Transitioning the Surgery Clerkship from Third-Year to Second-Year Medical Students: Lessons Learned

Authors: Carlos Theodore Huerta, Alex Hernandez, Brianna Cohen, Chad M. Thorson, Neha Goel, Steven Rodgers, Vanessa W. Hui, and Laurence Sands

Medical education has undergone sweeping pedagogical changes over the past few decades with over one-third of US allopathic medical schools having redesigned their curricula as of 2015 [1–3]. Historically, medical institutions utilized the Flexnerian model consisting of two preclinical didactic years prior to two clinical training years [4]. However, there has been a growing emphasis in the past few decades reform to shorten the preclinical phase of medical education to allow for earlier clinical experiences during the second year of medical school. Benefits of shortening preclinical time can include more elective rotation opportunities and time for specialty selection by students.[4] Potential drawbacks of reducing the preclinical education can be decreased performance on both clinical rotations and standardized exams [5].

Within our own institution, the core clerkships were transitioned to the second-year (MS2) in 2022-2023. This resulted in TWO graduating classes (MS2 Class of 2024 and MS3 Class of 2023) simultaneously completing the surgery clerkship during the 2022-2023 Academic Year (total of 396 students). Our “Legacy” curriculum, based on the Flexnerian model, involved 8 weeks of surgery. While our current Surgery Clerkship, “ER to OR” model, currently includes 4 weeks of a general surgery service followed by two 2-week rotations of subspecialty services with integration of Emergency Medicine and Anesthesia. Amongst MS3s alone, the transition from a traditional 2 preclinical + 2 clinical years model, our “Legacy” curriculum, to our “ER to OR” curriculum improved NBME and quiz performance, with overall surgery grades and clinical evaluations remaining similar to previous years. From our experiences, these were the most frequent areas to ease the transition for students’ and faculty expectations for MS2 student performance on the Surgery Clerkship.

1. Create Targeted Workshops/Educational Material to Fill in Gaps

A Surgically-Oriented Anatomy Bootcamp – After the transition to the Surgery Clerkship in the MS2 year, gross anatomy was eliminated from the MS1 curriculum. This is a growing trend and issue throughout other institutions. To fill in this gap at our institution, we instituted a focused 4 hour anatomy bootcamp session in the first week of the Surgery clerkship. The training session consisted of six 30-minute stations covering common surgical anatomy: anterior abdominal wall, hepatobiliary, stomach/small intestine, colon/rectum, neck/breast, and cardiothoracic. As each of our sessions hosted around 100 students, each station consisted of four donor prosections with two anatomy faculty or student volunteers as station presenters. Each station consisted of a 20-minute presentation of prosected donor anatomy and clinical correlations, followed by 10 minutes of student-led anatomical identification. Ultimately, this curriculum improved medical student knowledge of, and confidence in, surgical anatomy at our institution [6]. Methods like these can help fill in gaps in these condensed curricula.

Surgery Clerkship Bootcamp – Before the Surgery Clerkship at our institution, students now attend a 3-day long bootcamp to orient them to the clerkship expectations and basic skills. The bootcamp begins with a general overview of expectations during the clerkship with an opportunity to discuss any questions or concerns with the clerkship director. Students are given materials on basic trauma resuscitation, tubes and lines, and OR etiquette.  Our residents then conduct an in-person workshop to introduce students to basic OR instruments and handling, how to scrub in to an OR, knot-tying and suturing, and laparoscopic instrumentation and camera holding. This session reviews commonly used surgical instruments, their names and functions, various suture materials and their specific uses, and allows time to practice handling these instruments. We also introduce the basics of knot-tying with time for supervised practice. We found dedicated skills teaching such as this is essential to orient younger medical students and give them confidence to succeed on rotations.

2. MS2s Have Similar Clinical Performance but Lower Examination Performance than MS3s

Reduced Preclinical Time Effects Examination Performance – Given that performance on the United States Medical Licensing Exam (USMLE) Step 1 has been shown to be correlated with ABSITE performance as well as the recent conversion of USMLE Step 1 to a pass/fail scoring system, performance on the surgery clerkship is likely to become of even greater significance in the residency selection process [7]. We were concerned that MS2s would not perform as high on both clinical and written exams compared to MS3s, and we performed a retrospective study to assess this at the end of this curriculum transition year. MS3s demonstrated higher median scores on weekly quizzes, NBME shelf exam, and the overall clerkship grade. MS3s also more frequently scored in the top 50% of performers on objective metrics including the shelf exam, weekly quizzes, and overall surgery grade. To our surprise, there were no significant differences in MS3s and MS2s performance on clinical evaluation scores and OSCE performance. These data draw attention to the need for all clinical clerkships to consider the fund of knowledge that MS2s with reduced preclinical education time have compared to students from traditional curricula when designing written examinations [8].

Utilize Multiple Pedagogical Modalities – We utilize several multimodal forms of learning in our clerkship including self-directed learning, lectures, and group  PBLs. In our experience, Problem-Based Learning (PBL) groups are vital to the engagement and preparation of students during their Surgery Clerkship. Each week, a video-conference PBL session is led by General Surgery Residents and focuses on common surgical pathophysiology and patient care cases related to the assigned learning topic of the week. This session offers the student an opportunity to apply the knowledge obtained from suggested reading, lectures, and online self-directed modules in an actual clinical case. This reaffirms the core fund of knowledge for patient care and allow the student to ask questions as well during this live session. We have found methods such as these are even more important for MS2 students in engaging them early on and providing them more context for the surgical management of disease that they do not get from their condensed preclinical curriculum.

3. Utilizing MS4 Time

Transition to Surgical Internship Bootcamp – Although the redesignation of the Surgery clerkship to the MS2 year allows students to explore more elective and subinternship rotations during their MS3 year, this provided more time in the MS4 year for specialty specific training. As a result, we implemented a 4 weeklong Transition to Internship Bootcamp course for MS4 students recently matched into surgery residencies (General, Plastic, and Vascular Surgery). This course consists of a variety of lectures related to the diagnosis and management of common consults and perioperative care scenarios that interns are most likely to encounter. Several skills workshops are included related to knot tying, suturing, laparoscopic and robotic surgery skills, bedside and ICU procedures. Importantly, we further incorporate several one-on-one workshops in which MS4 students receive common perioperative care and ED consult scenarios in a mock orals examination format administered by our Resident Educators.

4. Residents as Educators

Medical Education Scholars Program – Given the need for these initiatives above and the opportunity to grow future leaders in medical education, Dr. Laurence Sands created the Medical Education Scholars Program in which research residents are selected to become more involved with education and teaching. Each year, 1-2 residents during their professional development time join the program and serve as the liaisons between students and faculty. In addition to creating schedules, the Medical Education Scholars run the Bootcamps for the MS2s and MS4s, lead PBLs, and demonstrate hands on surgery skills for students. Leveraging residents for this position enables the MS2s and MS4s to learn from teachers who were more recently in medical school, while also providing students with an approachable liaison that they can voice any issues about their rotation experience with. Moreover, for those interested in surgery, the “Med Ed” scholars are a fantastic resource for research opportunities and advice for how to apply to and become a resident in general surgery. In addition to further supporting medical students, this program affords the research residents a unique experience in guiding students, giving the residents the tools to become surgical educators and clerkship directors in the future.

References:

[1]        Barzansky B, Etzel SI. Medical Schools in the United States, 2015-2016. JAMA 2016;316:2283–90. https://doi.org/10.1001/jama.2016.13620.

[2]        Phase (Academic Level) Length and Distribution. AAMC n.d. https://www.aamc.org/data-reports/curriculum-reports/interactive-data/phase-academic-level-length-and-distribution (accessed January 23, 2023).

[3]        Flexner A. Medical education in the United States and Canada. From the Carnegie Foundation for the Advancement of Teaching, Bulletin Number Four, 1910. Bull World Health Organ 2002;80:594–602.

[4]        Scudder DR, Sherry AD, Jarrett RT, Fernando S, Kuhn AW, Fleming AE. Fundamental Curriculum Change with 1-Year Pre-Clerkship Phase and Effect on Stress Associated with Residency Specialty Selection. Med Sci Educ 2019;29:1033–42. https://doi.org/10.1007/s40670-019-00800-7.

[5]        Kelley JK, Matusko N, Finks J, Robinson K, Reddy RM. Shortened pre-clerkship medical school curriculum associated with reduced student performance on surgery clerkship shelf exam. The American Journal of Surgery 2021;221:351–5. https://doi.org/10.1016/j.amjsurg.2020.11.018.

[6]        Draper AJ, Saberi RA, Huerta CT, Ramos ED, Hui VW, Thorson CM, et al. A prosection-based surgical anatomy training session that improves medical student anatomical knowledge and confidence on the surgery clerkship. Global Surg Educ 2022;1:68. https://doi.org/10.1007/s44186-022-00074-5.

[7]        Ozair A, Bhat V, Detchou DKE. The US Residency Selection Process After the United States Medical Licensing Examination Step 1 Pass/Fail Change: Overview for Applicants and Educators. JMIR Med Educ 2023;9:e37069. https://doi.org/10.2196/37069.

[8]        Huerta CT, Cohen BL, Hernandez AE, Saberi RA, Thorson CM, Hui VW, et al. Examination Scores but not Clinical Performance Correlate With Duration of Preclinical Didactic Time: A Synchronous Comparison of Second- Versus Third-Year Medical Students on the Surgery Clerkship. Journal of Surgical Education 2023. https://doi.org/10.1016/j.jsurg.2023.05.001.