The American Journal of Surgery (2015) 209, 21-25
Association for Surgical Education
A nonmetropolitan surgery clerkship increases interest in a surgical career Mackenzie R. Cook, M.D.*, Moon Yoon, B.S., John Hunter, M.D., Karen Kwong, M.D., Laszlo Kiraly, M.D. Department of Surgery, Oregon Health and Science University, Mail Code L611, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USA KEYWORDS: Rural surgery; Medical student; Surgical education
Abstract BACKGROUND: The optimal way to recruit the best and brightest medical students to fill the impending shortfall of general surgeons is uncertain. METHODS: Forty-three students were placed into nonmetropolitan sites for their basic surgical clerkship over 3 years. We surveyed students and compared match trends. RESULTS: When students selected to participate in the nonmetropolitan clerkship were examined, only 22% of students reported interest in a surgical career before their clerkship. This interest in surgery increased to 63% after the nonmetropolitan clerkship, P , .05. When match numbers were examined, students who completed the nonmetropolitan clerkship were significantly more likely to match to a general surgical residency than students who completed the standard clerkship (17% vs 6%, P , .02). CONCLUSIONS: These data challenge the perception that students should remain at a teaching university for their introductory clerkships. It may be that pairing students with individual faculty, or chief residents, could increase interest in a surgical career. Ó 2015 Elsevier Inc. All rights reserved.
The projected shortfall in general surgeons remains significant, despite increasing interest in general surgery careers.1,2 This shortfall may preferentially affect nonmetropolitan hospitals as they have trouble competing against urban hospitals for surgeons.2 Despite significant job opportunities in general surgery, most graduating residents elect to pursue subspecialty training, furthering the need for general surgeons.3 There is, as a result, an imperative
The authors have no conflicts of interest to disclose. This article was presented at the 2014 meeting of the Association for Surgical Education in Chicago, IL. * Corresponding author. Tel.: 503-494-5335; fax: 503-494-6519. E-mail address: [email protected] Manuscript received April 18, 2014; revised manuscript August 1, 2014 0002-9610/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjsurg.2014.08.027
to recruit students into surgery and provide early exposure to nonmetropolitan general surgery practices. Students have, traditionally, been placed at large academic hospitals for their clerkships, and many students and educators believe that this is advantageous to match in surgery. This curriculum model includes student clerks on resident-staffed services at major hospitals where residents are the primary clinical teachers and mentors.4–6 Although many residents are very invested in student education, they routinely underestimate their impact on students and have competing demands on their time. The service, learning, and multiple teaching demands on residents’ time may interfere with the mentorship and operative experience students crave.7–11 A nonmetropolitan model of medical student education based on apprenticeship principles may help light a fire of interest in some students. We hypothesized that the increased participation
22 in cases and close mentorship inherent in these sites would increase interest in a surgical career.
Methods The general surgery residency at Oregon Health and Science University (OHSU) has, for the past 10 years, had a nonmetropolitan year built into the residency curriculum.12,13 Building from this experience, 3 nonmetropolitan surgical sites were identified as sites for third-year surgical clerkships and students first rotated during the 2008 to 2009 academic year. These sites were chosen based on 3 factors: an interested and excited faculty mentor, sufficient clinical volume for a complete education, and the absence of traditionally structured resident-based teams. During each of the 5-week blocks devoted to the third-year surgical clerkship at OHSU, students were given a list of clerkship sites (metropolitan and nonmetropolitan), and they ranked these sites in order of preference. Approximately 5 students per rotation were then directly paired with an attending surgeon at one of the 3 nonmetropolitan sites, whereas 10 to 15 students remained at the 3 metropolitan sites. Nonmetropolitan students were housed locally, and housing costs were split between the clerkship site and the OHSU School of Medicine. There was no direct monetary compensation of the local preceptors. In addition to the clinical experience at these sites, students participated in weekly didactic sessions through electronic link with students at the main university hospital and presented learning topics to their faculty mentors and peers in an interactive format. This one-on-one interaction between nonmetropolitan students and their faculty mentors focused on clinical decision making and was in addition to the streamed lectures from the university. The video teleconferencing allowed for interactive discussions between remote students, the remainder of the class, and faculty. Students additionally participated in the academic functions of their institution, which varied by setting. These activities included morbidity and mortality conference and grand rounds. All students had electronic access to the OHSU library’s resources and a required online surgical curriculum through the Web Initiative for Surgical Education Modules. The traditional metropolitan-based clerkship is also 5 weeks long with 8 to 10 students based at the university hospital, 2 to 3 students based at the affiliated Veterans Affairs hospital, and 2 to 3 at a private tertiary care hospital in metropolitan Portland. Students are placed onto residentbased teams, which include at least an intern and a seniorlevel resident and often include a midlevel resident and other health care professionals. Students are based on the same general surgery service for their entire clerkship. In addition to student didactics, they attend departmental grand rounds, divisional and departmental Morbidity and Mortality conferences, and any divisional conferences pertinent to their individual service. Although medical education entails continuous process improvement, there were no major changes to the structure of this traditional clerkship within
The American Journal of Surgery, Vol 209, No 1, January 2015 the study period. Students on metropolitan rotations also have electronic access to the OHSU library resources and Web Initiative for Surgical Education of Medical Doctors (WISE-MD). To determine student response to and impact of this novel clerkship, we sent out 2 surveys. The initial survey was sent a single time during the 2010 to 2011 academic year to all medical students (Supplementary Data 1). The second survey was distributed from 2008 to 2012 to students on the nonmetropolitan clerkship (Supplementary Data 2). They completed the survey before leaving for their nonmetropolitan rotation and again after completing the clerkship. The questions of both surveys were focused on the student’s interest in a nonmetropolitan career and their interest in a surgical career. We additionally reviewed OHSU National Residency Match Program (NRMP) data from 2010 to 2013. These years corresponded to the match years of students who went through the nonmetropolitan surgical clerkship. Data were gathered anonymously, compiled in Microsoft Excel (Microsoft Corporation), and analyzed using SPSS, version 22 (IBM Corporation, Armonk, NY). Data were analyzed using Fisher exact or paired t test and a general linear regression model of probabilities with logit link function and quasibinomial error function to mode the percent of students matching to a surgical residency by year. Significance was set as P , .05. Approval for this study was obtained from the Institutional Review Board at the OHSU.
Results All OHSU students were surveyed regarding their interest in nonmetropolitan practice and interest in surgery. Our response rate to the first survey, sent to the entire medical school, was 37% (180 of 535) and divided relatively equally among classes with first-, second-, third-, and fourth-year students accounting for 22.7% (41 of 180), 38.3% (69 of 180), 18.9% (34 of 180), and 15.6% (28 of 180) of the respondents, respectively. There were 4.4% (8 of 180) of students who listed their class as ‘‘other’’ and represented dual degree students. Class size during the time period was between 113 and 138 students. Within the respondents, 65% (117 of 180) were interested in a nonmetropolitan clerkship. Interestingly, only 33.3% (60 of 180) were interested in a nonmetropolitan practice after training, only 32.2% (58 of 180) reported any interest in a surgical career, and just 10.0% (18 of 180) were interested in a surgical career at a nonmetropolitan hospital. Students who completed the nonmetropolitan clerkship were surveyed, and 63% (27 of 43) had complete pre- and post-rotation survey data. Students did not report a significant change in their interest in a nonmetropolitan practice after their nonmetropolitan surgical clerkship (Fig. 1). There was, however, a significant increase in the number of students reporting an interest in a surgical career after the nonmetropolitan clerkship, 22.2% (6 of 27) to 62.9% (17 of 27), P , .05 (Fig. 2).
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Non-metropolitan surgery clerkship
Figure 1 Students before and after a nonmetropolitan surgical clerkship were not significantly more interested in a rural medical career.
When we compared match trends at our institution, we first examined baseline rates of matching into surgery. In 2008 and 2009, just 4.2% (10 of 236) chose careers in general surgery, whereas 10.2% (24 of 236) chose careers in any surgical specialty. These were chosen to represent a baseline as classes matching in 2008 and 2009 did not have the opportunity to participate in the nonmetropolitan clerkship. These baseline values were no different than the 2010 match rates, the first class where students participated in the nonmetropolitan clerkship. In 2010, 2.8% (4 of 138), P 5 .58, of students chose general surgery, whereas just 5.7% (8 of 138), P 5 .18, matched into any surgical career. As we compared the subsequent match years, we found a trend toward increasing numbers of students matching into a categorical general surgery residency from 2.8% (4 of 138) in 2010% to 8.6% (11 of 128) in 2013 (Fig. 3A). When compared by Fisher exact test, there was a trend but no statistically significant difference between the proportion of students matching into a general surgical residency when 2010 and 2013 were compared, P 5 .06. On regression analysis, however, we identified a yearly
23
Figure 2 Students before and after a nonmetropolitan surgical clerkship were significantly more interested in a surgical career. ‘‘**’’ Denotes P , .05.
increase in the odds ratio of matching into a general surgery residency of 1.5 (95% confidence interval 1.3 to 1.7, P , .05) suggesting a significant trend over time. When NRMP matches into all surgical specialties were considered, we found a similar trend. We considered matches into categorical or preliminary general surgical positions and matches to urology, orthopedics, neurosurgery, and integrated thoracic, vascular, and plastic surgery programs. There was a statistically significant increase in the number of students matching to all surgical specialties when 2010 was compared with 2013 by Fisher exact test, 5.7% (8 of 138) vs 15.6% (20 of 128), P , .01. Similarly, regression analysis demonstrated a yearly increase in the odds ratio of matching to any surgical program of 1.4 (95% confidence interval 1.2 to 1.7, P , .05), again suggesting a statistically significant trend (Fig. 3B). To further characterize the impact of the nonmetropolitan clerkship on specialty choices, we next compared students who completed their clerkship at a nonmetropolitan site with those who completed their clerkship at a metropolitan site. Data were available for this analysis only from 2012 and
Figure 3 (A) Significant increase in the percentage of graduating students matching into general surgery residencies after implementation of the nonmetropolitan clerkship. The first class of students completing the nonmetropolitan clerkship graduated in 2010. (B) Significant increase in the percentage of graduating students matching into any surgical residency after implementation of the nonmetropolitan clerkship. The first class of students completing the nonmetropolitan clerkship graduated in 2010.
24
Figure 4 Significantly more graduating students matching into all surgical and general surgical residencies after completing the nonmetropolitan surgical clerkship compared with a metropolitan clerkship.
2013 match years. We found that 19% (9 of 47) graduating students who did their clerkship in a nonmetropolitan site entered a surgical residency, whereas 14% (30 of 211) of students in the metropolitan clerkship group entered any surgical residency, a difference that was borderline statistically significant, P 5 .05. Importantly, we found that 17% (8 of 47) of students who completed the nonmetropolitan clerkship group entered a categorical general surgery residency, compared with just 6% (12 of 211) of the metropolitan clerkship group, a statistically significant difference, P , .02 (Fig. 4).
Comments Surgical training in the United States has evolved significantly from its origins with William Halsted, although the importance of graded responsibility and the primacy of education in the operating room remain.14 Students routinely cite the intellectual challenges of a surgical residency and the subsequent career opportunities and technical aspects of surgery as reasons for pursuing a surgical career. They additionally highlight relationships with strong role models and the opportunity to participate in procedures during medical school as factors involved in their choice of a surgical career.7–11 Students matching into categorical general surgery positions participated in more operations than those choosing other specialties, a correlation that some have suggest may include an element of causation.8,9 This study describes our early experience with placing students on their initial surgical clerkship at a variety of nonmetropolitan sites. We show that students, in an anonymous survey, report broad interest in a nonmetropolitan clerkship. According to our survey results, this interest outstrips interest in either nonmetropolitan or surgical careers. We demonstrate that this clerkship increases students’ self-reported interest in a surgical career and that in the years after this implementation of this clerkship, our university saw a significant increase in the number of
The American Journal of Surgery, Vol 209, No 1, January 2015 students matching to surgical specialties. Although specialty choice is multifactorial, students who completed the nonmetropolitan surgical clerkship were significantly more likely to enter a surgical residency than their classmates who completed their introductory clerkship at the major metropolitan teaching hospitals on resident-staffed service teams. The reasons for this increased interest in surgery among the students in the nonmetropolitan clerkship are challenging to elucidate clearly, although may be based on that the learning styles of medical student differ significantly from that of the surgical residents and faculty. Surgical residents and attending surgeons share similar learning styles, a style that differs significantly from the learning style of the typical medical student. Students tend to favor an assimilating model, with a high priority on theoretical frameworks, whereas residents and faculty favor a converging style and place a high priority on the practical application of concepts. This difference in learning styles suggests that training paradigms effective in resident education may need to be reconsidered and optimized for medical student education.15 These optimizations may include the avoidance of concomitant resident learners and close pairing with highly invested and interested faculty preceptor. Other specialties have suggested that students placed in clerkships without residents feel less overwhelmed and have a more supportive learning environment than those students placed at sites that include residents. This is a critical observation because a welcoming environment in the operating room has been highlighted as 1 way to improve surgical clerkships.11,16 A nonmetropolitan surgical clerkship, specifically a rotation away from competing surgical learners with an invested faculty preceptor, may allow for improved mentorship, a more supportive learning environment, and an increased operative experience. This clerkship model provides access to strong, invested, and welcoming mentors who self-identified as interested in medical student education. Although our study did not specifically address operative participation of students, it may be that students at nonmetropolitan sites’ clerkship played a more active role in operations, given the lack of competing learners, than students at the central teaching site. This hypothesis was supported by a small number of free text comments from students, although a full qualitative analysis could not be done because of limited numbers of comments. One student remarked, ‘‘I wouldn’t have gone into surgery . if I didn’t get to first assist with Dr. [X].’’ In addition to mentorship and operative experience when paired with an individual attending surgeon, students may have had the opportunity to more fully address their concerns regarding a surgeons’ lifestyle and a nonmetropolitan practice. This is again an important point as one of the most frequently cited limitations to a career in surgery is the impact on lifestyle.7–10 It is important to highlight that the goal of a surgery clerkship is not only to spark a fire in future surgeons but also provide a basic surgical curriculum for students interested in other fields of medicine. As might be extrapolated from the broad student interest in a nonmetropolitan surgical
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Non-metropolitan surgery clerkship
clerkship, many students think this nonmetropolitan clerkship meets those goals. The didactic portion of the surgical curriculum was covered through distance learning, and the broad diversity of cases at smaller institutions covered the basics of general surgery. Distance learning in clerkships has been shown to be equally effective as classroom learning, despite occasional technical difficulties that are generally acceptable to students.17,18 Similarly, faculty development is conducted annually with videoconferencing and sporadically with site visits by the clerkship director. This study carries with it typical limitations of a surveybased study. Although a reporting bias is unavoidable, the observed increase in students pursuing a surgical career through the NRMP corroborates the reported increase in surgical interest. The term ‘‘nonmetropolitan’’ also has limitations. Oregon is a large state with health systems that tend to cover large geographic areas. Several of the nonmetropolitan sites are actually medium-sized hospitals with multispecialty medical groups and not true rural critical access hospitals. All the sites, however, are within counties designed as having significant unmet health care need.19 In this setting, the distinction between a rural critical access hospital and a nonmetropolitan hospital with a multispecialty practice in a county with a large unmet health care may need not be particularly critical. The key difference in the curriculum may be the faculty mentorship in a setting without competing learners. These data, in summary, challenge the perception that all medical students should remain on resident-staffed and team-based clinical services during their introductory clerkships. Although some students are clearly successful in the standard model of education, some students seem to benefit significantly from the close mentorship of the apprenticeship model. As placing all students in nonmetropolitan clerkships is logistically impractical, future efforts will be focused on building stronger mentorship relationships within the traditional clerkship model and identifying students who may benefit most from the nonmetropolitan clerkship structure.
Supplementary data Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j.amjsurg.2014.08.027.
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References 1. National resident matching program. Results and Data: 2013 Main Residency MatchÒ. Washington, DC: National Resident Matching Program; 2013. 2. Williams Jr TE, Satiani B, Ellison EC. A comparison of future recruitment needs in urban and rural hospitals: the rural imperative. Surgery 2011;150:617–25. 3. Decker MR, Bronson NW, Greenberg CC, et al. The general surgery job market: analysis of current demand for general surgeons and their specialized skills. J Am Coll Surg 2013;217:1133–9. 4. Musunuru S, Lewis B, Rikkers LF, et al. Effective surgical residents strongly influence medical students to pursue surgical careers. J Am Coll Surg 2007;204:164–7. 5. Griffith III CH, Georgesen JC, Wilson JF. Specialty choices of students who actually have choices: the influence of excellent clinical teachers. Acad Med 2000;75:278–82. 6. Cohn E, Larson E. Improving participant comprehension in the informed consent process. J Nurs Scholarsh 2007;39:273–80. 7. Quillin III RC, Pritts TA, Davis BR, et al. Surgeons underestimate their influence on medical students entering surgery. J Surg Res 2012;177: 201–6. 8. O’Herrin JK, Lewis BJ, Rikkers LF, et al. Medical student operative experience correlates with a match to a categorical surgical program. Am J Surg 2003;186:125–8. 9. O’Herrin JK, Lewis BJ, Rikkers LF, et al. Why do students choose careers in surgery? J Surg Res 2004;119:124–9. 10. Brundage SI, Lucci A, Miller CC, et al. Potential targets to encourage a surgical career. J Am Coll Surg 2005;200:946–53. 11. Tahiri M, Liberman M. What is an ideal surgical clerkship? Can J Surg 2013;56:151–2. 12. Vangelisti GR. Training in rural surgery: a resident’s perspective. Bull Am Coll Surg 2003;88:18–20. 13. Deveney K, Deatherage M, Oehling D, et al. Association between dedicated rural training year and the likelihood of becoming a general surgeon in a small town. JAMA Surg 2013;148:817–21. 14. Reznick RK, MacRae H. Teaching surgical skillsdchanges in the wind. N Engl J Med 2006;355:2664–9. 15. Engels PT, de Gara C. Learning styles of medical students, general surgery residents, and general surgeons: implications for surgical education. BMC Med Educ 2010;10:51. 16. Prunuske JP, Deci DM. Learning environment: the impact of clerkship location on instructional quality. Fam Med 2013;45:193–6. 17. Bertsch TF, Callas PW, Rubin A, et al. Effectiveness of lectures attended via interactive video conferencing versus in-person in preparing third-year internal medicine clerkship students for clinical practice examinations (CPX). Teach Learn Med 2007;19:4–8. 18. Callas PW, Bertsch TF, Caputo MP, et al. Medical student evaluations of lectures attended in person or from rural sites via interactive videoconferencing. Teach Learn Med 2004;16:46–50. 19. 2014 Areas of Unmet Health Care Need in Rural Oregon Report. http://www.ohsu.edu/xd/outreach/oregon-rural-health/data/upload/2014Unmet-Need-Report.pdf. Accessed July 27, 2014.
Association for Surgical Education
A nonmetropolitan surgery clerkship increases interest in a surgical career Mackenzie R. Cook, M.D.*, Moon Yoon, B.S., John Hunter, M.D., Karen Kwong, M.D., Laszlo Kiraly, M.D. Department of Surgery, Oregon Health and Science University, Mail Code L611, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USA KEYWORDS: Rural surgery; Medical student; Surgical education
Abstract BACKGROUND: The optimal way to recruit the best and brightest medical students to fill the impending shortfall of general surgeons is uncertain. METHODS: Forty-three students were placed into nonmetropolitan sites for their basic surgical clerkship over 3 years. We surveyed students and compared match trends. RESULTS: When students selected to participate in the nonmetropolitan clerkship were examined, only 22% of students reported interest in a surgical career before their clerkship. This interest in surgery increased to 63% after the nonmetropolitan clerkship, P , .05. When match numbers were examined, students who completed the nonmetropolitan clerkship were significantly more likely to match to a general surgical residency than students who completed the standard clerkship (17% vs 6%, P , .02). CONCLUSIONS: These data challenge the perception that students should remain at a teaching university for their introductory clerkships. It may be that pairing students with individual faculty, or chief residents, could increase interest in a surgical career. Ó 2015 Elsevier Inc. All rights reserved.
The projected shortfall in general surgeons remains significant, despite increasing interest in general surgery careers.1,2 This shortfall may preferentially affect nonmetropolitan hospitals as they have trouble competing against urban hospitals for surgeons.2 Despite significant job opportunities in general surgery, most graduating residents elect to pursue subspecialty training, furthering the need for general surgeons.3 There is, as a result, an imperative
The authors have no conflicts of interest to disclose. This article was presented at the 2014 meeting of the Association for Surgical Education in Chicago, IL. * Corresponding author. Tel.: 503-494-5335; fax: 503-494-6519. E-mail address: [email protected] Manuscript received April 18, 2014; revised manuscript August 1, 2014 0002-9610/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjsurg.2014.08.027
to recruit students into surgery and provide early exposure to nonmetropolitan general surgery practices. Students have, traditionally, been placed at large academic hospitals for their clerkships, and many students and educators believe that this is advantageous to match in surgery. This curriculum model includes student clerks on resident-staffed services at major hospitals where residents are the primary clinical teachers and mentors.4–6 Although many residents are very invested in student education, they routinely underestimate their impact on students and have competing demands on their time. The service, learning, and multiple teaching demands on residents’ time may interfere with the mentorship and operative experience students crave.7–11 A nonmetropolitan model of medical student education based on apprenticeship principles may help light a fire of interest in some students. We hypothesized that the increased participation
22 in cases and close mentorship inherent in these sites would increase interest in a surgical career.
Methods The general surgery residency at Oregon Health and Science University (OHSU) has, for the past 10 years, had a nonmetropolitan year built into the residency curriculum.12,13 Building from this experience, 3 nonmetropolitan surgical sites were identified as sites for third-year surgical clerkships and students first rotated during the 2008 to 2009 academic year. These sites were chosen based on 3 factors: an interested and excited faculty mentor, sufficient clinical volume for a complete education, and the absence of traditionally structured resident-based teams. During each of the 5-week blocks devoted to the third-year surgical clerkship at OHSU, students were given a list of clerkship sites (metropolitan and nonmetropolitan), and they ranked these sites in order of preference. Approximately 5 students per rotation were then directly paired with an attending surgeon at one of the 3 nonmetropolitan sites, whereas 10 to 15 students remained at the 3 metropolitan sites. Nonmetropolitan students were housed locally, and housing costs were split between the clerkship site and the OHSU School of Medicine. There was no direct monetary compensation of the local preceptors. In addition to the clinical experience at these sites, students participated in weekly didactic sessions through electronic link with students at the main university hospital and presented learning topics to their faculty mentors and peers in an interactive format. This one-on-one interaction between nonmetropolitan students and their faculty mentors focused on clinical decision making and was in addition to the streamed lectures from the university. The video teleconferencing allowed for interactive discussions between remote students, the remainder of the class, and faculty. Students additionally participated in the academic functions of their institution, which varied by setting. These activities included morbidity and mortality conference and grand rounds. All students had electronic access to the OHSU library’s resources and a required online surgical curriculum through the Web Initiative for Surgical Education Modules. The traditional metropolitan-based clerkship is also 5 weeks long with 8 to 10 students based at the university hospital, 2 to 3 students based at the affiliated Veterans Affairs hospital, and 2 to 3 at a private tertiary care hospital in metropolitan Portland. Students are placed onto residentbased teams, which include at least an intern and a seniorlevel resident and often include a midlevel resident and other health care professionals. Students are based on the same general surgery service for their entire clerkship. In addition to student didactics, they attend departmental grand rounds, divisional and departmental Morbidity and Mortality conferences, and any divisional conferences pertinent to their individual service. Although medical education entails continuous process improvement, there were no major changes to the structure of this traditional clerkship within
The American Journal of Surgery, Vol 209, No 1, January 2015 the study period. Students on metropolitan rotations also have electronic access to the OHSU library resources and Web Initiative for Surgical Education of Medical Doctors (WISE-MD). To determine student response to and impact of this novel clerkship, we sent out 2 surveys. The initial survey was sent a single time during the 2010 to 2011 academic year to all medical students (Supplementary Data 1). The second survey was distributed from 2008 to 2012 to students on the nonmetropolitan clerkship (Supplementary Data 2). They completed the survey before leaving for their nonmetropolitan rotation and again after completing the clerkship. The questions of both surveys were focused on the student’s interest in a nonmetropolitan career and their interest in a surgical career. We additionally reviewed OHSU National Residency Match Program (NRMP) data from 2010 to 2013. These years corresponded to the match years of students who went through the nonmetropolitan surgical clerkship. Data were gathered anonymously, compiled in Microsoft Excel (Microsoft Corporation), and analyzed using SPSS, version 22 (IBM Corporation, Armonk, NY). Data were analyzed using Fisher exact or paired t test and a general linear regression model of probabilities with logit link function and quasibinomial error function to mode the percent of students matching to a surgical residency by year. Significance was set as P , .05. Approval for this study was obtained from the Institutional Review Board at the OHSU.
Results All OHSU students were surveyed regarding their interest in nonmetropolitan practice and interest in surgery. Our response rate to the first survey, sent to the entire medical school, was 37% (180 of 535) and divided relatively equally among classes with first-, second-, third-, and fourth-year students accounting for 22.7% (41 of 180), 38.3% (69 of 180), 18.9% (34 of 180), and 15.6% (28 of 180) of the respondents, respectively. There were 4.4% (8 of 180) of students who listed their class as ‘‘other’’ and represented dual degree students. Class size during the time period was between 113 and 138 students. Within the respondents, 65% (117 of 180) were interested in a nonmetropolitan clerkship. Interestingly, only 33.3% (60 of 180) were interested in a nonmetropolitan practice after training, only 32.2% (58 of 180) reported any interest in a surgical career, and just 10.0% (18 of 180) were interested in a surgical career at a nonmetropolitan hospital. Students who completed the nonmetropolitan clerkship were surveyed, and 63% (27 of 43) had complete pre- and post-rotation survey data. Students did not report a significant change in their interest in a nonmetropolitan practice after their nonmetropolitan surgical clerkship (Fig. 1). There was, however, a significant increase in the number of students reporting an interest in a surgical career after the nonmetropolitan clerkship, 22.2% (6 of 27) to 62.9% (17 of 27), P , .05 (Fig. 2).
M.R. Cook et al.
Non-metropolitan surgery clerkship
Figure 1 Students before and after a nonmetropolitan surgical clerkship were not significantly more interested in a rural medical career.
When we compared match trends at our institution, we first examined baseline rates of matching into surgery. In 2008 and 2009, just 4.2% (10 of 236) chose careers in general surgery, whereas 10.2% (24 of 236) chose careers in any surgical specialty. These were chosen to represent a baseline as classes matching in 2008 and 2009 did not have the opportunity to participate in the nonmetropolitan clerkship. These baseline values were no different than the 2010 match rates, the first class where students participated in the nonmetropolitan clerkship. In 2010, 2.8% (4 of 138), P 5 .58, of students chose general surgery, whereas just 5.7% (8 of 138), P 5 .18, matched into any surgical career. As we compared the subsequent match years, we found a trend toward increasing numbers of students matching into a categorical general surgery residency from 2.8% (4 of 138) in 2010% to 8.6% (11 of 128) in 2013 (Fig. 3A). When compared by Fisher exact test, there was a trend but no statistically significant difference between the proportion of students matching into a general surgical residency when 2010 and 2013 were compared, P 5 .06. On regression analysis, however, we identified a yearly
23
Figure 2 Students before and after a nonmetropolitan surgical clerkship were significantly more interested in a surgical career. ‘‘**’’ Denotes P , .05.
increase in the odds ratio of matching into a general surgery residency of 1.5 (95% confidence interval 1.3 to 1.7, P , .05) suggesting a significant trend over time. When NRMP matches into all surgical specialties were considered, we found a similar trend. We considered matches into categorical or preliminary general surgical positions and matches to urology, orthopedics, neurosurgery, and integrated thoracic, vascular, and plastic surgery programs. There was a statistically significant increase in the number of students matching to all surgical specialties when 2010 was compared with 2013 by Fisher exact test, 5.7% (8 of 138) vs 15.6% (20 of 128), P , .01. Similarly, regression analysis demonstrated a yearly increase in the odds ratio of matching to any surgical program of 1.4 (95% confidence interval 1.2 to 1.7, P , .05), again suggesting a statistically significant trend (Fig. 3B). To further characterize the impact of the nonmetropolitan clerkship on specialty choices, we next compared students who completed their clerkship at a nonmetropolitan site with those who completed their clerkship at a metropolitan site. Data were available for this analysis only from 2012 and
Figure 3 (A) Significant increase in the percentage of graduating students matching into general surgery residencies after implementation of the nonmetropolitan clerkship. The first class of students completing the nonmetropolitan clerkship graduated in 2010. (B) Significant increase in the percentage of graduating students matching into any surgical residency after implementation of the nonmetropolitan clerkship. The first class of students completing the nonmetropolitan clerkship graduated in 2010.
24
Figure 4 Significantly more graduating students matching into all surgical and general surgical residencies after completing the nonmetropolitan surgical clerkship compared with a metropolitan clerkship.
2013 match years. We found that 19% (9 of 47) graduating students who did their clerkship in a nonmetropolitan site entered a surgical residency, whereas 14% (30 of 211) of students in the metropolitan clerkship group entered any surgical residency, a difference that was borderline statistically significant, P 5 .05. Importantly, we found that 17% (8 of 47) of students who completed the nonmetropolitan clerkship group entered a categorical general surgery residency, compared with just 6% (12 of 211) of the metropolitan clerkship group, a statistically significant difference, P , .02 (Fig. 4).
Comments Surgical training in the United States has evolved significantly from its origins with William Halsted, although the importance of graded responsibility and the primacy of education in the operating room remain.14 Students routinely cite the intellectual challenges of a surgical residency and the subsequent career opportunities and technical aspects of surgery as reasons for pursuing a surgical career. They additionally highlight relationships with strong role models and the opportunity to participate in procedures during medical school as factors involved in their choice of a surgical career.7–11 Students matching into categorical general surgery positions participated in more operations than those choosing other specialties, a correlation that some have suggest may include an element of causation.8,9 This study describes our early experience with placing students on their initial surgical clerkship at a variety of nonmetropolitan sites. We show that students, in an anonymous survey, report broad interest in a nonmetropolitan clerkship. According to our survey results, this interest outstrips interest in either nonmetropolitan or surgical careers. We demonstrate that this clerkship increases students’ self-reported interest in a surgical career and that in the years after this implementation of this clerkship, our university saw a significant increase in the number of
The American Journal of Surgery, Vol 209, No 1, January 2015 students matching to surgical specialties. Although specialty choice is multifactorial, students who completed the nonmetropolitan surgical clerkship were significantly more likely to enter a surgical residency than their classmates who completed their introductory clerkship at the major metropolitan teaching hospitals on resident-staffed service teams. The reasons for this increased interest in surgery among the students in the nonmetropolitan clerkship are challenging to elucidate clearly, although may be based on that the learning styles of medical student differ significantly from that of the surgical residents and faculty. Surgical residents and attending surgeons share similar learning styles, a style that differs significantly from the learning style of the typical medical student. Students tend to favor an assimilating model, with a high priority on theoretical frameworks, whereas residents and faculty favor a converging style and place a high priority on the practical application of concepts. This difference in learning styles suggests that training paradigms effective in resident education may need to be reconsidered and optimized for medical student education.15 These optimizations may include the avoidance of concomitant resident learners and close pairing with highly invested and interested faculty preceptor. Other specialties have suggested that students placed in clerkships without residents feel less overwhelmed and have a more supportive learning environment than those students placed at sites that include residents. This is a critical observation because a welcoming environment in the operating room has been highlighted as 1 way to improve surgical clerkships.11,16 A nonmetropolitan surgical clerkship, specifically a rotation away from competing surgical learners with an invested faculty preceptor, may allow for improved mentorship, a more supportive learning environment, and an increased operative experience. This clerkship model provides access to strong, invested, and welcoming mentors who self-identified as interested in medical student education. Although our study did not specifically address operative participation of students, it may be that students at nonmetropolitan sites’ clerkship played a more active role in operations, given the lack of competing learners, than students at the central teaching site. This hypothesis was supported by a small number of free text comments from students, although a full qualitative analysis could not be done because of limited numbers of comments. One student remarked, ‘‘I wouldn’t have gone into surgery . if I didn’t get to first assist with Dr. [X].’’ In addition to mentorship and operative experience when paired with an individual attending surgeon, students may have had the opportunity to more fully address their concerns regarding a surgeons’ lifestyle and a nonmetropolitan practice. This is again an important point as one of the most frequently cited limitations to a career in surgery is the impact on lifestyle.7–10 It is important to highlight that the goal of a surgery clerkship is not only to spark a fire in future surgeons but also provide a basic surgical curriculum for students interested in other fields of medicine. As might be extrapolated from the broad student interest in a nonmetropolitan surgical
M.R. Cook et al.
Non-metropolitan surgery clerkship
clerkship, many students think this nonmetropolitan clerkship meets those goals. The didactic portion of the surgical curriculum was covered through distance learning, and the broad diversity of cases at smaller institutions covered the basics of general surgery. Distance learning in clerkships has been shown to be equally effective as classroom learning, despite occasional technical difficulties that are generally acceptable to students.17,18 Similarly, faculty development is conducted annually with videoconferencing and sporadically with site visits by the clerkship director. This study carries with it typical limitations of a surveybased study. Although a reporting bias is unavoidable, the observed increase in students pursuing a surgical career through the NRMP corroborates the reported increase in surgical interest. The term ‘‘nonmetropolitan’’ also has limitations. Oregon is a large state with health systems that tend to cover large geographic areas. Several of the nonmetropolitan sites are actually medium-sized hospitals with multispecialty medical groups and not true rural critical access hospitals. All the sites, however, are within counties designed as having significant unmet health care need.19 In this setting, the distinction between a rural critical access hospital and a nonmetropolitan hospital with a multispecialty practice in a county with a large unmet health care may need not be particularly critical. The key difference in the curriculum may be the faculty mentorship in a setting without competing learners. These data, in summary, challenge the perception that all medical students should remain on resident-staffed and team-based clinical services during their introductory clerkships. Although some students are clearly successful in the standard model of education, some students seem to benefit significantly from the close mentorship of the apprenticeship model. As placing all students in nonmetropolitan clerkships is logistically impractical, future efforts will be focused on building stronger mentorship relationships within the traditional clerkship model and identifying students who may benefit most from the nonmetropolitan clerkship structure.
Supplementary data Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j.amjsurg.2014.08.027.
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