cardiothoracic surgery research program. Ann Thorac Surg. 2009;87(6):1816-1819. http://dx.doi.org/10. 1016/j.athoracsur.2009.03.007. 7. Berman L, Rosenthal MS, Curry LA, Evans LV,
Gusberg RJ. Attracting surgical clerks to surgical careers: role models, mentoring, and engagement in the operating room. J Am Coll Surg. 2008;207(6):793-800. http://dx. doi.org/10.1016/j.jamcollsurg.2008.08.003 [800.e1-2]. 8. Al-Heeti KNM, Nassar AK, Decorby K, Winch J, Reid
AUTHOR CONTRIBUTIONS Galinos Barmparas, MD; Nicole Fierro, BS; and Eric J. Ley, MD, contributed to the study conception and design. Galinos Barmparas, MD; Nicole Fierro, BS; Debora Lee, BS; and Beatrice J. Sun, BS, contributed to the acquisition of data. Galinos Barmparas, MD; Nicole Fierro, BS; Debora Lee, BS; and Beatrice J. Sun, BS, contributed to analysis and interpretation of data. Galinos Barmparas, MD, and Nicole Fierro, BS, contributed to the literature review. Galinos Barmparas, MD, and Nicole Fierro, BS, contributed to the drafting of manuscript. Eric J. Ley. MD, and Galinos Barmparas, MD, contributed to the critical revision of the manuscript.
S. The effect of general surgery clerkship rotation on the attitude of medical students towards general surgery as a future career. J Surg Educ. 2012;69(4):544-549. http: //dx.doi.org/10.1016/j.jsurg.2012.04.005. 9. Goldin SB, Schnaus MJ, Horn G, et al. Surgical
interest and surgical match for third-year students: results of a prospective multivariate longitudinal cohort study. J Am Coll Surg. 2012;215(5):599-606. http: //dx.doi.org/10.1016/j.jamcollsurg.2012.06.416. 10. Import WT. Summer Research Internship Program—
SRIP. Available at: 〈http://www.medicine.virginia.edu/edu cation/phd/gpo/srip/home-page〉; Accessed 05.04.2014.
11. RA Program at St. Vincent’s Medical Center—
Research. Available at: 〈http://raprogram.org/research〉; Accessed 05.04.2014.
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