Predicting which medical students will go into surgery: Do residents matter?

[SLUser11]

I'm attaching an article from last month's JACS that I found interesting. USF conducted a nice survey study assessing student interest in surgery before and after the clerkship, as well as who matches into what specialty.

Have a look at table 3 for the disturbing data. For students who had interest in a non-surgical specialty prior to their 3rd-year clerkship, only 1/148 went into general surgery, and 3/148 went into a surgical subspecialty. That means 97% of these students successfully continue their disinterest in a surgical career.

For those who have general surgery as a "top 3" possible specialty choice, 27% will ultimately go on to become surgical residents, 16% will choose a surgical subspecialty, and 57% will choose a non-surgical specialty.

The paper's conclusion is that pre-existing interest in a surgical career has the largest impact on specialty choice.

There have been previous papers that suggest that a good experience on the clerkship leads to increased interest in a surgical career, but this study implies the choices are made much earlier.

So, this raises some questions:

1. Are we not doing a good enough job on the clerkship of developing and maintaining interest in surgery?

2. Should we be starting much earlier? In order to secure the greatest talent, should we be increasing exposure to MS1s and MS2s?

3. For those with an initial interest in surgery, should we be content with a 27% retention rate?

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[filter07]

There will always be people interested in surgery and there will always be people who want to avoid it at all costs. I'm not sure that we gain much by trying to cater to people earlier. Some people just have surgical personalities and you can see it plainly. Not all of them will go into surgery but many of them do. By trying to cast a wider and earlier net you can mislead people into thinking they are a good fit for this field when they are not. In my humble opinion we should focus on keeping people's interest during the clerkship rather than reaching out to future pediatricians and trying to sell them on surgery. Those with interest will have sought out opportunities and shown some interest by the time of their clerkship, and and those who haven't... Do you really want someone so passive as a surgeon anyway?

Also I would not be quick to generalize on one school's result. I'm not sure what my program's percentages are but I know the net effect is that more are going into general surgery and subspecialties each year for the past 5 or so years.

 

[judasreznor]

There will always be people interested in surgery and there will always be people who want to avoid it at all costs. I'm not sure that we gain much by trying to cater to people earlier. Some people just have surgical personalities and you can see it plainly. Not all of them will go into surgery but many of them do. By trying to cast a wider and earlier net you can mislead people into thinking they are a good fit for this field when they are not. In my humble opinion we should focus on keeping people's interest during the clerkship rather than reaching out to future pediatricians and trying to sell them on surgery. Those with interest will have sought out opportunities and shown some interest by the time of their clerkship, and and those who haven't... Do you really want someone so passive as a surgeon anyway?

Also I would not be quick to generalize on one school's result. I'm not sure what my program's percentages are but I know the net effect is that more are going into general surgery and subspecialties each year for the past 5 or so years.

What is the surgical personality?

 

[blue2000]

I think it's an interesting article, and a complicated issue. I was one of the very few who thought I wouldn't want to be a surgeon had some exposure that led to curiosity, did my MS3 rotation early to "rule it out" and then spent the rest of third year trying to convince myself I didn't want to be a general surgeon. Considering my current job, clearly that didn't work.

So what changed my mind? I think having a surgery chief resident on my third year rotation who took me aside and said "you know, you might not think you have the typical 'surgeon personality,' but you are really good at this and you could be really successful if you like surgery" was HUGE in allowing myself to pursue surgery. I'm not saying that we should try to pretend surgery and surgical training is anything it's not, and paint a picture of unicorns and rainbows and 8AM starts and be unrealistic about what surgery and training is, but on the other hand I think it did me a world of good to be encouraged, and I think encouraging people who are interested but don't fit the most narrow stereotype of surgeon will probably lead to a better yield of medical students. On the other hand, general surgery is continuing to remain a very competitive match, so maybe we're not doing that badly.

 

[filter07]

Exactly... Surgery has no problem filling and neither do the subspecialties. So the whole surgeon shortage mentioned in the article is irrelevant. Want more surgeons, then open more residency spots. Convincing a pediatrician to do surgery won't help get more surgeons in the workforce... And maybe less if considering attrition.

 

[DoctwoB]

So, this raises some questions:

1. Are we not doing a good enough job on the clerkship of developing and maintaining interest in surgery?

2. Should we be starting much earlier? In order to secure the greatest talent, should we be increasing exposure to MS1s and MS2s?

3. For those with an initial interest in surgery, should we be content with a 27% retention rate?

For those who lose their interest in surgery, it would be interesting to see why that was. For some, it was likely a good thing in the long run, as in they learned that they couldn't handle the hours or didn't love the OR like they thought they would. For others, it may be bad experiences and malignant or indifferent residents/attendings that drive someone away. These are the people that efforts at retention should focus on.

For better or worse, the personalities you encounter on your rotation end up playing a big role in specialty selection.

 

[SLUser11]

I think it's an interesting article, and a complicated issue. I was one of the very few who thought I wouldn't want to be a surgeon had some exposure that led to curiosity, did my MS3 rotation early to "rule it out" and then spent the rest of third year trying to convince myself I didn't want to be a general surgeon. Considering my current job, clearly that didn't work.

So what changed my mind? I think having a surgery chief resident on my third year rotation who took me aside and said "you know, you might not think you have the typical 'surgeon personality,' but you are really good at this and you could be really successful if you like surgery" was HUGE in allowing myself to pursue surgery. I'm not saying that we should try to pretend surgery and surgical training is anything it's not, and paint a picture of unicorns and rainbows and 8AM starts and be unrealistic about what surgery and training is, but on the other hand I think it did me a world of good to be encouraged, and I think encouraging people who are interested but don't fit the most narrow stereotype of surgeon will probably lead to a better yield of medical students. On the other hand, general surgery is continuing to remain a very competitive match, so maybe we're not doing that badly.

Just to clarify, I actually do ride a unicorn to work, and I generally travel on a rainbow.

This article is not trying to say that the clerkship experience doesn't matter, but it does say that the experience matters less than we think.

Another example is student shelf scores. I used to think the quality of resident instruction mattered, but the literature doesn't support it. Instead, the step 1 and step 2 scores are the most predictive of student performance on the shelf.

 

[Winged Scapula]

Too lazy too look up but what's the relevant data for other specialties?

We constantly beat the drum here on SDN that, "oh you'll change your mind about your speciality, I did". But is that true? Do the majority of students end up in the same specialty they declared as an MS-1 (I know that data's out there)?

It is interesting to see how little the clerkship seems to matter, especially given all the gnashing of teeth that goes on on SDN about the surgical core. I, like blue2000, had no interest in surgery as an MS-1; I'd never even met a surgeon. Then I found myself in 3rd year with faculty and residents who enjoyed their work and encouraged me to pursue the same. It was definitely the defining experience for me. Had I trained elsewhere (apparently at all the schools SDNers go to), I might not have made the same choice.

 

[powermd]

What is the surgical personality?

Surgeon:

Don't just stand there, DO SOMETHING.

Non-surgeon:

Don't just do something, STAND THERE. Then let's get some coffee in the cafeteria and have bagel rounds.

 

[DoctwoB]

Surgeon:

Don't just stand there, DO SOMETHING.

Non-surgeon:

Don't just do something, STAND THERE. Then let's get some coffee in the cafeteria and have bagel rounds.

Or the unfortunate alternative

Surgeon:
You're doing the thing I told you to do but you've never seen or done before WRONG!

Non-Surgeon:
Let me show you how to do this X # of times, and then you can do it on your own.

*disclaimer: I had an amazing experience on surgery with terrific faculty, but I have classmates that have gotten the above treatment, or worse, gotten completely ignored.

 

[ShyRem]

I had a great surgery rotation. Actually considered going into surgery. Then I did a plastics elective and REALLY considered surgery. In the end, I loved medicine more. And I loved my family more and heard horror stories about the hours of a surgery resident. It was close for a while though.

Now, I say I had a great experience, but many in my class did not. There were still instruments thrown at students, profanity, yelling... All kinds of what I would definitely consider abuse. Needless to say none of those students considered surgery.

 

[Winged Scapula]

I had a great surgery rotation. Actually considered going into surgery. Then I did a plastics elective and REALLY considered surgery. In the end, I loved medicine more. And I loved my family more and heard horror stories about the hours of a surgery resident. It was close for a while though.

Now, I say I had a great experience, but many in my class did not. There were still instruments thrown at students, profanity, yelling... All kinds of what I would definitely consider abuse. Needless to say none of those students considered surgery.

Why was your experience different than those (presuming same ill behaved beasts throwing instruments)?

I found it amusing that SDNers think you're a surgeon anyway.

What is interesting about the article SLUser posted is that choices are made before the rotation and in some cases, reinforced, but in most, students are making choices other than surgery (57% of those declaring surgery chose other fields). For some it may be that surgery isn't the glamorous experience that pre-meds and tv and film writers seem to think it is.

 

[ShyRem]

Different ill behaved beasts.

And different personality on my part. I had an attending yell at me on surgery. Once. He snagged my glove with a needle and I said so before it could rip my glove. He asked if it pierced my skin. I said I didn't know. He yelled. I said would you like me to release these retractors and look? He quieted down, thanked me for not going bat crazy, and held the retractor himself while I looked at the underside of my gloved hand. Afterward he was quite concerned and looked at my hand (which was fine). I also got on the good side of the nurses and scrub techs who fought for me to get into the good surgeries with the good attendings. I'm not sure what I did differently than the other students.... I always tried to be helpful, nothing was too demeaning, was polite, courteous, looked folks in the eye, worked hard, showed interest, looked stuff up, and if I went for coffee offered to bring some back for others.

But I think first and foremost different ill behaved beasts.

 

[Winged Scapula]

I think in some ways it helps to be a bit older (as you and I are); we tend to treat the attendings with less fear and stand up for ourselves if treated inappropriately.

 

[Buzz Me]

I've often said, most med students like surgery - the parts where you get to tie, cut, suture, etc. Most people like getting their gloves dirty in the OR. But those of us that go into surgical fields are the ones who like it so much, we're willing to put up with the malignant attendings, lifestyle, workhours, etc.

And thankfully my skin is quite thick and tough after going through a traditional old-school Gen Surg residency...prepared me for all the beatdowns in fellowship now.

 

[Winged Scapula]

I've often said, most med students like surgery - the parts where you get to tie, cut, suture, etc. Most people like getting their gloves dirty in the OR. But those of us that go into surgical fields are the ones who like it so much, we're willing to put up with the malignant attendings, lifestyle, workhours, etc.

And thankfully my skin is quite thick and tough after going through a traditional old-school Gen Surg residency...prepared me for all the beatdowns in fellowship now.

So how is fellowship going now? I assume it must be busy since we never see you around here anymore.

There is a lot of interest in your field amongst the premed and med students so if you have time to let us know about the training you would have an eager audience.

 

[Black Surgeon]

So how is fellowship going now? I assume it must be busy since we never see you around here anymore.

There is a lot of interest in your field amongst the premed and med students so if you have time to let us know about the training you would have an eager audience.

Im curious, What fellowship is Buzz doing?

 

[Winged Scapula]

im curious, what fellowship is buzz doing?

cts

 

[Black Surgeon]

cts

Thanks WS and Oooooh snap, Buzz is the man we need to somehow also get JAD back on SDN, I'd like to hear about his practice.

 

[Buzz Me]

So how is fellowship going now? I assume it must be busy since we never see you around here anymore.

There is a lot of interest in your field amongst the premed and med students so if you have time to let us know about the training you would have an eager audience.

Ah yes...would love to talk more about my fellowship experience thus far. Just need more time! How I miss the days when I could occasionally only SLIGHTLY break the 80-hour workweek rule...

I will say, though, that it's nice to finally be in my dream field after all these years. Above the diaphragm, I say!

 

[duckie99]

For some it may be that surgery isn't the glamorous experience that pre-meds and tv and film writers seem to think it is.

For me I think choosing IM over surgery was mainly a result of that notion. Starting medical school with no knowledge lots of people, including myself, have misconceptions of what any one field entails. Personally I thought I would definitely be a surgeon of some kind, but most likely a general surgeon, throughout my first 2 years. But on my rotation (before IM) the management style, the cases, and the OR surgeries didn't mesh with who I was or what I was looking for. I didn't have much of a problem on a daily basis with the people I worked with and saw a really good variety of surgeries throughout all my rotations from very long, complex open cases to robotic. It just didn't click with me the way I thought it would.

As other people have pointed out, and from my anecdotal experience, I don't think there is a problem for any surgical field in finding good candidates. Probably half my class of 150+ is going into a surgical field. Also all surgical fields (from gen surg to ophtho, not including obgyn) are very competitive and have people with great scores and determination looking to get a spot. So it may be true that the 3rd year rotation turns students off but this isn't necessarily a bad thing.

 

[45408]

I didn't have much of a problem on a daily basis with the people I worked with and saw a really good variety of surgeries throughout all my rotations from very long, complex open cases to robotic. It just didn't click with me the way I thought it would.

You mean your surgery residents/staff weren't all *&#*#%* who should go #^#*&#)) themselves?

 

[judasreznor]

But on my rotation (before IM) the management style, the cases, and the OR surgeries didn't mesh with who I was or what I was looking for.

Could you elaborate on this a bit?

 

[duckie99]

Could you elaborate on this a bit?

well it's nothing very specific to be honest. The management style mostly has to do with the type of cases I saw surgeons deal with. Some were terrible and there's not much you can really do (trauma, recurrent cancer, etc). Others were basic stuff that mainly dealt with pain management after a case. Others involved doing a surgery on a patient who was already diagnosed with x y or z.

However, the main issue was that I simply wasn't a big fan of the OR. Part of it may have been an inability to understand the thought process going into each situation. Other parts are the lack of control I saw that the surgeon has over his/her daily schedule with having to deal with so many different people (techs, anesthesia, etc). And I would also say likely the biggest reason was that I personally didn't find actually doing surgery to seem all that interesting as it was just too slow paced and repetitive for me (again this is likely a result of me not understanding the thought process in each case). Surgery is very meticulous. I am too inpatient for it. Finally, I didn't find the surgical issues I was exposed to throughout 3rd year to be all that mentally stimulating to me. As I said there was a good variety but it just didn't click with me.

I think it's important to understand each physician's role in the care of a patient. The surgeon's main role was to evaluate for surgery, treat if possible, and manage surgical issues afterwards. That really wasn't what I wanted to do when it came right down to it. I wanted to play a different role in that care (obviously more from the IM side of things). If you like "procedures" there are plenty of nonsurgical fields that have lots of "procedures". But "surgery" is a whole different beast and only surgeons can perform it.

You mean your surgery residents/staff weren't all *&#*#%* who should go #^#*&#)) themselves?

lol I generally liked the attendings and most residents. One pgy3 had sort of a hardass personality but she was pretty nice overall. The pgy5 actually tried to teach me some stuff hands on. The nps were also really friendly. One of my attendings was one of the cooler people I worked with throughout 3rd year.

However, for those students who are wondering, I didn't feel like I fit in overall with them as well as I did with those on IM. There's no hard line reasoning for this. It's just a feeling you get over the weeks as you work with people.

 

[Dr.LeoSpaceman]

Finally, I didn't find the surgical issues I was exposed to throughout 3rd year to be all that mentally stimulating to me.

I think it's important to understand each physician's role in the care of a patient. The surgeon's main role was to evaluate for surgery, treat if possible, and manage surgical issues afterwards.

Relating to the original topic of this post, it would seem like your experience did affect your perception of the field.

Overall, it seems like you made the right choice. If you're impatient and don't like having your schedule held hostage to who's getting another break and how close it is to 3pm, then yes, surgery is probably not the best option.

However, I'd whole-heartedly disagree with your above statement. I think you are pretty self-aware in that you realized that some of the stuff was flying over your head in the OR, which may have been why you didn't find it so stimulating. You really do have to see the same case a number of times to understand the nuances that may exist and can very much change what you're doing.

Also, how much clinic did you do? And what kind of clinics? As much as we all hate it, that's where you really see the medical decision making--and it's much more involved than "evaluate for surgery". To suck up to Winged Scapula, take for instance breast surgery. Breast cancer affords some very interesting questions with regard to clinical decision making. And it's not just, "Oh, you have a tumor. Lets take it out." Same goes for any number of diseases where surgery is only part of the treatment algorithm.

 

[duckie99]

However, I'd whole-heartedly disagree with your above statement. I think you are pretty self-aware in that you realized that some of the stuff was flying over your head in the OR, which may have been why you didn't find it so stimulating. You really do have to see the same case a number of times to understand the nuances that may exist and can very much change what you're doing.

I think it was more that I didn't find the actual act of surgery in the OR from open to laproscopic to robotic to be all that interesting. I like procedures like angios, caths, etc but not surgery. So a bunch of the reason was the day to day work flow and the major differences in what a surgeon vs IM actually does.

Also, how much clinic did you do? And what kind of clinics? As much as we all hate it, that's where you really see the medical decision making--and it's much more involved than "evaluate for surgery". To suck up to Winged Scapula, take for instance breast surgery. Breast cancer affords some very interesting questions with regard to clinical decision making. And it's not just, "Oh, you have a tumor. Lets take it out." Same goes for any number of diseases where surgery is only part of the treatment algorithm.

I did clinic probably 1-2 days/week for 10 weeks. It wasn't a very good experience admittedly (more shadowing than anything). One clinic was a guy who saw end stage cancer cases. Another one was mostly bariatric/general and the third was cardiothoracic. The last one I thought was most interesting.


I think it overall boiled down to that the fact that I found non-surgical disease more interesting to me. But as I said that is likely because 1.) I didn't really like the OR/doing surgery, 2.) I didn't fully understand everything that was going on during an operation and 3.) I felt it was too meticulous for me.

I agree my rotation had a big effect but do feel like I got a variety of exposure (trauma, robotic, lap, open, clinic, etc). It was enough for me to see a good bit of scope anyway. Just didn't click and imo was a result of disproving some preconceived notions I had from popular media.