Sophia K. McKinley, MD, EdM, and Roy Phitayakorn, MD, MHPE
December 1, 2018
The surgical clerkship is the primary method of exposure to surgery for the majority of medical students, yet students often lack meaningful involvement in a range of surgical activities during their rotation. For example, in terms of procedural skills, multiple groups have demonstrated that many surgical students are not permitted to have hands-on clinical experiences.1–3 In one study, less than half of surgical students made an incision by the end of their clerkship and less than 60 percent sutured.3 Another group demonstrated that up to 40 percent of surgical clerks did not learn how to place a nasogastric tube by the end of their core surgical rotation.2 Similarly, medical students are often excluded from meaningful involvement in non-procedural clinical activities. Surgical students report limited experience seeing consults independently and some hospitals have prohibited students from writing notes in the electronic medical record.3,4 Ultimately for some students, the core surgical experience or role has become one of a “tourist,” characterized primarily by observation. This type of exposure to surgery is antagonistic to the meaningful and authentic participation that characterizes optimal clinical and workplace learning, leading some students to feel that they have been left at the periphery.5–7 We surveyed students at four local teaching hospitals and confirmed that, intentional or not, students can complete the surgical clerkship feeling as if they have been marginalized by their surgical educators (unpublished data). The procedural, high risk nature of surgery may also make it particularly prone to inadvertent marginalization of medical students. We found that students sometimes describe feeling excluded from meaningful involvement in the operating room, writing statements such as “80 percent of my time was spent standing in the operating room (OR) while doing absolutely nothing and barely being able to see.”
Like many complex problems in medical education, the etiologies of the marginalized medical student are multifactorial. One possible etiology is competition with other medical students or residents. Competition for bedside procedures among various types of learners is increasing at the same time as overall resident autonomy decreases and the total number of available procedures declines.8 Concerns regarding patient safety, duty hours restrictions, OR costs, and the rapid rate of emerging technology have all challenged surgical resident autonomy, and this may have a trickle-down effect to medical students as residents keep procedural learning experiences for themselves or honor patient requests not to have a student “practice” on them.
Another etiology is the increasingly challenging medico-legal environment and external regulations. Until recently, CMS policy led some institutions to prohibit medical student documentation. Inability to write a note decreases a student’s ability to complete history and physicals or surgical consultations independently as all documentation would have to be repeated by a supervising resident or faculty.4
Finally, resident and attending expectations toward medical student participation may inadvertently generate a sense of marginalization as students often have higher expectations regarding their involvement than house staff and surgeons.9–12 In particular, students express expectation for greater procedural involvement, including in the operating room.10,12 This mismatch in expectations is often exacerbated by a nationwide decrease in overall time spent on the surgical clerkship and “face time” with individual resident-attending surgeon teams. A possible consequence of unmet student expectations is that students conclude that their presence is an inconvenience to their surgical educators.11 This belief may discourage students from attempting integration into the surgical team and activities, further hampering their meaningful involvement in clinical activities.
The costs of medical student marginalization during the surgical clerkship are not trivial. First, new surgical interns may be inadequately prepared for independent patient care duties because they did not have meaningful patient care activities as medical students. The rise of the surgical “boot camp” and other pre-internship preparatory courses are a direct response to concerns that standard medical student surgical experiences are insufficient to prepare students for the demands of surgical internship and that supplementary experiences are necessary for a safe transition to residency.13–15 Additionally, meaningful engagement in the OR and positive surgical role models contribute to student interest in surgical careers.3,16–18 Therefore, medical student marginalization, both in terms of participation in clinical activities and by their surgical educators, may result in fewer students deciding to pursue surgery, contributing to a surgical workforce shortage.
A number of interventions have been proposed to combat medical student marginalization in the surgical clerkship. One low-cost intervention is to ensure standardization of the medical student experience during their surgical clerkship. For example, some programs give their students a clinical skills “passport” to present to residents and faculty for documentation of completion of critical clinical skills.2 Prospective study of student activities demonstrated significant increase in the proportion of students completing the eight skills listed on the passport, including venipuncture, nasogastric tube placement, and urinary catheter placement. The similar creation of a standardized clerkship portfolio, which is essentially a checklist of required activities, has also been shown to improve student clerkship activities ranging from use of local anesthetic to involvement in patient discharge.19
One reason that these passports or checklists may be effective is that they provide the student with resources to advocate for his or her own learning and involvement. Giving students a procedure passport or checklist clarifies expectations for both students and their instructors while increasing the student’s responsibility for recognizing and capitalizing on important clinical opportunities. Ideally, giving students a mechanism to ask for more meaningful engagement in patient care should initiate a virtuous cycle whereby they demonstrate their capability and are consequently provided with more responsibility and opportunity from residents and attendings. Other interventions that empower students to shape their own learning could also combat the potential for marginalization by encouraging students to avoid the passive “tourist” role. When asked what they wish they had known prior to the surgical clerkship, many students at our local teaching institutions describe wishing they had known that they did not have to wait to be invited to suture, observe a greater variety of operations, or participate in other activities such as completing post-op checks and bedside procedures. We have changed the surgical orientation at our hospital to emphasize to students that they are welcome to ask for additional participation and will not be punished for doing so.
Another possible solution is to increase the integration within the surgical resident teams. Including students on a one-week night float rotation may increase student cohesion with the surgical team, helping to alleviate the sense of student marginalization or inconvenience to residents.20 Of course, simulation continues to be a mainstay for supplementing limited bedside procedural experiences and preparing students for procedural opportunities that arise.21,22
Similarly, the implementation of a high-quality resident-as-teacher program may provide residents with the tools necessary to effectively and efficiently include and coach students in meaningful participation. Few residency programs offer formal instruction on how to teach, and yet numerous studies demonstrate that residents are the primary educators for surgical students and have significant impact on student career trajectories.3,11,16,17,23
Larger structural changes to the surgical clerkship also hold promise for better integration and participation of the medical student in surgical activities. One compelling model of core clinical learning is the Longitudinal Integrated Clerkship (LIC), which enables students to complete all core rotations simultaneously across the year instead of in traditional blocks.24,25 LICs are organized around the principle of continuity and the belief that students should be supported in active participation in all disciplines along a year-long developmental trajectory.26 Because learners establish longer relationships with both educators and patients, they may be better integrated into surgical practice and patient care activities than students on block rotations with shorter patient and preceptor relationships. At least one study suggests students who complete a LIC grow in their participation to collaborate with their supervising physicians and inhabit a doctor-like role, indicating more meaningful clinical involvement than students attain in the traditional block rotation.27 Although it may be impractical to completely restructure a surgical clerkship to a longitudinal model, certain longitudinal surgery experiences could be built into the overall clinical curricula. It is important to note that this integration would require surgical educators to be involved and represented within the pertinent medical school committee structures.
Another ambitious change to the surgical clerkship would be to create a special “clinical education ward” (CEW) in which medical, nursing, and physical/occupational therapy students work under supervision to provide the majority of patient care to a select group of patients. In Europe, orthopedic surgery CEWs designed to increase active student participation in the care of surgical patients have led to enhanced interprofessional education; importantly, these wards have been found to be acceptable to patients.28,29 Students must be appropriately supported by supervisors or the increase in responsibility can be overly stressful and place students at risk for burnout.30 Another drawback of the CEW is that students are engaged primarily in perioperative care and do not go into the OR. Surgical educators may consider the merits of including time on the CEW as one part of a longer surgical clerkship experience.
Finally, the most important change is that surgeons need to maintain a “seat at the table” of medical school curriculum and assessment committees. Despite the lack of adequate compensation for time, surgeons must advocate for equal time and access to medical students and fight institutional or legislative rules that minimize the role of our medical students. A successful example of this idea is the recent change in CMS regulations from a large coalition of physician medical student educators that makes it easier for students to see consults and practice documentation.4
Medical student marginalization during the surgical clerkship is multifactorial and costly to the field of surgery both in terms of surgical intern preparedness and student interest in surgical careers. A number of short and long-term interventions to the surgical clerkship can combat the risk of medical student marginalization, potentially leading to improved student surgical learning and interest.
S.K. McKinley, MD, EdM, is a resident physician and surgical education research fellow in the Department of Surgery, Massachusetts General Hospital, Boston, MA.
R. Phitayakorn is associate professor, Department of Surgery, Massachusetts General Hospital, Boston, MA.