Abstract
Objectives: To identify the role and impact of surgical residents on the various activities of a senior (4th year) surgical clerkship, and to explore students’ perceptions of differences between the teaching behaviours of attending physicians and residents.
Design: A survey by questionnaire.
Setting: McGill University, Montreal.
Method: A 67-item questionnaire was administered to fourth-year medical students at the end of their 8-week surgical clerkship. Analysis of the data was performed using the Wilcoxon signed-rank test, Dunn’s multiple comparison test and mean average.
Main outcome measures: Overall satisfaction with the clerkship, teaching behaviours and teaching of clinical skills and basic principles.
Results: Overall satisfaction with the clerkship was 6.31 out of 10. Surgical residents were perceived as being significantly more active than the attending staff in 14 out of 15 teaching behaviours. They were also seen as important in teaching certain clinical skills such as suturing, assisting in the operating room and managing emergency situations. They also contributed significantly to teaching the basic principles of surgery such as infections, surgical bleeding and fluid and electrolytes. On a 10-point scale, students felt that more learning was achieved by independent reading, tutorials and residents’ teaching than by other teaching modalities, including attending physicians’ and nurses’ teaching.
Conclusions: Medical students perceive surgical residents as being significantly more active in their education process than the attending staff. Residents appear to be responsible for teaching various technical and patient management skills necessary for patient care. Along with independent reading and tutorials, resident teaching contributes a significant portion of the medical student’s acquisition of knowledge and appears to contribute to the students’ choice of surgery as a career.
Recent trends in medical education have emphasized a shift toward self-directed learning and a renewed focus on basic clinical skills.1 For surgical program directors, implementing these ideas and assuring their effectiveness often causes logistical problems. In some fields of medicine, such as pediatrics and internal medicine, residents are recognized as important, influential teachers of medical students.2–4 Efforts to optimize the resident’s role in education have yielded encouraging results with teaching retreats5 and teaching rotations for residents.6 However, few studies have looked specifically at general surgery residents7 and their role in the educational stream.8 Data are also scarce on quantifying the amount of teaching that students derive from residents as opposed to attending staff and various other activities (seminars, lectures and rounds).
In general surgery, students are assigned to a surgical team where a great proportion of their time is spent interacting with the residents, who have not traditionally been trained as teachers. The purpose of this study was to identify the role and impact of surgical residents in the various activities of a senior (4th year) surgical clerkship. We also attempted to explore students’ perception of differences between attending physicians and residents in their teaching behaviours during clinical clerkships.
Methods
A 67-item questionnaire, based on previous studies in this field,9 was created to optimize quantifiable data such as Likert-type scales (Fig. 1). It was administered to all groups of senior medical students at the end of their 8-week surgical clerkship at McGill University during the 1994/95 academic year. It was divided into 7 groups of questions inquiring about various activities and interactions students had experienced. Students were informed that responses were independent of their rotation evaluations and would not be seen by surgical staff or residents.
Questionnaire given to fourth-year medical students at the end of their 8-week surgical clerkship to determine their perceptions of the teaching behaviours of attending physicians and surgical residents.
In the first 2 groups of questions, students were asked to compare the frequency with which attending physicians and residents evidenced certain teaching behaviours such as teaching, role modelling and providing feedback. A total of 30 variables were available, 15 each for attending physicians and residents. For each question, a 3-point coding system was used, where 3 = frequently, 2 = sometimes and 1 = never. The questions were asked in exactly the same format for both attending physicians and residents (Fig. 1). For each of the 15 questions, the scores of the attending staff were compared with those of the residents, using the Wilcoxon signed-rank test for ordinal data.
Next, the students were asked to give their overall rating of the clerkship using a 10-point scale, where 1 = weak and 10 = excellent.
The fourth group of questions was designed to assess the importance of residents in either improving or teaching medical students to perform clinical skills such as tying knots, suturing and inserting central lines. A 5-point scale was used, where 1 = not important and 5 = very important (Fig. 1).
The fifth group of questions assessed the importance of residents in either improving or teaching medical students about basic principles of general surgery such as fluid and electrolytes, wound healing and surgical bleeding. Again, a 5-point scale was used, where 1 = not important and 5 = very important (Fig. 1).
The sixth group of questions evaluated the importance of various people and activities on the students’ learning experience. Students were asked to rank 10 modalities in terms of how much of their learning was achieved through that specific modality, with 1 = least important and 10 = most important (Fig. 1). For these last 3 groups of questions, item comparison was achieved with Dunn’s multiple comparison test.
The last group of questions asked the students to describe the influence that residents had on their attitude toward general surgery as a career, and what appeal the lifestyle of surgical residents had on them. It also asked students to identify (marking either yes or no) if certain personal traits were found in the residents with whom they worked. The traits inquired about were availability, helpfulness, respect toward patients, and whether or not the residents were good teachers and role models (Fig. 1).
In total, 97 forms were completed by the senior class totalling 123 students, for a response rate of 79%. Response to the questionnaire was voluntary, no students’ names were collected in order to assure anonymity. All statistical values were calculated with the use of InStat and Microsoft Excel computer programs.
Results
Mean scores for the 15 questions inquiring about attending physician and resident teaching behaviours revealed that in all 15 teaching behaviours except 1, residents were felt to be significantly more active than the attending staff (p < 0.05) (Table I). Mean (and standard deviation) satisfaction with the clerkship was 6.31 (2.15) out of 10.
Comparison of Attending Physicians and Residents in Frequency of Teaching Behaviours
On a series of 13 clinical and technical skills, surgical residents were seen as more important in teaching medical students about suturing, assisting in the operating room, dealing with emergency situations, nasogastric tube placement, knot tying and insertion of Foley catheters. They were viewed as less important in some skills such as surgical record keeping, arterial blood-gas sampling and physical examination skills. They were significantly uninvolved in other skills such as applying casts, removing cutaneous lesions, central line placement and taking blood (Table II).
Importance of Surgical Residents in Teaching Clinical Skills
Concerning basic principles of surgery, residents were viewed as most important in teaching medical students about surgical infections. They were less important in teaching about surgical bleeding, wound healing, and fluid and electrolytes. Students felt that residents were uninvolved in teaching about nutrition and burns (Table III).
Importance of Surgical Residents in Teaching Basic Principles of Surgery
In describing the importance of various teaching modalities, students felt that 4 modalities were very important, 2 were equivocal and 4 were of less value. The 4 most important modalities were independent reading / studying, tutorials, residents’ teaching and seminars. The 2 equivocal modalities were ward/service rounds and the operating room. The 4 least important modalities were clinics, other rounds, attending physicians’ teaching and nurses’ teaching (Table IV).
Importance of Various Teaching Modalities
Medical students described the influence that residents had on their attitude toward general surgery as a career as a slightly positive one (3.40 out of 5) (p = 0.007) (hypothetical mean 3), whereas their lifestyle had a negative appeal for medical students (1.98 out of 5), p < 0.0001.
When asked about residents’ personal traits, students stated that most were helpful, available and good teachers, but fewer were either respectful of their patients or served as role models (Table V).
Students’ Perceptions of Residents
Discussion
The main purpose of this study, to assess the role of surgical residents in teaching medical students, appears to be addressed by the first 2 sections of this survey. Table I highlights the direct comparison of attending physicians and residents in frequency of teaching behaviours. The significantly higher scores given to residents based on our questionnaire supports the frequency of their interaction with medical students but cannot allow any inference as to the quality or importance of the material taught. Reasons for which the residents may have scored better are probably owing to several mechanisms of the surgical clerkship. First, students spend much more time interacting with residents than they do with attending physicians because of the nature of the inpatient services at McGill University. This correlates with other surgical programs, where residents have been found to spend up to 25% more time than faculty members in training undergraduate medical students.10,11 Second, students are more likely to view residents as peers. In that sense, residents may be more accessible and perhaps less threatening, so that students may feel more comfortable discussing certain topics with them than with attending staff. Third, staff are involved in a more didactic teaching process, focussing on important theories and basics of general surgery. The teaching done by residents usually involves more technical and practical aspects, directly related to specific patients and their problems. This is similar to problem-based learning, which encourages students to develop the schema necessary for memory recall.12
With certain clinical and technical skills, along with basic surgical principles, this survey suggests that residents have an interactive role to play with the medical student. Residents appear to serve as an important link between the theory and practice of surgery to clinical clerks, often teaching them important “survival skills.” Although it is difficult to assess the quality and quantity of teaching offered by residents, students identified certain areas as more important than others. If a program were established to teach residents about teaching, these areas would serve as important points of focus to ensure an adequate knowledge base within the resident group. This idea of “quality control” could be incorporated into the residency training program in one of several ways. A clinical teaching retreat5 has met with some success in internal medicine, where residents reported significant improvement in several educational categories after these sessions. A similar type of retreat in pediatric medicine has been popular at the University of Massachusetts.13 Also meeting with success has been a teaching rotation for residents, where they participate in additional instructional teaching methods, medical-student teaching and computer-based literature searches during a 1-month rotation.6
It is interesting that students identified resident-based teaching as the third most important learning modality, after independent reading and tutorials. This is perhaps the strongest finding in this study to quantify the importance of the surgical resident in providing a significant learning experience. For the clerkship director, this question points to various areas in which the clerkship may benefit from improvement. For example, since nurses’ teaching assumes a low priority in the students’ learning process, improving this component of their clerkship will be of least benefit. However, stimulating the students to read while improving tutorials and residents’ teaching should yield the greatest improvements.
The final group of questions attempted to yield insight into the attitudes that surgical residents may foster in their students’ minds. Although it is encouraging that residents had a positive influence on their students’ feelings toward surgery, it is disappointing that the lifestyle of these same residents had a negative influence. More troublesome, however, is that only 66% of students felt that their residents were respectful of patients. Although only 56% of students perceived the residents as role models, this is not unusual given that these are essentially peer groups. The fact that 86%, 81% and 77% of students felt that residents were helpful, available and good teachers, respectively, is encouraging.
Data from this study have shown that in our institution surgical residents have an important role in several areas of medical students’ teaching, specifically in skills acquisition. Their teaching is the third most important teaching modality available to students. However, most residents have very little teaching background, which may hinder their abilities to seize upon good teaching opportunities. In addition, this study has confirmed the high level of frequency with which surgical residents are involved in teaching activities. Although this aspect is perceived to be significantly higher than the attending physicians’ involvement, no inferences as to the quality of the teaching can be made. It does, however, support the premise that residents should be taught how to teach, how to take better advantage of limited time, how to explore different teaching styles and how to acquire specific teaching techniques.13 As already mentioned, several modalities exist to do this. Since residents are most likely to improve student learning through clinical precepting with brief lectures,14 the course content of a teaching retreat or rotation should be designed accordingly. Using the information derived from this study and other published reports,15 we have since undertaken a randomized prospective study to evaluate the effects of a teaching skills workshop for surgical residents. Like many other areas, some residents will prove to be natural teachers and others will not. Only then can the lesser teachers be made acceptable and the good teachers molded into excellent ones.
Acknowledgments
Special thanks are extended to Gloria Morgan, Rita Piccione and Nettie Epstein for their diligent work in data collection.
Footnotes
Presented as a poster at the annual meeting of the Association for Surgical Education, Lexington, Ky, Apr. 10 to 13, 1996.
- Accepted November 3, 1998.