ORIGINAL REPORTS
Perception of Undergraduate Pediatric Surgery Clerkship in a Developing Country Sebastian O. Ekenze, MD, and Uchechukwu M. Obi Sub-department of Paediatric Surgery, University of Nigeria Teaching Hospital, Enugu, Nigeria OBJECTIVE: Medical students’ perception of their clerk-
ship may influence their choice of ultimate career. In most medical schools, pediatric surgery clerkship (PSC) is not compulsory. This study evaluates the perception of PSC by students and determines the importance of this on the choice of pediatric surgery as a career. METHODS: We surveyed 2009 and 2010 graduating medi-
cal classes of University of Nigeria, Nsukka, using selfadministered questionnaires. The clerkship evaluation was assessed using a 3-point scale (1 ¼ poor and 3 ¼ excellent). Students who had PSC were analyzed to compare their rating of pediatric surgery vis-à-vis other clinical clerkships and determine the effect of the clerkship on their ultimate choice of a career. RESULTS: Overall response rate was 70.3% (275/391), and
119 (43.3%) had PSC. For overall quality, PSC rated (2.16) compared with general surgery (2.04), internal medicine (2.11), obstetrics and gynecology (2.13), and pediatrics (2.37). Aspects of PSC that rated poorly include opportunity to participate in direct patient care, feedback on performance during clerkship, ability to manage problem in a general medical setting, and experience in learning history-taking skills and interpretation of laboratory data. Among the students who had PSC, 14 (11.8%) selected pediatric surgery as a specialty choice compared with 13 (8.3%) who did not have PSC (p ¼ 0.457). Of those that had PSC, pediatric surgery was selected as a career by 2 of 19 (10.5%), 6 of 63 (9.5%), and 6 of 37 (16.2%) who rated PSC as poor, just right, and excellent, respectively. The decision to select pediatric surgery was influenced mostly by clerkship experience in 37% (10/27) and personal satisfaction in 40.7% (11/27). Improvement in the quality of PSC may involve more participation of the students in direct patient care (n ¼ 54; 45.4%) and enhancement in student-faculty interaction (n ¼ 31; 26.1%). CONCLUSION: PSC may have a good rating in our setting. Nonetheless, improving the quality and experience
Correspondence: Inquiries to Sebastian O. Ekenze, MD, Sub-department of Paediatric Surgery, University of Nigeria Teaching Hospital, No. 1, Unth Road, Enugu 400001, Nigeria; e-mail: [email protected]
of the clerkship through a well-thought-out curriculum modification may enhance interest in pediatric surgery as a C 2014 Association of career choice. ( J Surg ]:]]]-]]]. J Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: clerkship, pediatric surgery, undergraduate, career, developing country COMPETENCIES: Patient Care, Medical Knowledge, Practice Based Learning and Improvement, Systems Based Practice, Professionalism, Interpersonal Skills and Communication
INTRODUCTION Pediatric surgery may be one of the young specialties of surgery, but the past decades have witnessed significant dynamic advances in the specialty, especially in workforce development and surgical care of children.1,2 At the level of undergraduate medical education, there are indications that inclusion of pediatric surgery in the undergraduate curriculum has tremendously improved the total surgical care of infants and enabled pediatric surgeons to reach out to undergraduates to enhance interest in the specialty.2-5 Previous reports have suggested that the choice of surgical specialty by undergraduates may be influenced by gender, age, marital status, prestige influence, surgeon mentors, career opportunity, intellectual challenge, and clerkship experience.6-8 Important positive factors identified in clerkship experience were exposure and active participation in operations, residents’ interaction, surgeon/faculty interactions, and number of cases observed during the rotation.6-10 A previous study has shown that approximately 25% of undergraduates undertake clerkship in pediatric surgery usually as elective.2 However, there is paucity of data on medical students’ assessment of their clerkship in pediatric surgery in developed as well as developing countries. In addition, the evaluation of the students’ experience in learning basic clinical skills in pediatric surgery and the
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.2013.11.010
1
student/faculty interaction during the clerkship is rarely reported. This study looks at the assessment of the learning experience during pediatric surgery clerkship (PSC) by students of University of Nigeria, Nsukka, and determines the importance of this on their career choice.
participation, the study procedure, risks, and confidentiality regarding the information in the survey. Those who consented proceeded with the survey. Completed questionnaires were collected the following day. The rating in pediatric surgery was compared with the ratings for other major clerkships at our school (general surgery, internal medicine, pediatrics, and obstetrics and gynecology).
MATERIAL AND METHODS At the Faculty of medicine, University of Nigeria, Nsukka, PSC is not compulsory to qualify for final examination in surgery. Medical students are posted to pediatric surgery randomly in 1 of the 4 postings required in undergraduate surgery. There are 4 pediatric surgeons at our institution and 2 independent clinical units. Each of the units runs separate outpatient clinic, ward rounds, and theater sessions, with emergencies, minor ward procedures, and ward rounds undertaken daily. Didactic teaching rounds, joint pediatric surgery conference, and interspecialty surgery conference/ presentations are undertaken weekly. In addition, joint morbidity/mortality and interdisciplinary sessions take place monthly and quarterly, respectively. During the PSC, which lasts for a period of 6 weeks, the students are tutored and exposed clinically to the evaluations and treatment of pediatric surgical conditions at these clinical/academic sessions and are continuously evaluated by way of scoring the relevant procedures in the students’ surgery procedure book and through end-of-posting assessment test. The graduating classes of 2009 and 2010 were surveyed after they completed the last surgery posting. The survey (Appendix 1) explored the demographics of the students, their evaluation of pediatric surgery and other clerkships, and their choice of career. The clerkship evaluation rated aspects of students’ learning experience using a 3-point scale (1 ¼ poor, 2 ¼ just right, and 3 ¼ excellent). The survey was administered by hand to individual students. Before completing the survey, the respondents received a separate note detailing the voluntary nature of
DATA ANALYSIS Statistical Package for Social Sciences (SPSS 15.0 version, SPSS Inc, Chicago, IL) was used for data entry and analysis. Results were expressed as percentages or mean. Data were analyzed by chi-square test as appropriate. In all, critical p o 0.05 was regarded as significant, and conclusions were drawn based on this level of significance.
RESULTS Overall, 275 of the 391 (70.3%) students responded. Among them, 179 (65.1%) of the respondents were male, and 96 (34.9%) were female. Their median age was 25 years (IQR, 24-26 years). A total of 119 (43.3%) undertook PSC. Clerkship Experience This is summarized in Table 1. The mean rating of overall quality of pediatric surgery clerkship was 2.16 on the 3-point scale. On this, 52.9% (63) of the respondents rated the clerkship as just right, 31.1% (37) as excellent, and 16% (19) as poor. The aspects of the clerkship experience with the best rating (Table 2) were the overall quality of consultants’ teaching (mean ¼ 2.48), accessibility of resident doctors (mean ¼ 2.20), and accessibility of the consultants (mean ¼ 2.19). Remarkably, the least ratings involved aspects of the posting related to
TABLE 1. Summary of the Rating of the Aspects of Pediatric Surgery Clerkship Experience Rating Aspects of Clerkship
Poor (%)
Experience in learning history-taking skills Experience in learning basic physical examination skills Experience in interpreting laboratory data Clarity of posting goals and objectives Accessibility of consultant Accessibility of residents Quality of opportunity to participate in direct patient care Quality of feedback on your performance in the posting Ability to manage problems in a general medical setting Overall quality of residents teaching Overall quality of consultants teaching Overall quality of posting
33 20 37 22 22 21 55 38 39 18 8 19
2
(27.7) (16.8) (31.1) (18.5) (18.5) (17.7) (46.2) (31.9) (32.8) (15.1) (6.7) (16.0)
Just Right (%) 69 78 65 68 52 53 49 71 68 66 46 63
(58.0) (65.5) (54.6) (57.1) (43.7) (44.5) (41.2) (59.7) (57.1) (55.5) (38.7) (52.9)
Excellent (%) 17 21 17 29 45 45 15 10 12 35 65 37
(14.3) (17.7) (14.3) (24.4) (37.8) (37.8) (12.6) (8.4) (10.1) (29.4) (54.6) (31.1)
Journal of Surgical Education Volume ]/Number ] ] 2014
TABLE 2. Comparison of the Aspects of PSC That Rated Poorly With the Rating in Other Major Clerkships Mean Rating Aspects of Clerkship
PSC General Surgery Medicine Pediatrics OBGYN
Quality of opportunity to participate in direct patient care Quality of feedback on your performance in the posting Ability to manage problems in a general medical setting Experience in interpreting laboratory data Experience in learning history-taking skills
1.66 1.76 1.77 1.83 1.87
1.58 1.70 1.80 1.93 2.04
1.71 1.82 1.84 2.10 2.19
1.90 2.02 2.06 2.29 2.58
1.69 1.81 1.86 2.07 2.22
OBGYN, obstetrics and gynecology.
patient management. These aspects include (Table 3) quality of opportunity to participate in direct patient care (mean ¼ 1.66), quality of feedback on performance in the posting (mean ¼ 1.76), ability to manage problems in a general medical setting (mean ¼ 1.77), experience in interpreting laboratory date (mean ¼ 1.83), and experience in learning history-taking skills (mean ¼ 1.87). Comparison of Pediatric Surgery Clerkship With Other Major Clerkships For overall quality of clerkship, the mean rating of PSC was less than that of pediatrics (mean ¼ 2.37), but better than obstetrics and gynecology (mean ¼ 2.13), internal medicine (mean ¼ 2.11), and general surgery (mean ¼ 2.04). Figure 1 shows the comparison of the mean ratings of the overall quality of these clerkships. When individual aspects of the clerkship experiences that rated poorly in PSC were compared with their rating in other clerkships (Table 2), 2 areas showed differences in the mean rating scores of Z0.1. These aspects were experience in interpreting laboratory data and experience in learning history-taking skills. On the contrary, comparison of aspects with the best rating in PSC (Table 3) showed difference of Z0.04 in the mean rating score for accessibility of resident doctors. Factors That may Improve the Clerkship Of the students that undertook PSC, 54 (45.4%) suggested that more involvement of students in direct patient care may improve the quality of surgery clerkship. Other factors advocated by the respondents to enhance quality of the clerkship include improvement in the faculty-student interaction by 31 (26.0%), improvement in the quality of feedback on the posting performance by 18 (15.1%), and
development of a program that would involve an initial block of surgery lectures before clinical postings by 7 (5.9%). A total of 9 (7.6%) respondents did not give any response on this item. Choice of Specialty Overall, 27 (9.8%) selected pediatric surgery, 69 (25.1%) selected other specialties of surgery, and 179 (65.1%) selected other medical specialties (Table 4). Among the 119 who had PSC, 14 (11.8%) selected pediatric surgery compared with 13 (8.3%) among those who did not have PSC (p ¼ 0.457). On analysis of choice of pediatric surgery and the overall rating of PSC, pediatric surgery was selected as career by 2 of 19 (10.5%), 6 of 63 (9.5%), and 6 of 37 (16.2%) who rated PSC as poor, just right, and excellent, respectively (p ¼ 0.444). Largely the factors indicated as influencing the choice of pediatric surgery as career varied between the student who had PSC and those who did not have PSC (Table 5). Although clerkship experience was the major influence in 10 of 14 (71.4%) of the former, personal interest was the main factor in 7 of 13 (53.8%) of the latter. All the 14 respondents with PSC who selected pediatric surgery as career indicated positive influence of pediatric surgery clerkship in their choice of the specialty. However, 4 of these respondents specified that the clerkship reinforced their personal inclination.
DISCUSSION This study indicates that though PSC rated fairly well when compared with the other major clerkships in our setting, the students’ rating of the various aspects of the clerkship
TABLE 3. Comparison of the Aspects of PSC That Rated High With the Rating in Other Major Clerkships Mean Rating Aspects of Clerkship
PSC
General Surgery
Medicine
Pediatrics
OBGYN
Quality of consultants teaching Accessibility of residents Accessibility of consultants
2.48 2.20 2.19
2.36 2.24 2.03
2.30 2.26 2.04
2.51 2.40 2.34
2.32 2.25 2.10
OBGYN, obstetrics and gynecology. Journal of Surgical Education Volume ]/Number ] ] 2014
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FIGURE 1. Final-year medical students' evaluation of the overall quality of pediatric surgery clerkship and other 4 major clerkships at the University of Nigeria.
appropriate hands-on experience during undergraduate clerkship in surgical specialties.6-9,15-18 The other aspects of PSC that rated poorly may be related to inadequate supervision and didactic clinical teaching of the students. Although consultants’ availability and teaching were rated high, the fact that other aspects of patients’ management were rated poorly may be a pointer to lack of structured teaching and emphasize the need to streamline the teaching to address the need of the students. Feasible interventions to address these shortcomings may be in the way of modification of the curriculum of the undergraduate training in our setting, as well as reorientation of the faculty to give a more focused teaching, supervision, and feedback to the students. This may ultimately improve the learning experience of the undergraduates during PSC. The choice of pediatric surgery as a career by a tenth of the graduating medical class in this study may not actually be indicative of interest in the specialty by our undergraduates because objective assessments in this domain were not undertaken in this study. Moreover, in the light of the scant information on medical students’ interest in PSC in current literature from both developed and developing countries, it may be difficult to provide a more valid comparison. However, the response of the students highlighted a number of factors that could contribute to the choice of pediatric surgery. Experience during the PSC was a major influence
uncovered areas that may have negatively affected their overall perception of the clerkship. These aspects include quality of opportunity to participate in direct patient care, quality of feedback on performance in the posting, ability to manage problems in a general medical setting, experience in interpreting laboratory data, and experience in learning history-taking skills. Incidentally, these aspects of the posting deal with patient management. On participation in direct patient care, a study11 has shown that the lack of hands-on experience is a major shortcoming in undergraduate surgery clerkship in some developing countries. Though not entirely limited to developing countries,6,12,13 the reason for this lack of hands-on exposure is largely unknown, but it may be related to the perception of specialties of surgery as highly specialized fields to allow such exposure at the undergraduate level of training.11,14 Also in the case of pediatric surgery, this may have a bearing on the expectations of the affected family about who will undertake procedures on their child. However, hands-on experience in the form of operative exposure and direct involvement of students in surgical care during clerkship may be essential in surgical specialties.15,16 This has been shown to stimulate students’ interest in surgery. Although some authors have argued that hands-on experience should be reserved for residency training period,14,17 recent trend however emphasize curriculum modification to include
TABLE 4. Choice of Specialty Among 275 Final-Year Medical Students Specialty Choice Category Pediatric surgery clerkship No pediatric surgery clerkship Total 4
n
Pediatric Surgery
Other Surgery Specialties
Other Specialties
119 156 275
14 (11.8%) 13 (8.3%) 27
29 (24.3%) 40 (25.6%) 69
76 (63.9%) 103 (66.1%) 179
Journal of Surgical Education Volume ]/Number ] ] 2014
TABLE 5. Factors in the Choice of Pediatric Surgery as a Career Among Medical Students Who Undertook PSC and Those Who did not Factor Personal interest Clerkship experience Prestige influence Financial reward Total
PSC
No PSC
4 10 – – 14
7 – 4 2 13
Total (%) 11 10 4 2 27
(40.7) (37.1) (14.8) (7.4) (100)
among the students who had PSC. This finding, which is irrespective of the students’ rating of the clerkship, underscores the effect of clerkship in the choice of specialty. It further reinforces the result of previous studies that show focused exposure to a specialty during clerkship helps to dispel myths and negative perceptions and inspire interest toward the specialty.7-9,15,18,19 The clerkship experiences most noted in previous reports to be positively influential were number of cases participated/scrubbed, resident interaction, faculty interaction, and number of cases observed.6-10 Another important factor in the choice of specialty is personal interest. This was a compelling sway in the choice of pediatric surgery amongst the students who did not undertake PSC. Although this has been previously reported in the choice of other surgical specialties,20 some authors believe that personal interest is in most cases strengthened by influence of positive role models and career and academic opportunities in the surgical specialty.13,15,16 The other factors also espoused by the students such as prestige influence and financial reward remarkably did not play significant role in the choice of the specialty in our setting. Although prestige influence was noted in some previous studies to be an important factor in the choice of surgical specialty, financial reward on the contrary is not known to be a major influence in the choice of surgical specialties.7,8,21 The other factors noted in literature to influence the choice of surgical specialty among medical students include surgical mentors, career opportunity, intellectual challenge and degree of participation in operative procedures, and number of hours on call/rotation.6-10,12,15 Available data
indicate that career opportunity, active participation in operative procedures, and surgical mentors have positive influence in the choice of surgical specialty whereas long hours on call/rotation negatively affect the choice of specialty.7-9,12,13,15,16,20,22 Most of these data explored general surgery and some surgical specialties. However, there is scant information in the available literature on the role of these factors in the choice of pediatric surgery. Unarguably, the response of our undergraduates indicate that a well-thought-out curriculum modification is imminent in our setting to ensure appropriate hands-on experience, focused teaching, feedback, and learning the ability to solve problems in a general medical setting. A re-evaluation of the students’ learning experience after the modifications is recommended to see if there may be either better perception of PSC, greater competence, and greater interest in pediatric surgery in our setting.
LIMITATIONS OF THE STUDY This study was limited by scant literature on undergraduate pediatric surgery clerkship especially from more developed countries. Because of this, valid comparison was not possible. In addition, the use of a 3-point scale led to a cluster of means. A 5-point scale would have been more appropriate.
CONCLUSION Pediatric surgery clerkship seems to have a good rating in our setting. Despite this, some aspects of the clerkship that deal with patient management rated poorly among the students. The choice of pediatric surgery as specialty may be influenced by clerkship experience in our setting, but other factors might also affect the choice of this specialty. Addressing the deficiencies of the clerkship through a well-thought-out curriculum modification and reorientation of the faculty for more focused teaching and feedback may improve the overall clerkship experience, and this might boost interest in pediatric surgery.
APPENDIX 1. CLINICAL CLERKSHIP SURVEY IN PEDIATRIC SURGERY Section A 1. 2. 3. 4.
Age……. Gender……… Year of Study…………… Postings completed in Surgery……Subspecialty S1…………………………. S2…………………………. S3…………………………. S4…………………………. 5. Which of the subspecialties was your best posting…………………………………………… 6. Which was your worst posting……………………..………………………………………… Journal of Surgical Education Volume ]/Number ] ] 2014
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7. Why did you chose the above as your worst posting…………………………………………… 8. Which of the posting do you think should be mandatory to all Medical students……………..and why……………………………………… Section B Clerkship evaluation Please rate the following items from 1 to 3 (1¼ “Poor,” 2 ¼ “Just right,” 3 ¼ “Excellent”) Item
Rating Surgery
Medicine
Paediatrics
Obs & Gynae
Paediatric surgery
1. Experience in learning history taking skills……………… 2. Experience in learning basic physical examination skills... 3. Experience in interpreting laboratory data………………. 4. Clarity of posting goals and objectives…………………... 5. Accessibility of Consultant……………………………… 6. Accessibility of Residents………………………………. 7. Quality of opportunity to participate in direct patient care 8. Quality of feedback on your performance in the posting 9. Ability to manage problems in a general medical setting 10. Overall quality of residents teaching…………………. 11. Overall quality of Consultants teaching……………… 12. Overall quality of Posting…………………………….
Section C 1) Which area of medicine would you like to specialize (please tick) a) Internal medicine b) Paediatrics c) OBS & Gynae d) Paediatric Surgery e) Other specialties of Surgery f) Others specify)…………………………… 2) What informed your decision above (please tick) a) Experience during posting b) Diligence of the consultants c) Fame of the specialty d) Financial rewards e) Personal inclinations f) Demands of the other specialties g) Others specify…………………………………. 3) For those who selected paediatric surgery, did your experience in the paediatric surgery clerkship positively influence your choice? Yes………… No………….. 4) Did your posting improve your understanding of paediatric surgery pathologies and management? Yes……… No………. 5) What in your opinion would improve the quality of paediatric surgery postings? a)………………………………………….... Thank you for completing the questionnaire 6
Journal of Surgical Education Volume ]/Number ] ] 2014
REFERENCES 1. Ehrenpreis T. 100 years of pediatric surgery in Stock-
holm, with personal memories from the last 50 years. Prog Pediatr Surg. 1986;20:17-33. 2. Postuma R. The pediatric general surgery undergrad-
uate medical curriculum: what should medical students learn? J Pediatr Surg. 1987;22(8):746-749. 3. Karp MP, Hassett JM, Doerr RJ, et al. The role of
pediatric surgery in the medical school curriculum. J Pediatr Surg. 1989;24(1):39-40. 4. Madhok P. Undergraduate medical education and pedia-
tric surgery. J Indian Assoc Pediatr Surg. 2010;15(1):42. 5. Dutta S, Wales PW, Fecteau A. The two-week
pediatric surgery rotation: is it time wasted? J Pediatr Surg. 2004;39(5):717-720. 6. Erzurum VZ, Obermeyer RJ, Fecher A, et al. What
influences medical students’ choice of surgical careers. Surgery. 2000;128(2):253-256. 7. Scott IM, Matejeek AN, Gowans MC, Wright BJ,
Breneis FR. Choosing a career in surgery: factors that influence Canadian medical students’ interest in pursuing a surgical career. Can J Surg. 2008;51(2):371-377. 8. Azizzadeh A, McCollum CH, Miller CC, Holliday
12. Cochran A, Paukerk JL, Neumayer LA. Does a general
surgery clerkship influence student perceptions of surgeons and surgical careers? Surgery. 2003;134(2): 153-157. 13. Kozar RA, Lucci A, Miller CC, et al. Brief intervention
by surgeons can influence students toward a career in surgery. J Surg Res. 2003;111(1):166-169. 14. Yamazaki Y. Surgical education and surgical board
system from the view of pediatric surgeons. Nihon Geka Gakkai Zasshi. 2003;104(3):297-300. 15. Chen H, Hardacre JM, Martin C, Lillemoe KD. Do
medical school surgical rotations influence subspecialty choice? J Surg Res. 2001;97(2):172-178. 16. Ek EW, Ek ET, Mackay SD. Undergraduate experi-
ence of surgical teaching and its influence on career choice. ANZ J Surg. 2005;75(8):713-718. 17. Chapman JR, Weidner BC, Nakayama DK. How
medical alumni now see their junior clerkships in surgery. Am Surg. 2011;77(9):1161-1168. 18. Ourian AJ, Nasseri Y, Kohanzadeh S, et al. Outreach
in surgery at the undergraduate level: an opportunity to improve surgical interest among women? Am Surg. 2011;77(10):1412-1415.
KM, Shilstone HC, Lucci A. Factors influencing career choice among medical students interested in surgery. Curr Surg. 2003;60(2):210-213.
19. Bindal T, Wall D, Goodyear HM. Medical students’
9. O’Herrin JK, Lewis BJ, Rikkers LF, Chen H. Why do
20. Deedar-Ali-Khawaja R, Khan SM. Trends of surgical
views on selecting paediatrics as a career choice. Eur J Pediatr. 2011;170(9):1193-1199.
students choose careers in surgery? J Surg Res. 2004; 119(2):124-129.
career selection among medical students and graduates: a global perspective. J Surg Educ. 2010;67(4):237-248.
10. Ehrlich PF, Seidman PA. Deconstructing surgical
21. Mwachaka PMaseghe, Mbugua EThuo. Specialty
education—teacher quality really matters: implications for attracting medical students to surgical careers. Am Surg. 2006;72(5):430-434.
preferences among medical students in a Kenyan university. Pan Afr Med J. 2010;5:18. 22. Thakur A, Fedorka P, Ko C, Buchmiller-Crair TL,
make a future career in surgery more appealing to medical students? Afr Health Sci. 2010;10(3):292-296.
Atkinson JB, Fonkalsrud EW. Impact of mentor guidance in surgical career selection. J Pediatr Surg. 2001;36(12):1802-1804.
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11. Makama JG, Ameh EA. Does general surgery clerkship
Perception of Undergraduate Pediatric Surgery Clerkship in a Developing Country Sebastian O. Ekenze, MD, and Uchechukwu M. Obi Sub-department of Paediatric Surgery, University of Nigeria Teaching Hospital, Enugu, Nigeria OBJECTIVE: Medical students’ perception of their clerk-
ship may influence their choice of ultimate career. In most medical schools, pediatric surgery clerkship (PSC) is not compulsory. This study evaluates the perception of PSC by students and determines the importance of this on the choice of pediatric surgery as a career. METHODS: We surveyed 2009 and 2010 graduating medi-
cal classes of University of Nigeria, Nsukka, using selfadministered questionnaires. The clerkship evaluation was assessed using a 3-point scale (1 ¼ poor and 3 ¼ excellent). Students who had PSC were analyzed to compare their rating of pediatric surgery vis-à-vis other clinical clerkships and determine the effect of the clerkship on their ultimate choice of a career. RESULTS: Overall response rate was 70.3% (275/391), and
119 (43.3%) had PSC. For overall quality, PSC rated (2.16) compared with general surgery (2.04), internal medicine (2.11), obstetrics and gynecology (2.13), and pediatrics (2.37). Aspects of PSC that rated poorly include opportunity to participate in direct patient care, feedback on performance during clerkship, ability to manage problem in a general medical setting, and experience in learning history-taking skills and interpretation of laboratory data. Among the students who had PSC, 14 (11.8%) selected pediatric surgery as a specialty choice compared with 13 (8.3%) who did not have PSC (p ¼ 0.457). Of those that had PSC, pediatric surgery was selected as a career by 2 of 19 (10.5%), 6 of 63 (9.5%), and 6 of 37 (16.2%) who rated PSC as poor, just right, and excellent, respectively. The decision to select pediatric surgery was influenced mostly by clerkship experience in 37% (10/27) and personal satisfaction in 40.7% (11/27). Improvement in the quality of PSC may involve more participation of the students in direct patient care (n ¼ 54; 45.4%) and enhancement in student-faculty interaction (n ¼ 31; 26.1%). CONCLUSION: PSC may have a good rating in our setting. Nonetheless, improving the quality and experience
Correspondence: Inquiries to Sebastian O. Ekenze, MD, Sub-department of Paediatric Surgery, University of Nigeria Teaching Hospital, No. 1, Unth Road, Enugu 400001, Nigeria; e-mail: [email protected]
of the clerkship through a well-thought-out curriculum modification may enhance interest in pediatric surgery as a C 2014 Association of career choice. ( J Surg ]:]]]-]]]. J Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: clerkship, pediatric surgery, undergraduate, career, developing country COMPETENCIES: Patient Care, Medical Knowledge, Practice Based Learning and Improvement, Systems Based Practice, Professionalism, Interpersonal Skills and Communication
INTRODUCTION Pediatric surgery may be one of the young specialties of surgery, but the past decades have witnessed significant dynamic advances in the specialty, especially in workforce development and surgical care of children.1,2 At the level of undergraduate medical education, there are indications that inclusion of pediatric surgery in the undergraduate curriculum has tremendously improved the total surgical care of infants and enabled pediatric surgeons to reach out to undergraduates to enhance interest in the specialty.2-5 Previous reports have suggested that the choice of surgical specialty by undergraduates may be influenced by gender, age, marital status, prestige influence, surgeon mentors, career opportunity, intellectual challenge, and clerkship experience.6-8 Important positive factors identified in clerkship experience were exposure and active participation in operations, residents’ interaction, surgeon/faculty interactions, and number of cases observed during the rotation.6-10 A previous study has shown that approximately 25% of undergraduates undertake clerkship in pediatric surgery usually as elective.2 However, there is paucity of data on medical students’ assessment of their clerkship in pediatric surgery in developed as well as developing countries. In addition, the evaluation of the students’ experience in learning basic clinical skills in pediatric surgery and the
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.2013.11.010
1
student/faculty interaction during the clerkship is rarely reported. This study looks at the assessment of the learning experience during pediatric surgery clerkship (PSC) by students of University of Nigeria, Nsukka, and determines the importance of this on their career choice.
participation, the study procedure, risks, and confidentiality regarding the information in the survey. Those who consented proceeded with the survey. Completed questionnaires were collected the following day. The rating in pediatric surgery was compared with the ratings for other major clerkships at our school (general surgery, internal medicine, pediatrics, and obstetrics and gynecology).
MATERIAL AND METHODS At the Faculty of medicine, University of Nigeria, Nsukka, PSC is not compulsory to qualify for final examination in surgery. Medical students are posted to pediatric surgery randomly in 1 of the 4 postings required in undergraduate surgery. There are 4 pediatric surgeons at our institution and 2 independent clinical units. Each of the units runs separate outpatient clinic, ward rounds, and theater sessions, with emergencies, minor ward procedures, and ward rounds undertaken daily. Didactic teaching rounds, joint pediatric surgery conference, and interspecialty surgery conference/ presentations are undertaken weekly. In addition, joint morbidity/mortality and interdisciplinary sessions take place monthly and quarterly, respectively. During the PSC, which lasts for a period of 6 weeks, the students are tutored and exposed clinically to the evaluations and treatment of pediatric surgical conditions at these clinical/academic sessions and are continuously evaluated by way of scoring the relevant procedures in the students’ surgery procedure book and through end-of-posting assessment test. The graduating classes of 2009 and 2010 were surveyed after they completed the last surgery posting. The survey (Appendix 1) explored the demographics of the students, their evaluation of pediatric surgery and other clerkships, and their choice of career. The clerkship evaluation rated aspects of students’ learning experience using a 3-point scale (1 ¼ poor, 2 ¼ just right, and 3 ¼ excellent). The survey was administered by hand to individual students. Before completing the survey, the respondents received a separate note detailing the voluntary nature of
DATA ANALYSIS Statistical Package for Social Sciences (SPSS 15.0 version, SPSS Inc, Chicago, IL) was used for data entry and analysis. Results were expressed as percentages or mean. Data were analyzed by chi-square test as appropriate. In all, critical p o 0.05 was regarded as significant, and conclusions were drawn based on this level of significance.
RESULTS Overall, 275 of the 391 (70.3%) students responded. Among them, 179 (65.1%) of the respondents were male, and 96 (34.9%) were female. Their median age was 25 years (IQR, 24-26 years). A total of 119 (43.3%) undertook PSC. Clerkship Experience This is summarized in Table 1. The mean rating of overall quality of pediatric surgery clerkship was 2.16 on the 3-point scale. On this, 52.9% (63) of the respondents rated the clerkship as just right, 31.1% (37) as excellent, and 16% (19) as poor. The aspects of the clerkship experience with the best rating (Table 2) were the overall quality of consultants’ teaching (mean ¼ 2.48), accessibility of resident doctors (mean ¼ 2.20), and accessibility of the consultants (mean ¼ 2.19). Remarkably, the least ratings involved aspects of the posting related to
TABLE 1. Summary of the Rating of the Aspects of Pediatric Surgery Clerkship Experience Rating Aspects of Clerkship
Poor (%)
Experience in learning history-taking skills Experience in learning basic physical examination skills Experience in interpreting laboratory data Clarity of posting goals and objectives Accessibility of consultant Accessibility of residents Quality of opportunity to participate in direct patient care Quality of feedback on your performance in the posting Ability to manage problems in a general medical setting Overall quality of residents teaching Overall quality of consultants teaching Overall quality of posting
33 20 37 22 22 21 55 38 39 18 8 19
2
(27.7) (16.8) (31.1) (18.5) (18.5) (17.7) (46.2) (31.9) (32.8) (15.1) (6.7) (16.0)
Just Right (%) 69 78 65 68 52 53 49 71 68 66 46 63
(58.0) (65.5) (54.6) (57.1) (43.7) (44.5) (41.2) (59.7) (57.1) (55.5) (38.7) (52.9)
Excellent (%) 17 21 17 29 45 45 15 10 12 35 65 37
(14.3) (17.7) (14.3) (24.4) (37.8) (37.8) (12.6) (8.4) (10.1) (29.4) (54.6) (31.1)
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TABLE 2. Comparison of the Aspects of PSC That Rated Poorly With the Rating in Other Major Clerkships Mean Rating Aspects of Clerkship
PSC General Surgery Medicine Pediatrics OBGYN
Quality of opportunity to participate in direct patient care Quality of feedback on your performance in the posting Ability to manage problems in a general medical setting Experience in interpreting laboratory data Experience in learning history-taking skills
1.66 1.76 1.77 1.83 1.87
1.58 1.70 1.80 1.93 2.04
1.71 1.82 1.84 2.10 2.19
1.90 2.02 2.06 2.29 2.58
1.69 1.81 1.86 2.07 2.22
OBGYN, obstetrics and gynecology.
patient management. These aspects include (Table 3) quality of opportunity to participate in direct patient care (mean ¼ 1.66), quality of feedback on performance in the posting (mean ¼ 1.76), ability to manage problems in a general medical setting (mean ¼ 1.77), experience in interpreting laboratory date (mean ¼ 1.83), and experience in learning history-taking skills (mean ¼ 1.87). Comparison of Pediatric Surgery Clerkship With Other Major Clerkships For overall quality of clerkship, the mean rating of PSC was less than that of pediatrics (mean ¼ 2.37), but better than obstetrics and gynecology (mean ¼ 2.13), internal medicine (mean ¼ 2.11), and general surgery (mean ¼ 2.04). Figure 1 shows the comparison of the mean ratings of the overall quality of these clerkships. When individual aspects of the clerkship experiences that rated poorly in PSC were compared with their rating in other clerkships (Table 2), 2 areas showed differences in the mean rating scores of Z0.1. These aspects were experience in interpreting laboratory data and experience in learning history-taking skills. On the contrary, comparison of aspects with the best rating in PSC (Table 3) showed difference of Z0.04 in the mean rating score for accessibility of resident doctors. Factors That may Improve the Clerkship Of the students that undertook PSC, 54 (45.4%) suggested that more involvement of students in direct patient care may improve the quality of surgery clerkship. Other factors advocated by the respondents to enhance quality of the clerkship include improvement in the faculty-student interaction by 31 (26.0%), improvement in the quality of feedback on the posting performance by 18 (15.1%), and
development of a program that would involve an initial block of surgery lectures before clinical postings by 7 (5.9%). A total of 9 (7.6%) respondents did not give any response on this item. Choice of Specialty Overall, 27 (9.8%) selected pediatric surgery, 69 (25.1%) selected other specialties of surgery, and 179 (65.1%) selected other medical specialties (Table 4). Among the 119 who had PSC, 14 (11.8%) selected pediatric surgery compared with 13 (8.3%) among those who did not have PSC (p ¼ 0.457). On analysis of choice of pediatric surgery and the overall rating of PSC, pediatric surgery was selected as career by 2 of 19 (10.5%), 6 of 63 (9.5%), and 6 of 37 (16.2%) who rated PSC as poor, just right, and excellent, respectively (p ¼ 0.444). Largely the factors indicated as influencing the choice of pediatric surgery as career varied between the student who had PSC and those who did not have PSC (Table 5). Although clerkship experience was the major influence in 10 of 14 (71.4%) of the former, personal interest was the main factor in 7 of 13 (53.8%) of the latter. All the 14 respondents with PSC who selected pediatric surgery as career indicated positive influence of pediatric surgery clerkship in their choice of the specialty. However, 4 of these respondents specified that the clerkship reinforced their personal inclination.
DISCUSSION This study indicates that though PSC rated fairly well when compared with the other major clerkships in our setting, the students’ rating of the various aspects of the clerkship
TABLE 3. Comparison of the Aspects of PSC That Rated High With the Rating in Other Major Clerkships Mean Rating Aspects of Clerkship
PSC
General Surgery
Medicine
Pediatrics
OBGYN
Quality of consultants teaching Accessibility of residents Accessibility of consultants
2.48 2.20 2.19
2.36 2.24 2.03
2.30 2.26 2.04
2.51 2.40 2.34
2.32 2.25 2.10
OBGYN, obstetrics and gynecology. Journal of Surgical Education Volume ]/Number ] ] 2014
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FIGURE 1. Final-year medical students' evaluation of the overall quality of pediatric surgery clerkship and other 4 major clerkships at the University of Nigeria.
appropriate hands-on experience during undergraduate clerkship in surgical specialties.6-9,15-18 The other aspects of PSC that rated poorly may be related to inadequate supervision and didactic clinical teaching of the students. Although consultants’ availability and teaching were rated high, the fact that other aspects of patients’ management were rated poorly may be a pointer to lack of structured teaching and emphasize the need to streamline the teaching to address the need of the students. Feasible interventions to address these shortcomings may be in the way of modification of the curriculum of the undergraduate training in our setting, as well as reorientation of the faculty to give a more focused teaching, supervision, and feedback to the students. This may ultimately improve the learning experience of the undergraduates during PSC. The choice of pediatric surgery as a career by a tenth of the graduating medical class in this study may not actually be indicative of interest in the specialty by our undergraduates because objective assessments in this domain were not undertaken in this study. Moreover, in the light of the scant information on medical students’ interest in PSC in current literature from both developed and developing countries, it may be difficult to provide a more valid comparison. However, the response of the students highlighted a number of factors that could contribute to the choice of pediatric surgery. Experience during the PSC was a major influence
uncovered areas that may have negatively affected their overall perception of the clerkship. These aspects include quality of opportunity to participate in direct patient care, quality of feedback on performance in the posting, ability to manage problems in a general medical setting, experience in interpreting laboratory data, and experience in learning history-taking skills. Incidentally, these aspects of the posting deal with patient management. On participation in direct patient care, a study11 has shown that the lack of hands-on experience is a major shortcoming in undergraduate surgery clerkship in some developing countries. Though not entirely limited to developing countries,6,12,13 the reason for this lack of hands-on exposure is largely unknown, but it may be related to the perception of specialties of surgery as highly specialized fields to allow such exposure at the undergraduate level of training.11,14 Also in the case of pediatric surgery, this may have a bearing on the expectations of the affected family about who will undertake procedures on their child. However, hands-on experience in the form of operative exposure and direct involvement of students in surgical care during clerkship may be essential in surgical specialties.15,16 This has been shown to stimulate students’ interest in surgery. Although some authors have argued that hands-on experience should be reserved for residency training period,14,17 recent trend however emphasize curriculum modification to include
TABLE 4. Choice of Specialty Among 275 Final-Year Medical Students Specialty Choice Category Pediatric surgery clerkship No pediatric surgery clerkship Total 4
n
Pediatric Surgery
Other Surgery Specialties
Other Specialties
119 156 275
14 (11.8%) 13 (8.3%) 27
29 (24.3%) 40 (25.6%) 69
76 (63.9%) 103 (66.1%) 179
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TABLE 5. Factors in the Choice of Pediatric Surgery as a Career Among Medical Students Who Undertook PSC and Those Who did not Factor Personal interest Clerkship experience Prestige influence Financial reward Total
PSC
No PSC
4 10 – – 14
7 – 4 2 13
Total (%) 11 10 4 2 27
(40.7) (37.1) (14.8) (7.4) (100)
among the students who had PSC. This finding, which is irrespective of the students’ rating of the clerkship, underscores the effect of clerkship in the choice of specialty. It further reinforces the result of previous studies that show focused exposure to a specialty during clerkship helps to dispel myths and negative perceptions and inspire interest toward the specialty.7-9,15,18,19 The clerkship experiences most noted in previous reports to be positively influential were number of cases participated/scrubbed, resident interaction, faculty interaction, and number of cases observed.6-10 Another important factor in the choice of specialty is personal interest. This was a compelling sway in the choice of pediatric surgery amongst the students who did not undertake PSC. Although this has been previously reported in the choice of other surgical specialties,20 some authors believe that personal interest is in most cases strengthened by influence of positive role models and career and academic opportunities in the surgical specialty.13,15,16 The other factors also espoused by the students such as prestige influence and financial reward remarkably did not play significant role in the choice of the specialty in our setting. Although prestige influence was noted in some previous studies to be an important factor in the choice of surgical specialty, financial reward on the contrary is not known to be a major influence in the choice of surgical specialties.7,8,21 The other factors noted in literature to influence the choice of surgical specialty among medical students include surgical mentors, career opportunity, intellectual challenge and degree of participation in operative procedures, and number of hours on call/rotation.6-10,12,15 Available data
indicate that career opportunity, active participation in operative procedures, and surgical mentors have positive influence in the choice of surgical specialty whereas long hours on call/rotation negatively affect the choice of specialty.7-9,12,13,15,16,20,22 Most of these data explored general surgery and some surgical specialties. However, there is scant information in the available literature on the role of these factors in the choice of pediatric surgery. Unarguably, the response of our undergraduates indicate that a well-thought-out curriculum modification is imminent in our setting to ensure appropriate hands-on experience, focused teaching, feedback, and learning the ability to solve problems in a general medical setting. A re-evaluation of the students’ learning experience after the modifications is recommended to see if there may be either better perception of PSC, greater competence, and greater interest in pediatric surgery in our setting.
LIMITATIONS OF THE STUDY This study was limited by scant literature on undergraduate pediatric surgery clerkship especially from more developed countries. Because of this, valid comparison was not possible. In addition, the use of a 3-point scale led to a cluster of means. A 5-point scale would have been more appropriate.
CONCLUSION Pediatric surgery clerkship seems to have a good rating in our setting. Despite this, some aspects of the clerkship that deal with patient management rated poorly among the students. The choice of pediatric surgery as specialty may be influenced by clerkship experience in our setting, but other factors might also affect the choice of this specialty. Addressing the deficiencies of the clerkship through a well-thought-out curriculum modification and reorientation of the faculty for more focused teaching and feedback may improve the overall clerkship experience, and this might boost interest in pediatric surgery.
APPENDIX 1. CLINICAL CLERKSHIP SURVEY IN PEDIATRIC SURGERY Section A 1. 2. 3. 4.
Age……. Gender……… Year of Study…………… Postings completed in Surgery……Subspecialty S1…………………………. S2…………………………. S3…………………………. S4…………………………. 5. Which of the subspecialties was your best posting…………………………………………… 6. Which was your worst posting……………………..………………………………………… Journal of Surgical Education Volume ]/Number ] ] 2014
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7. Why did you chose the above as your worst posting…………………………………………… 8. Which of the posting do you think should be mandatory to all Medical students……………..and why……………………………………… Section B Clerkship evaluation Please rate the following items from 1 to 3 (1¼ “Poor,” 2 ¼ “Just right,” 3 ¼ “Excellent”) Item
Rating Surgery
Medicine
Paediatrics
Obs & Gynae
Paediatric surgery
1. Experience in learning history taking skills……………… 2. Experience in learning basic physical examination skills... 3. Experience in interpreting laboratory data………………. 4. Clarity of posting goals and objectives…………………... 5. Accessibility of Consultant……………………………… 6. Accessibility of Residents………………………………. 7. Quality of opportunity to participate in direct patient care 8. Quality of feedback on your performance in the posting 9. Ability to manage problems in a general medical setting 10. Overall quality of residents teaching…………………. 11. Overall quality of Consultants teaching……………… 12. Overall quality of Posting…………………………….
Section C 1) Which area of medicine would you like to specialize (please tick) a) Internal medicine b) Paediatrics c) OBS & Gynae d) Paediatric Surgery e) Other specialties of Surgery f) Others specify)…………………………… 2) What informed your decision above (please tick) a) Experience during posting b) Diligence of the consultants c) Fame of the specialty d) Financial rewards e) Personal inclinations f) Demands of the other specialties g) Others specify…………………………………. 3) For those who selected paediatric surgery, did your experience in the paediatric surgery clerkship positively influence your choice? Yes………… No………….. 4) Did your posting improve your understanding of paediatric surgery pathologies and management? Yes……… No………. 5) What in your opinion would improve the quality of paediatric surgery postings? a)………………………………………….... Thank you for completing the questionnaire 6
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