PreOp program: Can we achieve a “trickle-up” effect?

The authors, from left: Ms. Lazow, Ms. Venn, and Dr. Dakin.

The authors, from left: Ms. Lazow, Ms. Venn, and Dr. Dakin.

Few moments really have the power to change an individual, but most people can point to at least one or two life-altering events. For the lead author, Rachael A. Venn, one of these experiences occurred when she was in her early 20s and was given the opportunity to scrub-in on an operation. Up to this point, becoming a surgeon had never crossed her mind. But there she stood, holding a retractor as if it were the most important task she would ever perform. And in that moment, it was. Words cannot adequately describe the intrigue and awe Ms. Venn felt at not only seeing, but touching the uterus, ovaries, and fallopian tubes, each with a gleam and texture that elude the diagrammatic representation of a medical textbook.

By the time the last suture was placed, Ms. Venn knew a few things: she loved the operating room (OR), she had to be that close to a patient again, and she would go to medical school. What she did not know was that, based on the current structure of medical education, if she wanted to re-enter the OR, she would either have to wait several years until her surgery clerkship, or she would have to create the opportunity for it to happen sooner.

PreOp—a preclinical surgical exposure program established through a joint effort at Weill Cornell Medical College and New York-Presbyterian Hospital, New York, NY—was the opportunity that Ms. Venn and co-author Stefanie P. Lazow created in their first year of medical school. This program explores the potential impact of preclinical surgical exposure on medical students’ specialty interest and their surgical confidence and competency. This article describes the PreOp model and how it successfully offers increased surgical exposure to first-year medical students, providing preliminary data from an ongoing longitudinal study of this program.

Generating enthusiasm

Exposure to surgery and surgical education has historically been neglected in the preclinical years of medical school. In light of ongoing concerns about the prospect of surgeon shortages in the near future and growing reports of reduced resident competency, the preclinical years may be an opportune time to pique medical students’ interest in surgery and guide them toward surgical careers. Intensive surgical exposure at this time may contribute to a “trickle-up” effect, providing students with early training that will not only stimulate surgical interest, but also serve as a foundation for increased competency at subsequent stages of their careers.

Most U.S. medical schools follow a two-plus-two pattern, in which the first two years of the curriculum are classroom-based, and the last two are clinical. While there has been a recent push to incorporate more skills-based learning and patient interaction into the preclinical years, early, structured surgical exposure is still lacking.

This dearth of early hands-on experience is especially problematic given projected physician shortages. The U.S. Department of Health and Human Services recently published a report indicating that by the year 2020, the field of general surgery will experience a shortage of more than 20,000 surgeons, meaning demand for their services will far exceed the supply. This projection is based not only on the changing demographic of an aging population, but also on a concomitant decrease in the number of practicing general surgeons.1

These changes emphasize a need to better understand what drives medical student interest in pursuing surgical training. Studies of clerkship students indicate that mentorship and hands-on participation in the OR are two factors that influence students’ desires to pursue surgical careers.2 Several medical school programs have attempted to provide both components to first-and second-year medical students. These institutions have found that participants in these programs had increased enthusiasm about surgery in comparison with matched control students who lacked such exposure.3,4 However, little long-term follow-up research has been conducted to assess whether this increased preclinical exposure ultimately affects specialty preferences or match outcomes.

Further complicating an undersupply of surgeons is the current climate of resident education. Based on examination scores and clinical performance, work-hour restrictions have been associated with a decline in patient outcomes and resident education.5 The same studies described previously also found that preclinical students who experienced more intensive surgical exposure had consistently higher self-reported confidence ratings when asked about basic surgical skills.3,4 Using confidence as a proxy for competence, which has yet to be directly measured, these results suggest that targeting interested students for training earlier in their medical education may enhance their preparedness as third-year clerks, then as residents, and ultimately as young attending surgeons—a sort of trickle-up effect.

Introducing PreOp

With these possibilities in mind, the authors set out to design a program that offers medical students mentored and active participation in the OR, starting from their first month of medical school to the time of their residency match. The purpose of this study is not only to show that there is a place for intensive surgical exposure in the preclinical years, but also to share a successful model that can be readily implemented in medical schools throughout the country. Examining the factors that influence student satisfaction, career interest, and confidence and competency in preclinical exposure programs may help guide the early stages of training for the next generation of surgeons.

Study design

The PreOp pilot program ran from September 2013 to June 2014 as a collaborative effort between Weill Cornell Medical College and New York-Presbyterian Hospital. Participants included 10 attending surgeons, who served as mentors, and 10 first-year medical students. (One of the 10 selected students decided to terminate his participation in PreOp and was not replaced.)

The mentors were recruited across a number of specialties—including cardiothoracic, general, neurologic, and plastic surgery, as well as otorhinolaryngology, and urologynd were selected based on their interest in medical education and their willingness to engage preclinical students in the OR.

Students from the class of 2017 were invited to apply and were accepted the summer before matriculating. Admittance to the program was based upon a qualitative review of a student’s personal statement and his or her curriculum vitae by Gregory F. Dakin, MD, FACS, the surgical faculty sponsor and a co-author of this article, and Charles L. Bardes, MD, associate dean of admissions at Weill Cornell Medical College. Each month, students rotated with one of the mentors, spending one to five days in the OR and/or clinic. A parallel skills component, which consisted of four skills workshops and two lectures, was designed to increase both student confidence and competence with basic surgical skills.

As part of a study approved by the institutional review board at Weill Cornell Medical College, PreOp program students completed a monthly survey detailing their involvement with and impression of that month’s rotation. Nine matched control first-year medical students were recruited based on a demonstrated interest in surgery, either by signing up to participate in Weill Cornell’s already established but less intensive surgical interest group or by applying to PreOp without being accepted.

Both PreOp and control students completed baseline and end-of-year surveys to gauge the extent to which surgical exposure influenced their specialty preferences. Over the next three years, these two cohorts will be followed longitudinally and resurveyed to assess whether participation in PreOp affects the following: specialty preference and ultimate match outcome, self-reported preparation before and after the third-year surgical clerkship, and competency during the third-year surgical clerkship as measured by the professor’s evaluations and grades. Thus, PreOp is a prospective cohort study that will span all four years of medical school.

Preliminary results

Data collection and statistical analysis included only the nine PreOp students who completed all 10 months of rotations. Results from the pilot year indicate that the PreOp program successfully provided students with increased hands-on surgical exposure. All PreOp students scrubbed in for at least one operation during the year, and the PreOp students had the opportunity to scrub in on more than half of the total rotations (52.6 percent). These numbers are in stark contrast to the control group, in which only one student had the opportunity to scrub in throughout the year, despite the fact that the control students observed more than 43 procedures. Moreover, all PreOp students were able to suture intraoperatively during at least one rotation, while none of the students in the control group had a similar opportunity.

Preliminary statistical analysis was performed to assess factors that increased student satisfaction with each individual rotation. This assessment showed that increased hands-on participation in the OR through scrubbing in was related to increased student satisfaction and higher rotation evaluations (p<0.001), supporting previously reported findings of the importance of hands-on participation in developing student surgical interest.3

After establishing a substantial difference in surgical exposure between the PreOp and control students and determining which factors influenced student satisfaction on a per rotation basis, students were asked whether 10-month participation in the PreOp program affected career interest overall. All PreOp and control students initially expressed an interest in exploring surgery at the start of the year. The students also were asked to anticipate how likely they would be to apply to match into a surgical field as fourth-year students. PreOp students reported increased surgical interest at the end of the year as compared with the beginning, with seven (77.8 percent) reporting being very likely to apply to match into surgery at the end, compared with four (44.4 percent) at the start of the program. In contrast, only two (22.2 percent) of the control students reported being very likely to apply to match into surgery at the end of the year—a number that remained unchanged from the start of the year.

Ready for implementation

PreOp was designed to provide students with attending mentorship and hands-on participation in the OR starting from their first month of medical school. Its successful implementation supports the idea that such programs can be readily formed and can offer markedly increased surgical exposure in comparison with conventional shadowing.

Preliminary data indicate that similar programs should promote hands-on participation to maximize student satisfaction. The authors’ goal is to determine whether surgical exposure through preclinical programs like PreOp can enhance both surgical interest and competency. This study is unique in its longitudinal nature, and the authors intend to continue following PreOp students to assess surgical competency and confidence throughout their four years of medical school. They anticipate that follow-up studies will show that preclinical students represent an ideal target population for career recruitment and earlier training, potentially providing a solution to the dual problem of physician shortages and inadequate resident preparation.

Disclosure

The PreOp program is funded by an education grant from W.L. Gore & Associates, Inc.


References

  1. Harris S. Physician shortage spreads across specialty lines. Association of American Medical Colleges. Available at: www.aamc.org/newsroom/reporter/oct10/152090/physician_shortage_spreads_across_specialty_lines.html. Accessed July 3, 2014.
  2. Berman L, Rosenthal MS, Curry L, Evans LV, Gusberg RJ. Attracting surgical clerks to surgical careers: Role models, mentoring, and engagement in the operating room. J Am Coll Surg. 2008;207(6):793-800.
  3. Drolet BC, Sangisetty S, Mulvaney PM, Ryder BA, Cioffi WG. A mentorship-based preclinical elective increases exposure, confidence, and interest in surgery. Am J Surg. 2014;207(2):179-186.
  4. Sammann A, Tendick F, Ward D, Zaid H, O’Sullivan P, Ascher N. A surgical skills elective to expose preclinical medical students to surgery. J Surg Res. 2007;142(2):287-294.
  5. Ahmed N, Devitt KS, Keshet I, et al. A systematic review of the effects of resident duty hour restrictions in surgery: Impact on resident wellness, training, and patient outcomes. Ann Surg. 2014;259(6):1041-1053.

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