Thursday, December 23, 2004

The Future of Surgery VII....
From the November edition of the Journal of the American College of Surgeons:General surgery as a career: A contemporary review of factors central to medical student specialty choice
There is much of the usual "lifestyle issue" that works against general surgery, of course, but it seems that medical students are a wishy-washy lot:
It appears that 14% of medical students have made their specialty choice before entering medical school, and an additional 41% to 45% of students make their specialty choice before their third year of medical school, before having had any clinical experiences. It is notable that general surgery is among the most popular specialties among medical students at matriculation.

Though many medical students make early decisions on choice of specialties, these decisions often change. Only 20% to 45% of medical students ultimately choose the specialty that they initially would have preferred if asked to choose before their first medical school lecture. About half of the students who ultimately match in their initial preference had changed their decision at some point before returning to their original choice. The other half never wavered from their original choice. Career choice remains at least as stable as students progress through medical school, reaching 69% in some studies. These numbers are similar for surgery in particular, with 40% to 60% of students initially interested in surgery changing their minds to pursue other specialties at some time during medical school. That being said, a medical student's choice of surgery as a career appears slightly more stable than the choice of most other specialties. Interestingly, it has been noted that premedical, summer, or extracurricular clinical experiences increase the certainty of choice, regardless of chosen specialty.

Many medical students, as noted in the preceding text, initially interested in general surgery eventually lose this interest and instead favor another career choice at some point during medical school. Though some medical students not initially interested in surgery do become interested at some point between matriculation and graduation, these are outnumbered by those initially interested in surgery who eventually choose other careers. The number of students who match into general surgery programs, as a result, is much smaller than the number of medical students initially interested in the specialty. In other words, there is a net efflux of interested medical students from general surgery to other specialties. In comparison, few medical students are interested in anesthesiology at matriculation, but many become interested in the specialty at some point during medical school, resulting in a net influx. Though many medical students initially interested in family practice change their decision, this number is offset by students who become interested in family practice. The result is a net balance.

So more medical students fall out of love with surgery than fall in love with it. My colleagues in academia often times do not provide a positive "role model" for students:
About 50% of medical students, as noted above, who choose surgery as a career and do not change their minds make this choice by the end of their second year of school, before any clinical experiences in surgery. Yet few efforts are made to mentor preclinical medical students in most medical schools, despite the fact that this may increase interest in general surgery.

Perhaps because of the absence of surgeons in preclinical undergraduate medical education, communication between medical students comprised more than 80% of the information second year students get about surgery, according to one study. It appears that students may have some influence on the career choices of one another through the negative comments, or "badmouthing" as described by some authors, of particular specialties. Indeed, one survey of 1,114 medical students reported that 76% of medical students heard negative comments about their career choice, sometimes as early as their first or second year of medical school. Surgery was the specialty most frequently criticized; 91% of students with interest in surgery reported hearing negative comments about the specialty. In contrast, pediatrics was the least frequently criticized; only 57% of students interested in pediatrics reported hearing negative comments. Seventeen percent of all respondents reported altering their career choice in response to these negative comments.

The importance of mentors or role models cannot be overstated. Medical students encouraged by role models to pursue a surgical career are less likely to be discouraged by lifestyle, time commitment, call schedules, or length of residency. Mentors may be especially influential when the personalities of the student and mentor are agreeable. Many students become interested in or choose surgery as a specialty after a rotation and exposure to mentors in that field. Seventy-three percent of medical students undecided on specialty choice and 80% of students who change their choice of specialty during the third year of clerkship eventually choose specialties they had experienced during the first half of the third year. Seventy-nine percent of students were influenced "very much" or "some" by faculty members during their surgery clerkship.

Although surgery faculty typically serve as role models or mentors for surgery students, residents also play a vital role in teaching and mentoring medical students. In one survey of 123 medical students, residents were notably more active in 14 of 15 teaching behaviors surveyed. The surveyed behaviors included physical diagnosis and bedside procedures and stimulating students to do additional reading, teaching students to be more analytical, and serving as role models. Residents were also rated as having a positive influence on the students' attitudes toward general surgery (p = 0.007). Indeed, resident teaching was viewed as more important than attending physician teaching, nurses' teaching, seminars, operating room experience, clinic experience, and conferences. Only independent reading and tutorials were viewed as more important.

The influence of role models or mentors may have either a very positive or a very negative impact on medical students' perceptions of the field of surgery. Students often make note of not only individual characteristics, but also how role models interact with patients, residents, and other physicians. The negative impact a poor role model may have was illustrated during a focus group discussion with one medical student:

[S]urgeons, I have to say honestly, they shred each other to pieces. That was a huge turn-off. I can stand sleep deprivation for ten years, but I can't stand five minutes with the way they get at each other; to be rude to each other, to be rude to the house officers who couldn't fight back, and to be rude to the students who couldn't say anything in defense.

Student perceptions of surgeons and surgical careers may be influenced by their third-year surgery clerkship. One questionnaire-based study reported that both students' ratings of surgeon compassion and respect for surgeons increased during the clerkship, though ratings of surgeon collegiality with other physicians and surgeon commitment to teaching decreased. There was no net interest in surgical careers during the clerkship.

Finally, operative experiences during a medical student's clerkship may affect interest in surgery. Students pursuing careers in most surgical subspecialties (including cardiothoracic, transplant, plastics, and pediatric surgery) have observed substantially more procedures in their chosen subspecialty field than have other students. In a similar study, exposure to general surgical procedures during the third year clerkship correlated to interest in general surgery, and no such correlation existed between exposure to general surgical procedures or surgical subspecialty procedures and interest in surgical subspecialties. It is not clear whether these experiences help determine interest in these surgical subspecialties or if such experiences were sought because of certain interests.

So while the FP faculty does an excellent job in fostering interest among the preclinical students, the surgical faculty does poorly, allowing the "badmouthing" that 91% of prospective surgeons hear about their calling.
So what to do? The authors suggest an increased mentoring presence by the faculty for the first and second year. Will this "selling of surgery" help offset the "lifestyle issue"? Time will tell


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