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| Journal of the New Zealand Medical Association,
19-May-2006, Vol 119 No 1234
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Surgical inclination in senior medical students from the
University of Auckland: results of the 2005 Senior Students Survey
Phillip Insull, Ritwik Kejriwal, Anand Segar, Phil Blyth
“Surgically inclined” is a term often used to
describe medical students who show a clear preference for surgery over other
specialties whilst at medical school.
Interest in surgical training is declining in the United
States and elsewhere.1 It has been suggested that surgical lifestyles, family
pressures, indemnity protection costs, and the increasing proportion of female
medical students are contributing to this trend. Females are less likely to
enter surgical training than males.3 Females make up more than half of New
Zealand medical students.2–4
Long hours are necessary for surgical trainees to gain
operative experience.6 Whilst reforms have decreased this time demand, surgical
training remains the most time-intensive of all specialties.7 This is
dissuasive, as medical students are more likely to choose specialties less
demanding of their time.8
Factors shown to be associated with medical graduate’s
decision to pursue a surgical career have included: a willingness to work long
hours; affinity for procedural tasks; the ability to focus for long periods on a
task; enjoyment of surgical rotations; and interest in a surgical career whilst
at medical school.9–11
Students will generally show a preference toward a specialty
during medical school.12 Fifty-three percent of fifth year students at the
Dunedin Medical School have been shown to have a strong idea of their career
direction.13 90% of Malaysian medical students (a number of which come to New
Zealand for their clinical training and subsequent employment) have already
decided on their future specialty before graduation.14 Surgeons may decide their
career direction earlier than those working in other specialties.15
MethodCreating the
definition—A literature review was conducted searching Medline, the
Cochrane Library, and BMJ.com. Search terms included:
medical students AND
career decisions AND
surgery;
female medical students AND
surgery;
gender AND
medical students.
Significant factors which were repeatedly identified in
the literature as being strongly predictive of medical graduates pursuing
post-graduate surgical training were included in our five point definition for
the surgically inclined medical student.11–13
Meeting four out of the following five criteria
positively identifies a surgically inclined student:
Development
of the survey—Ethical approval was sought from the Multi-regional
Ethics Committee. After reviewing a summary of the project’s aims and
proposed methodology, the Committee’s Chair consented to completion of the
project without formal ethical review, under the proviso that responses would be
made anonymous.
The anonymous survey questionnaire included 25 items.
These items were either tick box replies or a five-point Likert scale ranking (1
= strongly agree; 5 = strongly disagree). Demographic information included only
gender and year of medical study. Five items targeted the definition directly.
Three pairs of control questions were included to
provide a measure of reliability in responses. If answers were reliable, the
response to each item per pair clearly correlated and the response was included
in the analysis. Responses with no or only one consistent pair were to be
excluded from the analysis. Other items examined perception of the role of basic
medical sciences, the perceived amount of knowledge of basic sciences, and
methods of learning. These questions served to control bias potentially created
through a questionnaire which was overtly surgically.
A focus group of four medical students evaluated the
survey prior to pre-testing with a pilot survey. Pre-testing was conducted using
a sample of 10 fifth-year medical students who were also included in the final
sample. These respondents were asked to comment on content, consistency,
clarity, appearance and potential for bias in the questionnaire. Potential
ambiguities and inconsistencies in scales which were identified were corrected
prior to the study sample being completed.
Survey
administration—Fourth- and fifth-year class email lists were
obtained through class representatives from the University of Auckland Medical
School. 284 email addresses were mailed a pilot message; 66 messages were
returned to sender by service providers stating permanent failure (thus
suggesting those email addresses were no longer valid). Thus, those 66
undeliverable addresses were not sent surveys. The survey form was sent to 218
email addresses; 156 responses were received. These responses were organised
with any personally identifiable information removed by a third party.
Statistical
analysis—Questionnaire responses were manually entered into an
electronic spreadsheet. Responses were divided into two groups for each item
(1=strongly disagree/disagree/neutral, 2=strongly agree/agree). Statistical
analysis was performed using Microsoft Excel and SPSS software. Confidence
intervals for proportions were calculated using a continuity correction for
categorical data. Differences were tested for significance using the standard
error and a continuity correction for categorical data. P values of less than
0.05 were defined as significant.16
ResultsResponses—In
response to the email, 156 of 218 (71.60%) medical students returned a completed
survey (Table 1).
Table 1. Response rate (by study year and gender) of
the 218 medical students who received the survey
In all responses, at least two of the pairs of control
questions were consistent, thus no responses were excluded from the analysis.
Surgical
inclination—As shown in Table 2, the proportion of all respondents
meeting the criteria was 0.20 (20%). The proportion of males was significantly
greater than the proportion of females meeting the criteria (p<0.01).
Table 2. Proportion of students surgically
inclined
*meeting
criteria.
Interest in
surgery—Students were asked to rate their interest in a surgical
career (1=highly disagree/not at all interested, 5=highly agree/highly
interested).
Forty percent of students agreed that they were interested
in a surgical career (95% CI 0.32–0.48). Not surprisingly, more students
meeting the criteria were interested in a surgical career (p<0.01). No
statistically significant difference was found between males and females for
this item (p>0.05) (Table 3).
Table 3. Interest in a surgical career
*meeting
criteria.
Lifestyle—Students
were asked to rate the importance of lifestyle as a factor in choosing a career
within medicine (1=highly disagree/not at all a factor, 5=highly agree/very
important factor).
Fifty-six percent of all students agreed that lifestyle was
an important factor in choosing a career (95%CI 0.48-0.64). A significantly
smaller proportion of surgically inclined students agreed with this item
(p<0.01). No statistically significant difference was found between males and
females for this item (p>0.05) (Table 4).
Table 4. Importance of lifestyle as a factor in
choosing a career
Procedural
exposure—Students were asked to report how many procedures they had
performed from a list of five procedures commonly performed by medical students
(IV cannulation, LMA/ETT intubation, Foley catheter insertion, suturing, minor
surgical).
There was no statistically significant difference in the
number of procedures performed by surgically inclined medical students and
non-surgically inclined medical students (p>0.05). No statistically
significant difference found in the mean response between males and females for
this item (p>0.05) (Table 5).
Table 5. Number of procedures performed by students
Educational
value of theatre attendance—Students were asked to rate the
educational value of time spent in the operating theatre (1=highly disagree/not
at all useful, 5=highly agree/ very useful).
Forty-six percent of all students agreed that time spent in
the operating theatre was educationally valuable (95%CI 0.38–0.54). A
greater proportion of surgically inclined medical students agreed that time
spent in the operating theatre was educationally valuable (p<0.01). No
significant difference was found between males and females for this item
(p>0.05) (Table 6).
Table 6. Educational value of the operating
theatre
DiscussionMethodological
issues—As selection of the sample was not randomised, systematic
biases are possible. More females responded to the survey than males, yet this
is reflective of medical student demographics in New Zealand.5 The response rate
to this email survey was higher than the mean response to such survey published
in medical journals.17
Because this survey did not overtly seek surgical
respondents, the non-respondents were unlikely to adversely bias the results.
Non-respondent bias was thus felt to be well controlled. Socially desired
response bias was probably an issue for some items. Still, reliability in
student responses was pleasing as tested by responses to control question pairs.
Caution should be applied when generalising the results of this survey and
proportions should be interpreted as trends rather than absolute values.
The
definition—When students were asked if they were interested in a
surgical career, 40% of students agreed. As this is considerably higher than the
actual proportion of medical graduates who enter surgical training, it may
reflect socially desired response bias in this item. The five-point definition
of medical student surgical inclination appears to give a more reliable estimate
of the true proportion of students who are likely to enter surgical
training.
Gender bias in surgical
inclination—Females are less likely to enter surgical careers than
males.3 In the United States, the number of females entering medical school has
increased, yet the number of females applying for surgical training has remained
relatively constant.18 Thus the proportion of female medical graduates entering
surgical careers has actually decreased.
The findings of this investigation suggest these American
trends may be generalisable to New Zealand. Thirty-two percent of males surveyed
were found to be surgically inclined compared to 12% of females (p<0.01).
Kato et al (2004), who investigated the opinions of female surgeons from Japan,
commented that the demands of marriage and family on women were probably a major
factor in the under-representation of women undertaking a surgical career.19 Our
investigation, like others in the literature, was unable to demonstrate that
female medical students are significantly more concerned with lifestyle when
choosing a career than males.3,10
Encouraging interest in
surgery—The busy surgical lifestyle has been shown to be a
deterrent for medical graduates.9 Our analysis suggests that a significant
difference between those students who are surgically inclined and those who
aren’t is the importance they place on lifestyle.8
Reforms in the United States have significantly restricted
the long hours that trainees are expected to work.9 While it is hoped that this
will increase in surgical careers, there is also concern that shorter hours will
lead to inadequate operative experience.8
Mentoring for students has been advocated as another way to
improve interest in a surgical training.11 Some medical schools have established
surgical interest societies for this purpose.20 Consultants and trainees who
make a concerted effort to teach students on the ward and operating theatre have
been shown to motivate students to consider surgical careers.11
Our analysis showed that less than half of the students
surveyed found operating theatre attendance educationally valuable. Several
respondents noted that theatre was useful
when they could see into the operative
field and were being spoken to.
It is the belief of the investigators that identifying and
fostering student interest in surgery is important to the future of New
Zealand’s surgical workforce.
Future
study—We propose that future studies look at the experiences of
surgically inclined versus non-surgically inclined students as well as
experiences of male versus female students during surgical attachments.
Limitations—We
encountered difficulty in capturing a
higher response rate as unsolicited emails are frequently blocked or put into
junk-mail folders by service providers, and treated as spam.
Another limitation was subjectivity in the interpretation of
evidence relating to surgical inclination in the formulation of this
study’s criteria.
ConclusionsOf senior (fourth and fifth year) medical students at
University of Auckland Medical School:
Author
information: Phillip Insull, Trainee Intern; Ritwik Kejriwal, Trainee
Intern; Anand Segar, 5th Year Medical Student; Phil Blyth, Lecturer in Anatomy;
Auckland Medical School, University of Auckland, Auckland
Correspondence:
Phillip John Insull, Trainee Intern, Auckland Medical School. Mailing address:
6U Carlton-Gore rd, Grafton, Auckland; email: phillipinsull@gmail.com
References:
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