Who Should Teach Medical Students Surgery? Leigh A. Neumayer, MD, Salt Lake City, Utah, Ajit K. Sachdeva, MD, Philadelphia, Pennsylvania,

James C. Hebert, MD, Burlington, Vermont, Nicholas P. Lang, MD, Little Rock, Arkansas

BACKGROUND: Medical schools are undergoing major curricular reform, partly in attempts to in- crease the number of graduates pursuing careers in the generalist disciplines. These reforms have often resulted in a shortening of the surgery clerkship, decreasing students’ experiences in several domains important to the generalist.

METHODS: A seven-question survey of clerkship directors of US medical schools was adminis- tered to measure the magnitude of curriculum change during the past 5 years affecting the sur- gery and family practice clerkships. The survey also addressed attitudes about the purpose of the surgery clerkship.

RESULTS: There was an 80% (103 of 129) response rate. Between 1989 and 1994, surgery clerkships decreased on average from 11 to 10.2 weeks (/J ~0.05) while family practice clerkships increased from 4.2 to 6.8 weeks (P ~0.05). Ninety-one percent of clerkship directors felt the primary goal of the clerkship should be to train generalists.

CONCLUSIONS: The length of the surgery clerkship has decreased at several institutions. In order to ensure an appropriate educational experience for medical students, surgeons must participate ac- tively in curriculum reform within medical schools and highlight their unique role in training general- ists. Am J Surg. 1996;172:218-219. 0 1997 by Excerpta Medica, Inc.

M any medical schools are undergoing revision of their curricula. A major impetus for change re- sulted from the Association of American Medical

Colleges’ adopting a policy advocating that the majority of graduating medical students be committed to generalist ca- reers, and that efforts be made by all schools to reach this goal rapidly.’ The policy defines family medicine, general internal medicine, and general pediatrics as the only gen- eralist disciplines. In an effort to achieve this goal, many medical schools have made changes in the curriculum of the third year to include a rotation in family practice.

From the Salt Lake City VAMC and University of Utah (LAN), Salt Lake City, Utah; Allegheny University of the Health Sciences and MCP-Hahnemann School of Medicine (AKS), Philadelphia, Penn- sylvania; the University of Vermont (JCH), Burlington, Vermont; and Little Rock VAMC and the University of Arkansas (NPL), Little Rock, Arkansas.

Requests for reprints should be addressed to Leigh Neumayer, MD, VA Medical Center (112), 500 Foothill Blvd., Salt Lake City, Utah 84148.

Manuscript submitted August 13, 1996 and accepted in revised form September 26, 1996.

In order to accommodate this new clerkship, several other required clerkships have been shortened. Surgery clerkships have been especially vulnerable to such changes. However, surgeons have a unique role in the general professional edu- cation of students, and shortening of surgery clerkships may result in a negative impact on medical student education. Sur- geons need to play a visible and central role in the process of curriculum change at their respective institutions. Only then will the important role of surgeons in the education of medical students be recognized and accepted by the larger community of educators within each medical school. The Association for Surgical Education (ASE) has been interested in this issue for some time, and undertook a survey of medical schools to gather further information.

METHODS A seven-question survey was sent to the clerkship director

members of the ASE to address the magnitude of the changes in third-year medical school curricula between 1989 and 1994. Canadian and international members were excluded from the mailing owing to major curricular differ- ences that would prevent comparison. The ASE has mem- bers from 97 of the 124 US medical schools. However, since many schools have multiple campuses, the number of clerk- ship directors in the Association is more than the number of schools. Clerkship directors were contacted a second time if they did not respond to the first mailing, and data from all responses were collated.

The differences between mean lengths of rotation were tested using a two-tailed Student t test. Differences between median length of rotations were tested using a two-tailed Wilcoxon signed rank test.

RESULTS Of the 129 US clerkship director members, 103 responded

(80%). Seven of these did not have a third-year clerkship and so were excluded from further analysis. This left 95 surveys (74%) for analysis. The mean number of weeks re- quired in surgery and family practice in 1989 and 1994 rep- resented a significant decrease in length of the surgery ro- tation (from 11.0 to 10.2 weeks, P <0.05), and a significant increase in length of the family practice rotation (from 4.2 to 6.8 weeks, P <0.05). Of note is that 70% of respondents had experienced a change in the length of their surgery rotation-in all but two, a decrease. In 1994, the surgery clerkship was divided into an average of 7.0 weeks of gen- eral surgery and 3.2 weeks of subspecialty rotations. A mean of 20% of time on the surgery clerkship was spent in an outpatient clinic setting.

The schools of 89% of respondents had a required rotation in family practice and 86% a department of family practice. Thirty-six percent of respondents reported joint activities be- tween the departments of surgery and family practice; most of

218 0 1997 by Excerpta Medica, Inc. 0002-961 O/97/$1 7.00 All rights reserved. PII SOOO2-9610(97)00021-4

these activities consisted of joint conferences. Institutions with a department of family practice had significantly longer rota- tions in family practice compared with those without a de- partment (P <0.05), but this variable had no impact on the length of the surgery rotation (Figure).

When asked about the primary goal of a surgery clerkship, 36% of respondents thought it should be to introduce med- ical students to surgery as a career, whereas 91% of the surgery clerkship directors felt the primary goal of the clerk- ship should be to train generalists in what they need to know about surgery. (These numbers add to more than 100% owing to double marking.)

COMMENTS In attempts to produce more generalists, medical schools

are creating or increasing exposure to family practice in the third year of medical school. In this survey of third-year clerkship directors, a 62% increase in the length of the fam- ily practice rotations was found over a 5-year period. Over that same period, 70% of surveyed medical schools saw a change in the length of their surgery clerkships. At all but two of these, the change represented a decrease in the length, accounting for an overall 7% decrease.

Although this new emphasis on training generalists is nec- essary, the question remains whether increasing exposure to the discipline of family practice in the third year is the most appropriate strategy to accomplish this goal; the long-term impact of shortening other traditional third year clerkships also remains unclear. Many authorities agree that broad changes are needed to significantly increase the numbers of students pursuing generalist careers.“-’ These changes in- clude selection of appropriate students who are more likely to pursue generalist careers, increased size of generalist fac- ulty, a required family practice rotation, and educational reform to emphasize generalist training throughout the medical school curriculum.3*5*6 Although a required clerk- ship in family practice is thought to increase the percentage of students choosing that career, there are no data to sup- port whether this exposure should be in the third versus the fourth year. The amount of time students spend in a disci- pline (and perhaps exposure to role models) may be more important than when it occurs.6

Exposure to surgery and to the surgical subspecialities is an important part of medical student training. In addition, students need to be familiar with the principles of efficient evaluation and appropriate referral of patients with a variety of problems. Surgeons are uniquely qualified to teach med- ical students relevant surgical topics and attitudes that re- late to these subject areas. Family practitioners are often the ones to first evaluate patients with problems that require both surgical and medical treatment, such as otitis media, chronic sinusitis, acute tonsillitis, back disorders, breast dis- ease, and abdominal pain.7 Furthermore, many generalists are involved with the performance of minor surgical pro- cedures in their offices. The surgery clerkship can offer spe- cial opportunities to help students learn these skills. In a recent address, Cohen’ postulated that there are many basic clinical skills especially well taught by surgeons. These in- clude critical reasoning, physical examination, parsimoni- ous management of clinical resources, and professionalism. Furthermore, surgeons are very well qualified to teach

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0 Dept FP No Dept

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i WHO SHOULD TEACH SURGERY?/NEUMAYER ET AL

Figure. Effect of the presence of a department of family practice on the length of surgery and family practice clerkships (? <0.05).

pathophysiology, clinical epidemiology, and symptoms and signs, diagnostic approaches, and standard therapy for com- mon surgical conditions.

Surgery rotations continue to offer students many impor- tant tangible and intangible learning opportunities. During most third-year rotations, students function as integral team members. That allows students to develop special skills and professionalism that can prepare them for their future roles as members of interdisciplinary health care teams. Further- more, surgical rotations expose students to critically ill pa- tients whose management requires rapid decision making and efficient use of health care resources. Surgeons are uniquely qualified, because of their central role in multidis- ciplinary teams, to provide both the role modeling and the training necessary to educate medical students to function as members of these teams.

The commitment to train generalist physicians by the sur- vey respondents was clear, as 91% of surgery clerkship di- rectors felt the primary goal of the rotation was to train generalists in what they need to know about surgery. This commitment should be emphasized, and adequate time al- located to the surgery clerkships within the curriculum of medical schools. Shortening of surgery clerkships without consideration of the issues described above may result in a negative impact on the appropriate training of generalists.

REFERENCES 1. AAMC policy on the generalist physician. Acad Med. 1993;68(1):1-5. 2. Glasser M, Stearns J, McCord R. Defining a generalist education: an idea whose time is still coming. Acad Med. 1995;7O(suppl):69-74. 3. Cummings M. Ennls M. A model for improving generalist phy- sician output: the osteopathic experience. Acad Med. 1995; 7O(suppl):57-63. 4. Weitekamp MR, Ziegenfuss JT. Academic health centers and HMOs: a systems perspective on collaboration in traming generalist physicians and advancing mutual interests. Acad Med. 1995; 9O(suppl):47-53. 5. Cohen J. Generalism in medical education: the next steps. Acud Med. 1995;7O(suppl):7-9. 6. Campos-Outcalt D, Senf J, Watkins AJ, Bastacky S. The effects of medical school curricula, faculty role models and biomedical research support on choice of generalist physician careers: a review and quality assessment of the literature. Acad Med. 1995;70(7):611-619. 7. Sachdeva AK. Surgical educators and the contemporary training of generalists. Am J Surg. 1994;167:337-341. 8. Cohen JM. The role of specialty surgical education in medical schools. Address to the American College of Surgeons, Annual Clinical Congress, Chicago, IL, October 1 I, 1994.

THE AMERICAN JOURNAL OF SURGERY” VOLUME 173 MARCH 1997 219