The Philadelphia surgery conference: a value analysis of a hands-on surgical skill-building event

Design, setting, and participants

The 2019 Philadelphia Surgery Conference was held on January 19, 2019 at the Philadelphia College of Osteopathic Medicine (PCOM) campus by PCOM’s student-run surgery interest group, Wisely Surgical Association. Students were recruited from the following medical schools to participate: PCOM, PCOM-Georgia, Perelman School of Medicine at the University of Pennsylvania, Drexel University College of Medicine, Lewis Katz School of Medicine, Rowan University School of Osteopathic Medicine, Cooper Medical School of Rowan University, Geisinger Commonwealth School of Medicine, Lake Erie College of Osteopathic Medicine, and Touro College of Osteopathic Medicine. Recruitment was accomplished electronically via email correspondence. The President of each school’s surgery interest group was emailed with a link to the conference website, which provided registration, advertisement, and information about the conference. Attendance in each workshop was limited during the registration period to ensure that the students participating in a cadaver-based procedure, electronic/robotic simulation, or technical skill-building clinic could be as hands-on as possible.

Introductions began with a keynote address on the topic of leadership given by a DO attending physician and medical director of trauma and critical care. The keynote address at the conference was given by a physician who was not involved in the study or authorship of this manuscript. The day’s events commenced with an STOP THE BLEED^® certification workshop, a national bleeding control initiative [5]. Students were asked to choose four, 1-h workshops from a list of 23 that explored a variety of surgical procedures (Table 1): two workshops following the STOP THE BLEED^® certification workshop and two workshops after lunch. Attending and resident physicians (both osteopathic and allopathic) were recruited to lead these workshops and demonstrate the procedures while enlisting the help of the students. During the lunch hour, attending and resident physicians were invited as guest speakers to present on their surgical subspecialty to preregistered subgroups of students (Table 1). The conference day concluded with a personal perspective that highlighted initiative and selfless service practiced in international communities by an MD pediatric orthopedic surgeon and global surgery specialist.

Data collection and definitions

Institutional Review Board approval was given by the Philadelphia College of Osteopathic Medicine (Protocol #H19-046X). Informed consent was obtained during the opening and closing remarks of the conference, addressing all participants in attendance. A pre- and postconference survey were distributed to each participant in paper format at the beginning and end of the conference, respectively. The preconference survey was completed before the start of events on the day of the conference, and the postconference survey was completed at the conclusion of the conference. Each preconference survey was given an identification number matching that of a postconference survey to maintain confidentiality and allow for data analysis comparing pre- and postevent responses. Some students did not complete the surveys at the beginning or end of the conference.

The preconference questionnaire gathered demographic data, including sex, age, school, program, and year in program. Further questions were included to assess prior general clinical exposure to surgery both before and during medical school, prior clinical exposure to the specific desired surgical specialty of interest, activity in the surgery interest group at the respondent’s school, exposure to surgical training/events at the respondent’s school, exposure to surgical simulation opportunities, whether the respondent had a mentor in their desired surgical field of interest, whether the respondent had performed research in a surgical field, and whether the respondent had attended a prior surgical conference. Answers to these questions were completed using a Likert scale from 1 to 5, with 1 being “completely disagree,” 2 being “somewhat disagree,” 3 being “neutral,” 4 being “somewhat agree,” and 5 being “completely agree.” A variety of scales to subjectively assess participants’ confidence in their surgical knowledge and skills, and opinions regarding the importance of hands-on experiences and interactions with attending/resident physicians, were included. Answers to these questions were also completed using a Likert-type scale from 1 to 5, with 1 being “none/not at all,” 2 being “minimally,” 3 being “neutral,” 4 being “moderately,” and 5 being “highly.”

The postconference questionnaire included the same confidence and value scales as the preconference survey to assess changes in subjective scores following the event. Further, the postconference survey assessed participants’ likelihood of attending future surgery conferences in medical school or volunteering to run events for other medical students during/after resident training, whether the conference changed the respondent’s perception of osteopathic surgeons, whether the respondent would attend the following year’s conference, and how valuable the respondent considered collaboration with students from other medical schools. Answers to these questions were completed using a Likert-type scale from 1 to 5, with 1 being “none/not at all,” 2 being “minimally,” 3 being “neutral,” 4 being “moderately,” and 5 being “highly.”

Statistical analysis

Participant demographics and survey answers were summarized using count (%) for categorical variables and by mean (standard deviation, SD) for continuous variables. Changes in measures were assessed using paired samples t tests. Significance was set at p<0.05, and all tests were two-sided.

Participant demographics

Two hundred and 17 students registered for the 2019 Philadelphia Surgery Conference, and 175 students were in attendance. Of those in attendance, 141 participants (80.6%) were osteopathic medical students, 29 (16.6%) were allopathic medical students, and 5 (2.9%) were physician assistant (PA) students. Most students (128; 73.1%) were from the Philadelphia College of Osteopathic Medicine (PCOM) Philadelphia campus; 13 students (7.4%) were from Rowan University School of Osteopathic Medicine, 12 students (6.9%) were from Geisinger Commonwealth School of Medicine, seven students (4%) were from Drexel University College of Medicine, seven students (4%) were from Cooper Medical School of Rowan University, two students (1.1%) were from Lake Erie College of Osteopathic Medicine, two students (1.1%) were from Lewis Katz School of Medicine at Temple University, two students (1.1%) were from Touro College of Osteopathic Medicine, one student (0.6%) was from the Perelman School of Medicine at the University of Pennsylvania, and one student (0.6%) was from PCOM Georgia campus. Most students (94.3%) were either in their first or second year of medical/PA school (58.3% first year; 36.0% second year; 5.7% third year; 0.0% fourth year).

Preconference survey data

Of the 175 participants, 168 (96.0%) completed the preconference survey (Table 2). Most students (47; 28.0%) expressed a “neutral” response when asked if they had received adequate exposure to surgery from their respective medical school curriculum. More students “somewhat agree[d]” that they were active in their school’s surgery club (52; 31.0%) and had received adequate exposure to surgery with extracurricular clubs (57; 33.9%).

In assessing participants’ prior clinical exposure to surgery, 85 students (50.6%) had observed surgical cases, 55 (32.7%) had scrubbed into surgical cases, and 27 (16.1%) had no previous exposure to surgery. In assessing participants’ prior exposure to their surgical specialty of interest, 77 students (45.8%) had observed surgical cases, 39 (23.2%) had scrubbed into surgical cases, and 51 (30.4%) had no previous exposure. Most students had never been exposed to surgical simulators (91; 54.2%), did not have a current mentor in the surgical field (111; 66.1%), had never performed research in a surgical field (124; 73.8%), and had never attended a surgery conference (133; 79.2%).

When asked to rate their confidence in their own personal surgical skills, 70 students (41.7%) reported “none/not at all.” Many students (55; 32.7%) reported “neutral” confidence in their understanding of the various surgical specialties. However, students “highly” valued hands-on clinical practice (86; 51.2%), face-to-face interactions with resident and attending physicians (102; 60.7%), and the experiences in medical school (120; 71.4%) when considering a potential future career in surgery at this stage in their medical training. Responses are further detailed in Table 3.

Postconference survey data

Of the 175 students who attended the conference, 89 (50.9%) completed the postconference survey after the event. When asked to rate their confidence in their own personal surgical skills after the conference, 60 students (67.4%) reported an increase, 25 (28.1%) reported no change, and two (2.2%) reported a decrease in confidence level compared to before the conference (p<0.001). Fifty students (56.2%) reported an increase, 29 (32.6%) reported no change, and eight (9.0%) reported a decrease in their confidence level of their understanding of the various surgical specialties (p<0.001). Hands-on clinical practice became more valued for 28 students (31.5%), whereas the value stayed the same for 45 students (50.6%; p=0.014). Face-to-face interactions with resident and attending physicians became more valued for 21 students (23.6%), whereas the value stayed the same for 59 students (66.3%; p=0.002). The experiences in medical school became more valued for 15 students (16.9%), whereas the value stayed the same for 61 students (68.5%) when considering a potential future career in surgery at this stage in their medical training (p=0.470).

Of the 18 students who initially reported no interest in pursuing a career in surgery before the conference, six (33.3%) reported an interest after the conference. Overall, 38 students (42.7%) added or removed at least one surgical specialty of interest from their initial list. Thirty-eight students (42.7%) reported a change in their perception of osteopathic surgeons after the conference. An overwhelming majority of students (84; 94.4%) confirmed an interest in attending the following year’s conference.

After the conference, most students were “highly” likely to attend future surgical conferences in medical school (73; 82.0%) and volunteer to run events for medical students as residents (67; 75.3%). A majority (55; 61.8%) considered collaboration with students from other medical schools “highly” valuable. Responses are further specified in Table 4.

Broadening interest in surgical career opportunities

For first- and second- year medical students, there are limited chances to explore the vast majority of surgical disciplines. Apart from the occasional lectures dispersed throughout the didactic portion of the medical school curriculum and infrequent opportunities to shadow, exposure to surgery is not as readily available until the clinical years. Surgical interest clubs provide one of the most proactive and successful forums for recruitment of preclinical medical students [3]. A significant portion of students either completely or somewhat disagreed (19.6% “completely disagree”; 23.8% “somewhat disagree”) that they received adequate exposure to surgery from their respective medical school curriculum; a large percentage of students reported receiving exposure instead from extracurricular clubs (33.9% “somewhat agree”; 12.5% “completely agree”) (Table 3). In the current study, many students (16.1%) did not have any clinical exposure to surgical cases and 30.4% not have any clinical exposure to their specialty of interest. This lack of experience is accentuated with the concomitant lack of exposure to surgical simulators (54.2%), mentors (66.1%), research (73.8%), and conferences (79.2%).

Past literature [6], [7], [8] has reported a decline in interest in a surgical career at a rate of 5% per year throughout medical school. Students are often deterred from choosing a surgical specialty as a career choice due to perceptions of inadequate leisure and personal time, inadequate income for level of commitment, irregularity of schedule, quantity and intensity of work, high stress level, and lack of accommodations for women [7], [8]. Early exposure to positive role models is critical for attracting and maintaining students’ interest in surgery through exposure of the humanistic values of surgery, encouragement, and the opportunities for shadowing and research [3], [7], [8]. Following the conference, six of the 18 students (33.3%) in the current study who were not previously interested in surgery gained interest in pursuing a career in surgery after attending the conference. No students in this study reported losing interest in pursuing surgery following the event. Further, more than a third of students (37.1%) changed their surgical specialty of interest after exposure to the various surgical subspecialties.

Kassam et al. [6] found that students who were interested in surgery reported lower emotional exhaustion and higher personal achievement scores at the completion of their surgery clerkship rotation, compared with students who were not interested in surgery. Further, students were more likely to identify a mentor if they were interested in surgery, and if they applied for a residency, had lower levels of burnout. The results of the Kassam et al. study [6] illustrate the effects of exposure through skills workshops and the importance of establishing an interest in surgery prior to a clinical rotation, especially in the context of studies like the one from Brundage et al. [2], who reported that 59% of students made their career decision before the clinical year [2], [6]. The majority of participants at the Philadelphia Surgery Conference were first- or second year students who gained important preclinical exposure to the surgical fields.

Cultivating clinical surgical skills

The intention of the Philadelphia Surgery Conference was not only to broaden participants’ interest in surgery, but also to increase their sense of confidence in technical skills. One major focus of the event was to actively engage each attendee, with careful consideration of preparation for surgical rotations and comfort level in a surgical setting. Surgical skills workshops, whether led by student-run surgical interest groups [1], residents [9], or faculty [10], increase students’ confidence and perceived competence in suturing and interest in surgery. These results are also generalizable to many surgical subspecialties. Nitschmann et al. [11] implemented a gynecologic simulation training for medical students during their third-year core clerkship in obstetrics and gynecology and found that students reported improved confidence in performing the procedures and increased interest in pursuing a surgical field posttraining [11]. Encouraging data have also been revealed in previous studies in vascular [12] and cardiothoracic surgery [13]. Our results reiterate the value of surgical skills workshops, as our data showed a 52.6% increase from baseline in confidence in personal surgical skills (p<0.001) and a 34.6% increase in understanding of the various surgical subspecialties after the conference (p<0.001).

Facilitating interactions with resident and attending physicians

The event allowed students the unique opportunity to interact with resident and attending physicians from many surgical subspecialties. Size restrictions in each workshop served to establish a more personal, low-stress, academic setting for interaction between students and surgeon facilitators, encouraging students to ask questions and receive feedback. In a study done by Meyer and Weiner [14], subsequently described by Bland [3], lack of interest in surgery in second year medical students stemmed from a lack of contact with surgical faculty. Further studies have demonstrated that exposure to role models in specific fields of medicine strongly correlate with the student’s choice of specialty later in their career [15], with two-thirds of students in one study (n=56; 66%) choosing the same specialty as their mentor [16].

In addition to surgeons, surgical residents can play an important role as mentors and role models, as they usually have more interactions with medical students. Schmidt [17] summarized previous work by Musunuru et al. [18], who found that students exposed to surgical residents who are effective educators and mentors were more likely to pursue surgery than those who were not. Students value mentors with clinical skills, personality, and teaching ability [15]. Mentors set examples for their mentees; mentor-mentee interactions are the second most important factor in predicting excellence in the field [16]. Prior to the conference, more than half of students (168; 51.2%) “highly” valued hands-on clinical practice and face-to-face interactions with resident and attending physicians (168; 60.7%), and nearly three-quarters of students (168; 71.4%) “highly” valued the experiences in medical school when considering a potential future career in surgery. Our results further demonstrate the importance of interactions with resident and attending physicians, as there was a 7.3% increase from baseline in the value of hands-on clinical practice (p=0.014), a 9.3% increase in the value of face-to-face interactions (p=0.002), and a 4.4% increase in the value of experiences in medical school (p=0.470).

Assistance in establishing mentor relationships is crucial for medical students. From the relationships formed throughout the conference, students may have a more established outlet to seek out research opportunities, as performing research before or during medical school was strongly correlated with having a mentor [19], as well as an increased likelihood of matching into a surgical specialty and completing a surgical residency [20], [21].

Collaborating with medical counterparts

The conference intentionally invited osteopathic and allopathic medical students as well as physician assistant students from a wide range of institutions to put into early practice a collaborative effort in building competent, well-rounded surgical “team players.” With the evolution of medical care delivery, there has been increasing emphasis on the importance of interprofessional education (IPE), communication, and cooperation between healthcare providers to ensure patient safety [22]. Baker [22] summarized previous work by Alonso et al. [23], who found that the TeamSTEPPS curriculum released as the national standard in health care team training in 2006 has resulted in a reduction of retained foreign objects, reduction in errors, and improvement in properly timed administration of prophylactic measures in the operating room. Exposure and practice of effective communication skills and teamwork strategies during medical education can help develop knowledge, skills, and attitudes that facilitate effective interprofessional team behaviors and competence early on in students’ careers. Our results echo past literature, as 75.3% of our respondents “highly” valued collaboration with students from other schools and programs. In a study done by Reeves et al. [24], subsequently described by Baker [22], IPE positively changed learners’ attitudes towards one another’s professions. After the conference, nearly half of participants (89; 42.7%) reported a change in their perception of osteopathic surgeons.

Limitations

Although our data showed promising results, there were some limitations to the study. First, the students in attendance likely had an initial interest in surgery prior to the event, as registration was voluntary, which may have introduced bias and may not accurately represent all students in all clinical training programs. There also may have been attrition bias, as 96.0% of participants completed the preconference survey, but only 50.9% completed the postconference survey. Those who stayed to complete the postconference survey may have had a more positive attitude toward the conference, positively skewing the results. Additionally, self-reported data contain potential sources of bias, such as selective memory and exaggeration. Last, most participants were first- or second-year medical students, with a large majority (73.1% of attendants) being students from PCOM Philadelphia campus, which may affect external generalization.