Undergraduate surgical education for the twenty-first century.

This article addresses the problems associated with current undergraduate surgical education and discusses the requirements necessary for its improvement during the third and fourth years of medical school. It asserts that, coincident with the emphasis on faculty research and publication and expanded resident patient care duties, teaching, particularly medical student teaching, has assumed a very low priority. Third-year medical students are attached to surgical teams, where their education is haphazard and disorganized. Furthermore, because any teaching that occurs is teacher oriented rather than student centered, knowledge is accumulated passively and is not well retained. Traditional evaluation using shelf multiple choice examinations and ward ratings by residents and faculty may provide inaccurate assessments of the students' performance. The undergraduate surgical education program should be directed by a faculty member who has been grounded in educational techniques and research and supported by a department chairman committed to bettering the program. In the clerkship, medical students should be assigned to faculty rather than to services and should be presented problems that require solution. Students also should be provided with the resources to solve the problems and should be given sufficient time to solve them. Some operating room experience and bedside teaching should occur during the clerkship. A variety of evaluation and testing methods based on the learning objectives of the clerkship should be used. Third-year students should not be promoted until they have demonstrated their acquisition of appropriate knowledge and skills.(ABSTRACT TRUNCATED AT 250 WORDS)     

形成性评价之“美容外科学”教学实践与研究

目的:对中西医临床专业(美容医学方向)"美容外科学"课程,引入形成性评价考核,通过设立多元指标、多元主体参与、实施多元形式的评价,激发学生学习主动性和积极性,使之改进学习方法,提高学习能力,亦可促进教师教学改革,增强教学效果。方法:本课程形成性评价考核指标为考勤、提问和讨论、实验三项,建立了详细的评分标准,评价主体为本课程教师、学生和实习单位临床指导教师三个层次,采取提问讨论随堂反馈、布置作业随机检查、小组实验协调配合等多样化方式,对教学全过程进行考评。结果:征求学生的反馈意见,对学生试卷卷面成绩与综合成绩分布进行统计学分析。结果显示,经过形成性评价考核,学生的综合成绩构成并不会改变学生试卷卷面成绩的分布构成,加入了学习过程考核因素后,更能全面反映学生的学习状态以及学生对该门课程的综合素质;综合评价的离散趋势较卷面成绩下降,意味加入过程化考核的综合评价尚有降低学生成绩的变异度,增强集中趋势的作用,更能让学生成绩分布符合正态分布,也更符合学生学习规律。结论:严格教学纪律对培养医学生有必要,实行形成性评价考核教学效果良好,因课时有限带来的一些问题需要得到解决。     

UNIFORM EXPERIENCE AND ASSESSMENT DURING A MULTISITE SURGICAL CLERKSHIP

Major changes in health care delivery and the increased number of clerkship sites used for teaching by many medical schools has resulted in significant implications for medical education. Methods have become necessary to achieve and maintain a comparable clinical experience and a uniform assessment process at each teaching site. Following a review of existing practices, a new core curriculum, a problem-based approach and the Objective Structured Clinical Examination (OSCE) were introduced into this department. Over 1200 students have passed through this revised surgical clerkship over the past 8 years. The introduction of the OSCE has helped to direct student learning, provide an objective assessment to complement the ward grade, and enabled an audit of teaching and learning to be carried out. In one group of 103 students no significant correlation was found between the OSCE and ward grades. Performance at different hospitals was similar and those carrying out their clerkship later in the academic year benefited from their previous other attachments. The OSCE has enabled immediate feedback to be given to learners as well as providing teachers with an opportunity to see for themselves the outcome of their tuition. A clinical performance record card has now been introduced to improve the monitoring of students' clinical experience.     

Clerkship enhancement of interpersonal skills

BACKGROUND: The purpose of this research was to determine if students improve interpersonal skills as the third year progresses despite the lack of any specific curriculum or teaching methods. METHODS: Third-year students completed 1 of 3 16-week sequential clerkship blocks. Each student completed a clinical performance examination before and after clerkship consisting of a videotaped standardized patient interview and physical examination. Videotapes were randomly assigned to communication faculty for evaluation. RESULTS: Although the majority (73%) of students improved during their block, 17% showed no improvement, and 12% had deficient interpersonal skills after their clerkship. CONCLUSIONS: Despite the lack of skill-directed curriculum, most medical students showed improved interpersonal skill performance after a 16-week clerkship. Developing an interpersonal curriculum for all third-year students may not be necessary. Because faculty are being asked to do more with less, we believe efforts focused on individual students during the third year will be more productive.     

Validation and learning in the Procedicus KSA virtual reality surgical simulator

Background: Advanced simulator training within medicine is a rapidly growing field. Virtual reality simulators are being introduced as cost-saving educational tools, which also lead to increased patient safety. Methods: Fifteen medical students were included in the study. For 10 medical students performance was monitored, before and after 1 h of training, in two endoscopic simulators (the Procedicus KSA with haptic feedback and anatomical graphics and the established MIST simulator without this haptic feedback and graphics). Five medical students performed 50 tests in the Procedicus KSA in order to analyze learning curves. One of these five medical students performed multiple training sessions during 2 weeks and performed more than 300 tests. Results: There was a significant improvement after 1 h of training regarding time, movement economy, and total score. The results in the two simulators were highly correlated. Conclusion: Our results show that the use of surgical simulators as a pedagogical tool in medical student training is encouraging. It shows rapid learning curves and our suggestion is to introduce endoscopic simulator training in undergraduate medical education during the course in surgery when motivation is high and before the development of "negative stereotypes" and incorrect practices.     

Attending, house officer, and medical student perceptions about teaching in the third-year medical school general surgery clerkship

BACKGROUND: There has been declining interest in surgery among medical students and one reason might be the third-year clerkship experience. The aim of this study was to clarify the perceptions and expectations of attendings, residents, and medical students on the clerkship experience. STUDY DESIGN: A survey was distributed to all general surgery attendings, the entire general surgery house staff, and an entire third year medical school class inclusive of the 2001-2002 academic year at a single institution. Statistic analysis consisted of chi-square and Kruskal-Wallis-ANOVA on ranks with Dunn's test for multiple comparisons. A p < 0.05 was significant. RESULTS: Responses were obtained from 59 attending surgeons (50%), 38 surgical residents (32%), and 107 medical students (66%). Of this student cohort, 35% were planning to choose a surgical specialty as a career. Agreement was high among faculty, students, and residents about factors considered important in evaluation, expectations of skills, and level of skills needed before the clerkship. Medical students desired more hours of instruction, believed they performed fewer procedures per week, and thought that feedback was poor compared with the opinions of faculty and residents (p < 0.002). Nearly 50% of medical students believed they were an inconvenience to the service; 30% of house officers and 27% of faculty (p < 0.001) believed this also. Almost all faculty and residents, however, wanted medical students on the service (> 95%). Faculty believed residents did a better job teaching than either the students or residents themselves did (p < 0.001), and students thought that residents were the primary source of education in patient care. CONCLUSIONS: Considerable differences exist between faculty, surgical resident, and medical student perceptions and expectations of medical student education. Structured direct faculty contact, definition of medical student roles on the surgical team, and more consistent feedback can be rapidly improved.     

Effective use of human simulators in surgical education

BACKGROUND: We initiated a teaching module utilizing a human simulator midway through 2001-2002 to improve student skills specific to the evaluation of patients in shock during a required clerkship in surgery for fourth-year medical students. We tested the hypothesis that student skills would improve after implementation of this module and identified factors that predicted student performance. MATERIALS AND METHODS: Students (n = 86) chose one of two hospital sites for a clerkship that focuses on the care of acutely ill surgical patients. A case-based lecture focusing on the diagnosis and management of a patient in shock was replaced midway through the academic year by a simulator session with a computerized life-sized mannequin. A standardized clinical final evaluation (OSCE) was used to assess student skills. We evaluated the effect of the simulator session and other factors on student exam performance using univariate and multivariate analysis. RESULTS: The site of the clerkship and the simulator session were significant factors affecting the OSCE score identified by ANOVA, P < 0.05. A stepwise multiple regression analysis testing the effect of simulator module, site, time of year, prior NBME subject exam, and prior OSCE during the third year clerkship identified that the simulator module was the only independent factor that modeled performance on all shock stations, P < 0.01. CONCLUSIONS: In a clerkship that already emphasized faculty facilitated case-based learning, the use of a teaching module employing a human simulator significantly improved test scores. This study supports the efficacy of human simulators to improve student skills related to the management of complex critically ill patients.     

An encounter card system for increasing feedback to students

BACKGROUND: Student satisfaction with the feedback process is essential for motivating students to improve their performance. METHODS: Third-year medical students participated in a system to increase feedback from faculty, fellows, and residents during a 12-week surgery clerkship. Each student received 40 encounter cards to solicit verbal and written feedback on specific domains of clinical performance. The clerkship evaluations from the intervention group (Fall 2000-2001) were compared with a historical control group (Fall 1999-2000) on seven feedback-related items. Effect sizes were calculated and two-tailed t tests performed to determine statistical significance. RESULTS: All seven items had effect sizes greater than 0.30 (range, 0.38 to 0.85). Differences between the two groups' scores were statistically significant for six items. CONCLUSIONS: Implementation of an encounter card system improved student satisfaction with the feedback process. Intervention group students perceived that faculty and residents had improved their understanding of history-taking, physical-examination, and decision-making skills.     

Measuring medical students' experience with surgical problems and procedures.

BACKGROUND: Measuring medical students' experience on their surgical clerkship rotations to assess the adequacy of the breadth of exposure is essential for producing generalist clinicians. METHODS: A Surgical Clinical Checklist was developed by surveying the surgical faculty for those surgical problems and procedures that every generalist physician should experience. The checklist was then distributed to 48 consecutive third-year medical students for completion during their core clerkship in surgery. RESULTS: Students reported encounters with surgical procedures more frequently than with surgical problems (64.3% of procedures versus 21.9% of problems were encountered by 80% of respondents). Students actively participated as often as they reported passive observation alone. Students assigned to two different teaching sites encountered similar numbers of items at each site although the distribution of individual items was different. CONCLUSIONS: The Surgical Clinical Checklist provides a valuable measurement tool to assess student experiences on their surgical clerkship and can be used to direct future teaching initiatives.     

Does a general surgery clerkship influence student perceptions of surgeons and surgical careers?

BACKGROUND: Student perceptions of surgeons and surgical careers may influence their decision to pursue a surgical career. We evaluated the impact of a general surgery clerkship on medical student perceptions of surgeons and surgical careers and of the clerkship on student interest in surgical careers. METHODS: We conducted voluntary pre- and postclerkship surveys of third-year medical students who were enrolled in their required general surgery clerkship and used 5-point Likert scale rankings to capture agreement with declarative statements (1 = strongly agree; 5 = strongly disagree). T-tests were used to evaluate both paired and individual items. RESULTS: Students indicated that their surgical clerkship improved their opinion of surgeons (2.47; P <.001). Several perceptions changed after the clerkship. First, students agreed more strongly that surgeons were compassionate physicians (ranking, 2.87 vs 2.53; P =.003) and that patients respected surgeons (ranking, 1.84 vs 1.62; P =.026). Acknowledgment of career satisfaction by students increased (ranking, 2.57 vs 2.22; P =.008). Students more strongly disagreed that "surgeons [were] respectful of other physicians" (ranking, 3.29 vs 3.62; P =.009). Interest in surgical careers did not change significantly during the clerkship (ranking, 2.83 vs 2.68; P =.218). CONCLUSIONS: Medical student perceptions of surgeons and surgical careers generally improve during the surgical clerkship. However, student impressions of surgeons' collegial behavior and commitment to teaching deteriorate significantly during the surgical clerkship.     

Assessment of the core learning objectives curriculum for the urology clerkship

PURPOSE: The traditional approach to the surgical clerkship has limitations, including variability of clinical exposure. To optimize student education we developed and introduced the core learning objectives curriculum, which is designed to allow students freedom to direct their learning and focus on core concepts. We performed a prospective, randomized, controlled study to compare the efficacy of core learning objectives vs traditional curricula through objective and subjective measures. MATERIALS AND METHODS: Medical students were randomly assigned to the core learning objectives or traditional curricula during the 2-week urology clerkship. Faculty was blinded to student assignment. Upon rotation completion all students were given a 20-question multiple choice examination covering basic urology concepts. In addition, students completed a questionnaire addressing subjective clerkship satisfaction, comprising 15 questions. RESULTS: Between June 2005 and January 2007, 10 core learning objectives students and 10 traditional students completed the urology clerkship. The average +/- SEM multiple choice examination score was 12.1 +/- 0.87 and 9.8 +/- 0.59 for students assigned to the core learning objectives and traditional curricula, respectively (p <0.05). Subjective scores were higher in the core learning objectives cohort, although this result did not attain statistical significance (124.9 +/- 3.72 vs 114.3 +/- 4.96, p = 0.1). Core learning objectives students reported higher satisfaction in all 15 assessed subjective end points. CONCLUSIONS: Our experience suggests that the core learning objectives model may be an effective educational tool to help students achieve a broad and directed exposure to the core urological concepts.     

The role of anesthesiologists in Canadian undergraduate medical education

PURPOSE: To examine the current role of anesthesiologists in Canadian undergraduate medical education (UME). METHODS: A 93-item questionnaire was mailed to the undergraduate course chairs/coordinators for anesthesia at the 16 medical schools in Canada. RESULTS: Of the faculty anesthesiologists in Canada, 1.7%, 4.9%, and 4.9% teach pre-clerkship lectures, seminars, and PBL tutorials, respectively. Annually, anesthesiologists teach an average of 3.3 hr (range: 0 to 15) of pre-clerkship lectures and 12.8 hr (range: 0 to 48) of pre-clerkship seminars at each medical school. The topics most commonly taught by anesthesiologists in pre-clerkship lectures and seminars are pharmacology and perioperative patient assessment, respectively. An anesthesia rotation during clerkship is mandatory at 13 schools, with an average duration of 9.6 dy (range: 5-20 dy). Clerkship teaching methods vary: ten schools provide seminars, eight use videos, six use computers, six use an airway skills laboratory, and four use an anesthesia simulator. The most common topics taught in clerkship anesthesia seminars are airway management and fluid therapy. CONCLUSION: A very small proportion of faculty anesthesiologists participate in Canadian UME at the pre-clerkship level. Considerable variation exists in the amount and format of teaching by anesthesiologists among the Canadian undergraduate curricula, particularly at the pre-clerkship level. However, our results indicate that anesthesiologists are assuming a more important teaching role during clerkship. Our findings may suggest that Canadian medical schools are overlooking the advantages that anesthesiologists offer to UME at the pre-clerkship level, or that many anesthesiologists are reluctant to assume pre-clerkship teaching responsibilities.     

Undergraduate Surgery Clerkship and the Choice of Surgery as a Career: Perspective from a Developing Country

Background

There are concerns regarding a possible decline in the proportion of students choosing surgery as a career in some countries in sub-Saharan Africa. Published works indicate that most students choose their ultimate career during undergraduate training. The present study was undertaken to assess the medical student’s perception of the surgery clerkship and determine its influence in the choice of surgery as a career.

Methods

The study involved a cross-sectional survey of 2009 and 2010 graduating medical classes of the University of Nigeria based on self-administered questionnaires. The clerkship evaluation was assessed on a 3-point Likert scale (1 = poor; 3 = excellent).

Results

The response rate was 70.3 % (275/391); 179 (65.1 %) of the students were males and 96 (34.9 %), females. Sixty-one (22.2 %) rated the overall quality of their surgery clerkship as excellent (mean rating = 2). Compared with the other three major clerkships, surgery has the lowest rating for overall quality (mean rating: surgery = 2; others = 2.2). Aspects of the clerkship experience that contributed to the overall lower rating of surgery include quality of opportunity to participate in direct patient care; clarity of posting goals and objectives; experience in learning history taking skills, basic physical examination skills, and interpretation of laboratory data; accessibility of faculty; and students’ perception that they were treated in a respectful manner. The major suggestions to improve clerkship quality were these: (1) more involvement in direct patient care (n = 154; 56 %), and (2) improvement in student–faculty interaction (n = 9 1; 33.1 %). Overall, 96 (34.9 %) students selected surgery as a specialty, and 39.3 % (108/275) selected the other three major specialties. Surgery was selected by 17/48 (35.4 %), 59/166 (35.5 %), and 20/61 (32.8 %) students who rated the surgery clerkship as “poor,” “just right,” and “excellent,” respectively (p = 0.876). Factors indicated as major influences in the choice of surgical specialty included personal satisfaction 41.7 % (40/96), clerkship experience 36.4 % (35/96), and diligence of faculty 13.5 % (13/96).

Conclusions

Periodic assessment of the satisfaction of medical students regarding their surgical clerkship experience is important. In our setting, we have identified aspects of the surgical clerkship that could be improved to enhance the quality of the experience, ensure the attractiveness of the field to the most qualified candidates, and boost interest in surgery as a career.     

Perioperative pain management education: a short structured regional anesthesia course compared with traditional teaching among medical students

BACKGROUND AND OBJECTIVES: Previous research has demonstrated that a brief course on pain management improved knowledge and attitudes toward analgesic use among medical students. The purpose of this study is to compare a structured clinical instruction course on regional anesthesia techniques for perioperative pain management with traditional teaching given to senior medical students. METHODS: During a 1-month clerkship in anesthesiology, 40 fourth-year medical students were randomly and equally divided into 2 groups. The study group received a 2-hour structured course on regional anesthesia techniques for pain management, whereas the control group received a 1-hour lecture tutorial on regional anesthesia techniques for perioperative pain management and 1 hour of bedside teaching on acute pain management. Each student completed an objective structured clinical examination (OSCE) 2 weeks after completion of the course. RESULTS: The study group performed better on each of the 11 items of the OSCE and on the total performance scores (mean +/- SD of 36.2 +/- 7.3 for study group versus 14.8 +/- 8.4 for the control group; P < .05). All students rated the clinical course highly valuable (4.7 +/- 0.5). CONCLUSION: A structured clinical instructional course on regional techniques for perioperative pain management given to fourth-year medical students can significantly improve their understanding and knowledge compared with traditional teaching.     

Educational value of the operating room experience during a core surgical clerkship

Background

The amount and content of medical student teaching in the operating room and its alignment with clerkship goals was unknown.

Methods

A qualitative research design using field observations, followed by qualitative and quantitative data coding and analysis.

Results

A mean of 9.8% of the total case time (range 1.6%-20.2%) was spent teaching clerkship goals. Teaching strategies based on basic principles of learning were used during a mean of 66% of the total case time (range 30%-99%). The most common teaching strategy was active student participation (28%) followed by command (14%) and lecture (13%). Educational experience in the OR was rated 4.0 (out of 5) by faculty and 3.3 by students. No correlation existed between student satisfaction and time actively participating in the operation or time spent teaching to clerkship goals (P = .66, P = .95, respectively).

Conclusion

Teaching in the OR is more focused on technical aspects of the operation than the goals of a core surgery clerkship.     

Undergraduate medical students' perceptions and expectations of theatre-based learning: How can we improve the student learning experience?

OBJECTIVE: Much of the student experience in theatre depends on the interaction between student and surgeon, and having the opportunity to take part in procedures. Theatre-based teaching can be seen as having little inherent benefit otherwise. We wished to identify other factors contributing to the experience of theatre-based teaching. DESIGN: A questionnaire survey, using forced-choice and open questions, of undergraduate medical students with experience of surgical attachments. SETTING AND PARTICIPANTS: 54 final (5th) year medical students, University of Aberdeen. ANALYSIS: Responses on the closed questions are presented as percentages. The themes arising from the open questions were identified and the relationships among these themes explored. RESULTS: Student expectations of learning focused on knowledge acquisition. Students learning experiences varied widely, depending on how welcome they felt in theatre. Visibility and active participation influenced the experience. Students did not feel adequately prepared for getting the most out of this learning experience. CONCLUSIONS: The student experience may be skewed by unrealistic expectations of theatre-based learning. Clear and realistic learning objectives, preparation in terms of familiarity with the environment and staff roles, embedding the experience in the patient's journey/care pathways, faculty expectations being clearly communicated to clinical teaching staff and, perhaps above all, approachability of theatre staff are likely to improve the learning experience.     

Medical student contact with patients on a surgery clerkship: is there a chance to learn?

BACKGROUND: Earlier studies of medical students on nonsurgical rotations have shown that clinical clerks usually first interact with their patients late in the clinical course. This would seem disadvantageous to the student's learning because they would have less opportunity to generate diagnoses or a management plan. STUDY DESIGN: A questionnaire designed to assess the nature of medical student-patient interactions in all potential clinical sites was administered to third year medical students during their surgical clerkship. Students received questionnaires each day to evaluate their clinical experiences from the previous day. RESULTS: The results from 311 student-patient encounters were collected and analyzed by clinical site as follows: outpatient clinics, outpatient surgery, inpatient surgery, day of surgery admission, inpatient consults, or emergency room consults. Students reported significantly more opportunities to elicit chief complaint, generate potential diagnosis, develop or suggest a management plan, and perform the initial examination when in the clinic setting. CONCLUSIONS: Overall, students were given relatively few opportunities to be the first to interact with any patient in any setting. They infrequently had an opportunity to independently generate a hypothesis or generate a management plan. Currently, the clinic offers the best opportunity for the student to complete these processes.     

A model for tracking student experiences on surgical clerkships

This study was conducted to identify the range and nature of surgical clerkship experiences in three different hospital settings-university, community, and public. METHODS: An instrument was developed to track the location and type of learning experience, patient demographics, surgical content, and clinical experience of students on their surgical clerkship. Twenty-three students used the instrument to record the events of their surgical clerkship. Data were analyzed to describe the frequency of tasks performed, the nature and location of learning experience, exposure to surgical topics, and patient demographics. RESULTS: Students were involved in an average of 245 common surgical tasks over their 8-week clerkship. Of their exposure to common tasks, students had the opportunity to observe 25% and perform 70% of those tasks. Sixty-six percent of task work occurred on the patient floor and 23% occurred in the operating room. Students were exposed to a broad range of surgical topics, 71% of which were general surgery topics. Only 25% of these experiences were auditory, whereas 39% involved exposure to a patient, and 36% included participation in an operation. Patient load and characteristics tended to vary across hospital settings, and on average, students worked with 164 patients during their clerkship. The smallest patient load (m = 113) occurred in the university hospital and the largest patient load (m = 251) occurred in the public hospital. CONCLUSION: Although surgical services and hospital settings may offer students different clerkship experiences, the common clinical and didactic components of a surgical clerkship can balance a student's exposure to surgical topics and practice of clinical skills. Tracking surgical clerkship experiences is valuable in identifying the range and nature of medical students' didactic, clinical, and operative experiences.     

Reliability and usefulness of clinical encounter cards for a third-year surgical clerkship

BACKGROUND: Third-year medical students (MS3) were given clinical encounter cards (CECs) to stimulate feedback during their surgery clerkship. This study analyzes the feedback given on their clinical performance using CECs. METHODS: Two hundred one students enrolled in the 12-week surgery clerkship were given CECs. Each card contained the chief focus of the encounter, which was rated on a six-point Likert scale. The CECs were analyzed to determine if they provided reliable formative information, identified marginal performances, and identified differences between raters, settings, rotations, and aspects of clinical performance evaluated. RESULTS: Seven thousand three hundred eight CECs were submitted from 201 students. The CECs were completed most often (65%) in the inpatient setting. Technical skills were evaluated on 49% of CECs, history/physical examinations on 40%, and case presentations on 30%. There were comments written on half of the CECs and 89% of these were strictly positive. Women (52.8%) and faculty (63.3%) were more likely to provide written comments. The students were most likely to seek feedback from the interns and faculty who gave significantly higher ratings. The Cronbach-alpha reliability coefficient was 0.69, based on 12 raters per student. There was a significant positive correlation (P < 0.05) between the CEC composite rating and the clinical performance rating (r = 0.356), NBME score (r = 0.258), and the final grade (r = 0.250). CONCLUSIONS: The implementation of CECs in a surgery clerkship provided a large quantity of positive feedback. The quality was limited because there were minimal recommendations for improvement and they were a poor predictor of overall clinical performance.