Medical School Training for the Surgeon

A Mixed-Methods Needs Assessment for a Longitudinal Surgical Preparation Course in Undergraduate Medical Education

OBJECTIVE

To assess the unmet needs associated with surgical education and skill development during the pre-clerkship years of medical school.

DESIGN

A mixed-methods design was employed that leveraged semi-structured interviews and quantitative surveys followed by qualitative analysis.

SETTING

A large midwestern academic medical center.

PARTICIPANTS

Eighteen participants were enrolled representing second year medical students with an interest in surgery, surgical residents, and attending surgeons from a diverse array of surgical specialties.

RESULTS

Unanimous support for the creation of a pre-clerkship surgical skills course emerged due to 2 main themes: (1) gaps in current surgical education offerings and (2) the value of early exposure to surgery and surgical skills followed by longitudinal practice. The components that participants deemed essential to a well-designed course were also revealed. Each stakeholder group (medical students, residents, surgeons) would benefit across all factors uncovered.

CONCLUSIONS

There is a significant unmet need across all stakeholder groups for the creation of a longitudinal surgical skills course for pre-clerkship medical students. Future studies should seek to design a curriculum based on these study results and assess a pilot version of the curriculum to understand its feasibility under application.

Which Model Is Better to Teach How to Perform Tube Thoracostomy: Synthetic, Cadaver, or Animal?

INTRODUCTION

The lack of standardized skill training reported by medical students in performing tube thoracostomies may be associated with higher complications. The ideal training model is yet to be determined. This study sought to evaluate three different models.

METHODS

Between 2015 and 2017, 204 last-year medical students of Universidade de São Paulo with no prior training in tube thoracostomy were randomized into three groups: cadaver, pig, and synthetic models. All groups performed 1-d tube thoracostomy hands-on training and a 40-min theoretical class. The knowledge acquisition was measured by a comparison between a theoretical test before and 3 wk after the class, and the skills improvement was evaluated by a comparison between the skills test on the same day of the hands-on training and another after 24 wk (the retention skill test). A questionnaire was submitted to evaluate their satisfaction rate and self-reported confidence, as per a Likert scale.

RESULTS

The theoretical post-test score was higher compared to the pretest score in all groups (P < 0.001). The retention skills test in the cadaver and synthetic groups decreased compared to the skills test (P = 0.01 and P = 0.007, respectively). There was no difference between the groups either in the theoretical test or in the skills test. Student satisfaction was higher in the cadaver and pig groups. The confidence perception increased in all groups after the training.

CONCLUSIONS

The models used for tube thoracostomy training appear to have a similar impact on skills retention, knowledge acquisition, and confidence. Although the satisfaction rate is lower for the synthetic model, it has no biological risk or ethical issues and is more feasible.

Orthopaedic Surgery Boot Camp: An Immersion Course for Medical Students

Introduction

There is a substantial need for orthopaedic surgery-specific boot camps due to the limited orthopaedic and musculoskeletal education in medical school, which inadequately prepares medical students for their orthopaedic surgery sub-internships. The aim of this study is to identify the impact of the novel orthopaedic surgery boot camp on medical students’ confidence with key orthopaedic topics.

Methods

A cross-sectional study was conducted using an anonymous online survey distributed to medical students attending the novel orthopaedic surgery boot camp. The boot camp consisted of a four-day immersion course into the basics of orthopaedic surgery principles through both didactic and skills-based educational series. The medical students’ confidence in orthopaedic surgery clinical and technical skills were assessed by comparing the students’ survey responses before and after attending each of the sessions.

Results

Twelve fourth-year medical students and 15 second-year medical students attended the boot camp. All the sessions attended by the medical students were statistically significant in improving their confidence in the subject matter and skills-based training. Hundred percent (100%) of the fourth-year medical students recommend future orthopaedic surgery-bound medical students to attend this boot camp.

Conclusion

A dedicated orthopaedic surgery boot camp focused on clinical and technical skills plays a key role in increasing medical students’ confidence with key orthopaedic topics by providing an opportunity to practice these skills in a supervised environment with real-time feedback. This novel boot camp can provide a framework for creating a longitudinal course for medical students to augment the musculoskeletal education taught in medical school education.

¿Se deben confiar actividades profesionales en cirugía mínimamente invasiva al médico general? Una propuesta basada en el aprendizaje experiencial

Introducción. El entrenamiento en cirugía mínimamente invasiva y la definición de las actividades profesionales específicas, socialmente responsables y seguras para el paciente, son un desafío y un deber en la educación médica. Nuestro objetivo es argumentar a favor de esta intervención y describir las especificaciones, alcances y limitaciones de las actividades profesionales confiables a este nivel, así como su lugar en un modelo de aprendizaje experiencial en cirugía mínimamente invasiva para toda la vida. Métodos. Se evalúa el contexto de la actividad quirúrgica asistencial de los médicos generales, con relación a su participación en el equipo quirúrgico y la necesidad de incorporación en su perfil profesional de unas competencias propias de la cirugía mínimamente invasiva, acorde con su nivel y funciones. Mediante una postura académica y reflexiva, se identifican vacíos y oportunidades de avanzar en el tema. Resultados. El perfil profesional de un médico general debe contemplar la cirugía mínimamente invasiva como una competencia dentro de su formación, de manera análoga a las propias de la cirugía tradicional abierta. Para ello, se requiere afrontar coherentemente el cambio de teoría y educación quirúrgica, el cambio en la demanda de servicios quirúrgicos y procedimientos, así como fortalecer el rol activo del médico general en el equipo quirúrgico. Conclusiones. Es necesario modificar el paradigma educativo en cirugía, desde la formación médica en el pregrado. Se plantea un modelo de aprendizaje experiencial de cirugía mínimamente invasiva, y se establecen las competencias fundamentadas en actividades profesionales confiables, necesarias para el perfil profesional de un médico general del siglo XXI.

Interns Without Subinternships

Surgical interns who have completed medical school in the era of Covid-19 will not have the same experience gained through the traditional multi-month fourth-year surgical subinternships. During subinternships, medical students learn relevant anatomic and radiographic features of surgical pathologies, hone technical skills, and gain exposure to surgical consults and procedures. This lack of intensive exposure will have this cohort starting at a lower comfort and knowledge level compared to years prior. Residency programs, especially subspeciality programs, should review and utilize national resources to facilitate the transition to intern year, such as the American College of Surgeons Entering Resident Readiness Assessment and American College of Surgeons/ Association of Program Directors in Surgery/Association for Surgical Education Resident Prep Curriculum. We recommend the use of a specialty-tailored intern boot-camp and longitudinal curriculum that focuses on learning procedural skills and surgical conditions, anatomy, pathology, clinical examination, radiographic findings, surgical approach, and postoperative complications. These steps will help address knowledge gaps and promote intern readiness in this cohort of individuals.

In-person versus virtual suturing and knot-tying curricula: Skills training during the COVID-19 era

Background

The coronavirus disease 2019 restrictions on in-person simulation activities necessitated modifying the traditional boot camp skills curriculum for matriculating PGY1 general surgery residents to a virtual format. This study investigated the relative effectiveness of in-person versus virtual instruction on the development of suturing and knot-tying skills.

Methods

In all, 55 residents participated in a validated, proficiency-based, preinternship skills curriculum, 26 in 2019 and 29 in 2020. Both groups received an introduction to the curriculum, were given time for practice and offered one-on-one tutoring by faculty by request, and completed a filmed posttest. The 2019 class received in-person instruction during a boot camp at the end of June, while the 2020 class was provided with suture kits and received instruction via Zoom throughout June. The 2 groups were compared by post-test performance, date of task proficiency, and additional coaching required.

Results

In 2019, 5.7% of the posttest tasks were graded as proficient versus 87% in 2020. The 2020 class outperformed the 2019 class on every metric in every task (P < .001). In 2019, faculty spent 55.5 hours with residents in one-on-one remediation, resulting in proficiency in 64% of the tasks by November. In 2020, 18 hours of one-on-one remediation resulted in proficiency in 92% of the tasks by September.

Conclusion

Learners who received virtual instruction with access to materials at home gained proficiency in suturing and knot-tying skills earlier and with less coaching. These data demonstrate that the virtual curriculum is effective and an improvement on the previous in-person curriculum.

An Interprofessional Senior Medical Student Preparation Course: Improvement in Knowledge and Self-Confidence Before Entering Surgical Training

PURPOSE

Senior medical students are variably prepared to begin surgical training; and a national curriculum was established through the American College of Surgeons to better prepare senior medical students for surgical training. The purpose of our course is to prepare senior medical students to more effectively enter surgical training programs. We recently enhanced our independently developed surgical training preparation course by increasing exposure to surgical anatomy, medical physiology, surgical skills, and point-of-care ultrasound. We evaluated the impact of our interprofessional training course to increase confidence and readiness among senior medical students entering surgical training.

METHODS

The course focused on pre- and post-operative patient care, surgical anatomy, human physiology, and bedside ultrasound. Didactic lectures in anatomy, human physiology, and bedside ultrasound were provided prior to all hands-on simulated patient care sessions and mock surgical procedures. To evaluate our interprofessional curriculum, we administered pre- and post-course surveys, pre- and post-course knowledge tests, and a final surgical anatomy laboratory practical examination to 22 senior medical students who were enrolled in the course. All students created a final surgical anatomy presentation.

RESULTS

The students demonstrated a 100% pass rate in surgical anatomy. The knowledge test, which included assessment of knowledge on perioperative surgical decision making, human physiology, and bedside ultrasound, demonstrated an average improvement of 10%. Statistically significant improvements in median confidence values were identified in 10 of 32 surveyed categories, including surgical skills (p < 0.05); 84% of student goals for the course were achieved. The medical students' surveys confirmed increased confidence related to the use of point-of-care ultrasound, teamwork experience, and basic surgical skills through small group interactive seminars and surgical simulation exercises.

CONCLUSION

Our preparation for surgical training course resulted in high student satisfaction and demonstrated an increased sense of confidence to begin surgical training. The 10% improvement in medical student knowledge, as evaluated by a written examination, and the significant improvement in confidence level self-assessment scores confirms this surgery preparation course for senior medical students successfully achieved the desired goals of the course.

Surgery clerkship offers greater entrustment of medical students with supervised procedures than other clerkships

BACKGROUND

Medical student procedural participation is increasingly limited, creating concerns over poor preparation for internship. Inadequate experiences may also compromise patient safety. This study explores variances in procedural entrustment of medical students between core clerkships during the first clinical year.

METHODS

Students completing their first clinical year were surveyed on procedure participation. Holistic entrustment decisions are complex, thus participation was used as an objective proxy for entrustment.

RESULTS

138 students responded (66% response rate); 89% (123/138) wished they had performed more procedures. Students had higher participation rates during procedural clerkships (surgery, obstetrics/gynecology). Entrustment was highest during surgery, and lowest during pediatrics. Surgery gave statistically significantly higher entrustment for subcuticular suturing (compared to obstetrics/gynecology) and nasogastric tube removal (compared to internal medicine). Entrustment was generally inversely proportional to procedure complexity within each specialty.

CONCLUSIONS

Students encounter higher entrustment during procedural clerkships, especially surgery. Targeted areas for increased procedural involvement can be identified in all specialties.

Retrospective qualitative study evaluating the application of IG4 curriculum: an adaptable concept for holistic surgical education

OBJECTIVES

Faced with a costly and demanding learning curve of surgical skills acquisition, the growing necessity for improved surgical curricula has now become irrefutable. We took this opportunity to formulate a teaching framework with the capacity to provide holistic surgical education at the undergraduate level.

SETTING

Data collection was conducted in all the relevant healthcare centres the participants worked in. Where this was not possible, interviews were held in quiet public places.

PARTICIPANTS

We performed an in-depth retrospective evaluation of a proposed curriculum, through semi-structured interviews with 10 participants. A targeted sampling technique was employed in order to identify senior academics with specialist knowledge in surgical education. Recruitment was ceased on reaching data saturation after which thematic data analysis was performed using NVivo 11.

RESULTS

Thematic analysis yielded a total of 4 main themes and 29 daughter nodes. Majority of study participants agreed that the current landscape of basic surgical education is deficient at multiple levels. While simulation cannot replace surgical skills acquisition taking place in operating rooms, it can be catalytic in the transition of students to postgraduate training. Our study concluded that a standardised format of surgical teaching is essential, and that the Integrated Generation 4 (IG4) framework provides an excellent starting point.

CONCLUSIONS

Through expert opinion, IG4 has been validated for its capacity to effectively accommodate learning in a safer and more efficacious environment. Moreover, we support that through dissemination of IG4, we can instil a sense of motivation to students as well as develop robust data sets, which will be amenable to data analysis through the application of more sophisticated methodologies.

Senior-Year Curriculum in U.S. Medical Schools: A Scoping Review

Phenomenon: Many U.S. medical schools have responded to the adoption of competency-based medical education (CBME) frameworks by renewing their final-year curricula and including internship preparatory courses. The purpose of this scoping review was to map the published literature regarding the final year to discern how medical schools have responded to this paradigm change. Approach: A structured 5-step approach was used to conduct this scoping review. Electronic searches of PubMed, ERIC, Scopus, MedEdPortal, and 8 medical education journals were conducted to identify relevant articles published from 2006 to 2016. Four authors screened articles for inclusion using standardized eligibility criteria; interrater agreement was discussed and calculated. Authors extracted data elements, and a consensus-based approach was used to categorize, sort, and structure information gathered. Findings: Among 6,485 articles retrieved, 817 articles were included in the study. From 2007-2011 to 2012-2016, articles addressing the final year of medical school increased 93%, whereas articles describing internship preparatory courses increased 218%. The majority of articles did not reference a CBME framework (572/817; 70%), the frequency of mentions increased 268% from 2007-2011 to 2012-2016. Nearly three fourths of preparatory course-related papers reference a CBME framework (37/50; 74%). Insights: Our findings may reflect a movement in U.S. medical schools toward using shared assessment metrics to support 4th-year medical students' preparation for their postgraduate medical education. Despite an increased reference to CBME, there is relatively little use of competency-based assessment frameworks to evaluate learning outcomes. This review also found a substantial increase in the frequency of articles referencing senior-year preparatory courses in U.S. medical schools. Articles tended to describe institution-specific research or experiences. Opportunities likely exist for multi-institutional and organizational collaboration in determining the structure of the final year of medical school.

Curricular Innovation in the Surgery Clerkship: Can Assessment Methods Influence Development of Critical Thinking and Clinical Skills?

OBJECTIVE

Although key clinical skills have been defined in the Core Entrustable Professional Activities, there is a need to improve medical school curricula with standardized training opportunities and assessments of these skills. Thus, we aimed to develop an innovative curriculum that emphasized critical thinking and clinical skills. We hypothesized that we would be able to observe measurable improvement on assessments of students' critical thinking and clinical skills after the implementation of the new curriculum.

DESIGN

Prospective, Quasi-Experimental study with the use of historical controls.

SETTING

This study took place through the third-year surgical clerkship at the University of Texas Medical Branch at the Galveston, Houston, and Austin, Texas, locations.

PARTICIPANTS

A total of 214 students taking the third-year surgical clerkship for the first time during the periods of interest were included.

RESULTS

Although the students with traditional curriculum improved 9.5% on a short answer exam from preclerkship to postclerkship completion, the students with new curriculum improved by 40%. Students under the new curriculum performed significantly better on the Objective Structured Clinical Exam; however, their shelf scores were lower.

CONCLUSIONS

Under this new curriculum and grading system, we demonstrated that students can be incentivized to improve critical thinking and clinical skills, but this needs to be balanced with knowledge-based incentives.