Involvement of medical students in a surgery congress: impact on learning motivation, decision-making for a career in surgery, and educational curriculum

The congress was the 11th symposium of the German Society for Robot-Assisted Urology (Deutsche Gesellschaft für Roboter-assistierte Urologie e. V., DRUS) and simultaneously the first interdisciplinary symposium for robot-assisted and digital surgery in urology, gynecology, and visceral surgery organized by the Kurt Semm Center at the University Hospital of Schleswig-Holstein in Kiel (June 5th–7th, 2019). The congress format was unconventional and innovative. Instead of a single surgical discipline, those anatomical regions (pelvis, retroperitoneum) which are of interest for all disciplines were addressed. The organizers aimed to exchange and discuss current options, developments, and potentials of minimally invasive techniques among the three major fields of surgery. Interactive lectures, video sessions, and live surgeries were presented by urologists, gynecologists, and visceral surgeons. All surgical procedures were performed on a minimally invasive basis either by the laparoscopic or robotic approach, and included the following operations: radical prostatectomy with extended lymphadenectomy, salvage lymphadenectomy after prostatectomy, colorectal resection with total mesorectal excision/complete excision of the mesocolon, total hysterectomy with para-aortal lymphadenectomy, and sacrocolpopexy.

The intention to make the congress accessible to preclinical students was discussed in detail and planned at the Kurt Semm Center, Kiel School of Gynecological Endoscopy, and the Institute of Anatomy. The somewhat different format of the meeting was considered especially appropriate to address the pending issues outlined in the introduction: (1) to bridge the gap between preclinical theoretical knowledge and clinical application, (2) to induce enthusiasm for major surgical disciplines, (3) to establish early contact with minimally invasive and digital surgical techniques. Based on these considerations, the Medical Faculty of Kiel University funded this pilot teaching project to enable medical students to attend the congress free of charge. All chairmen and presenters were informed about the project well in advance, so that they could consider these special circumstances in their lectures, explanatory notes, and comments during live surgeries. The students attended all sessions of a full-day program instead of regular lectures at the university. They were also permitted to visit the industrial exhibition and become familiar with the latest technical innovations and simulator devices in the field of minimally invasive and robotic surgery. They were invited to approach the surgical faculty and other participants for further questions and networking. At the end of the congress the medical students were asked to fill in a questionnaire.

The questionnaire recorded age, gender, and previous vocational training, and consisted of the following questions:

The questions could be answered on a five-point Likert scale consisting of the following items:

Moreover, the following questions could be answered in free text:

Quantitative values were presented as means and standard deviations, minimum, maximum, and quartiles. They were tested for normal distribution using the Shapiro–Wilk test. Since the distribution of age showed significant deviations from the normal distribution, a non-parametric Kruskal–Wallis test was used to analyze questions 1 to 6. Ordinally and nominally scaled values were displayed in absolute and percentage frequencies. Nominally scaled educational background and gender were compared with ordinally scaled answers to the questions in contingency tables, and were tested for association using the exact linear trend chi-square test. Bowker’s symmetry test was used to compare the answers to questions 3 and 4. The tests were two-sided, with a significance level of 5%. Alpha adjustment for multiple testing was not performed, and the results were interpreted accordingly. SPSS Statistics 25 (SPSS Inc. an IBM Company, Armonk, NY, USA) was used for statistical calculations.

One-hundred and forty-three students attended the congress and filled in the questionnaire; 138 questionnaires were answered in full and used for further analysis. Ninety-eight students were female and their mean age was 23 years (range 19–36 years), Thirty-nine students were male and their mean age was 23 years (range 19–29 years). One student did not indicate his/her gender. While 64.1% of students had directly entered medical school, 35.9% had already completed a vocational training. Most of these students had worked as hospital or scrub nurses (16.2%) and emergency medical assistants (11.3%), whereas the others had been involved in medical, laboratory, biological, or pharmaceutical activities (8.4%).

Answers to the six questions (five-point Likert scale) were analyzed separately for male and female students, and are shown in bar charts (Figs. 1, 2, 3, 4, 5 and 6).

45.0% of female students and 43.6% of male students said “yes,” while 34.0% of female students and 41.0% of male students said “rather yes” (Fig. 1).

18.0% of female students and 20.5% of male students said “yes,” while 60.0% of female students and 46.2% of male students said “rather yes.” None of the students said they were unable to follow the surgical interventions (Fig. 2).

14.0% of female students and 25.6% of male students had had “very high” interest, while 19.0% of female students and 20.5% of male students had had “low” interest (Fig. 3).

16.0% of female students and 31.6% of male students had “very high” interest, while 9.0% of female students and 7.9% of male students had “low” interest (Fig. 4).

22.0% of female students and 30.8% of male students said “very high,” while 45.0% of female students and 59.0% of male students said “rather high” (Fig. 5).

38.0% of female students and 41.0% of male students said “yes,” while 34.0% of female students and 43.6% of male students said “rather yes” (Fig. 6).

A summary of the answers to all questions is shown in Fig. 7.

The answers to all questions were analyzed with regard to the influence of gender, age, and previous vocational training. The influence of gender was only statistically significant (p = 0.041) for question 5 (How highly do you rate the educational gains of participating in a clinical congress as a medical student?). 89.8% of male students and 67.0% of female students rated the didactic gain very high and rather high, whereas 28.0% of female students and only 5.1% of male students said it was neither high nor low. No statistically significant difference was registered with regard to age (Kruskal–Wallis, p ≥ 0.05).

The students’ interest in a professional career in surgery was evaluated before and after the congress (questions 3 and 4) and analyzed by a cross table (Fig. 8). While 37.6% of students had greater interest, 60.3% reported no change, and 2.1% reported less interest than before. The change in responses between question 3 and 4 was significant (Bowker symmetry test, p < 0.001).

Finally, the students had the opportunity to evaluate the congress in free-text fields. They could express praise, criticism, and suggestions for improvement. The participants appreciated their active involvement in congress activities and the respect given to them by the surgical community. Their learning motivation and fascination for surgical disciplines were enhanced by the experience. On the other hand, owing to their limited knowledge, some attendees found it difficult to follow all surgical interventions and fully understand the diverse procedures. The students suggested a more detailed introduction to the clinical topics and surgical techniques presented at the congress, and adaptation of their own teaching modules to the contents of the congress. A summary of the most common free-text comments is given in Table 1.

Confronted with a declining number of applicants for general surgery programs, a study group in Texas [4] analyzed the factors that influence the career choice of medical students. One-hundred and eleven medical students in their fourth year of medical school participated in the study and ranked 18 items on a scale from 1 (not important) to 8 (very important). The factors were: career opportunities, academic opportunities, experience in core rotation/sub-internship, role model(s) in that specialty (mentors), length of training required, lifestyle during residency, work hours during residency, ability to obtain a residency position, concern about loans/debts, call schedule, lifestyle after training, work hours after training, financial rewards after training, intellectual challenge, patient relationships/interaction, prestige, future patient demographics, and gender distribution in the specialty. Only 17.1% students were interested in pursuing a surgical career because of career opportunities (p < 0.04) and prestige (p < 0.003). In contrast, lifestyle during residency (p < 0.0007), work hours during residency (p < 0.008), and the quality of the patient/physician relationship (p < 0.05) were all significantly negatively correlated with the choice of a career in surgery [4].

Schmidt et al. [9] analyzed six electronic databases concerning the current published literature about US medical students’ experience in surgery and the factors influencing their intention to pursue surgery as a career. The authors concluded that early introduction to surgery as well as recruitment strategies during the preclinical and clinical years of medical school are liable to substantially enhance the students’ interest in a surgical career [9].

The congress was focused on specific anatomical regions (pelvis, retroperitoneum), which were addressed by visceral surgeons, urologists, and gynecologists via video sessions and live surgeries. This interdisciplinary platform provided optimal first-hand impressions of clinically relevant aspects of anatomy, thus bridging the gap between theoretical knowledge and practical application. Subsequently, the students were more motivated to learn anatomy: 45.0% of female students and 43.6% of male students said “yes” to this question; 34.0% of female students and 41% of male students said “rather yes.”

In addition to live surgeries, medical students were invited to become familiar with virtual training devices and surgical simulators, which were presented during the congress to demonstrate and practice surgical processes and management [10‐12]. The rationale for an early confrontation with these training tools was the observation that students using these devices in their medical curriculum were highly motivated, grasped the procedures rapidly, and became exceptionally skilled in the practical use of minimally invasive techniques [13].

The percentage of female medical students has increased significantly throughout the world over the past decade [14]. This demographic shift is expected to considerably change not only the proportion of male versus female physicians, but also their respective medical careers of choice. A large-scale study from the Royal College of Surgeons in Ireland (RCSI) [15] analyzed the differences between male and female students’ perceptions of a surgical career. The results of the questionnaire (464 students, 40% males vs. 60% females) indicated that male students were significantly more influenced by remuneration than females (p < 0.001). In contrast, female students were significantly more influenced by part-time work (p < 0.001), parental leave (p < 0.001), working hours (p < 0.001), and length of residency (p = 0.003). The authors noted that the preference for a career in surgery declines with advancing academic years in medical school among male as well as female students. Medical students reported intense feelings of intimidation or being ignored during their surgical internships. Consequently, their enthusiasm for surgical disciplines declines consistently during their exposure to surgical practice. These findings, along with the importance of role modeling, underline the urgent need to address those factors that make surgery less appealing, especially to female medical graduates [15].

Chiu et al. [14] analyzed another interesting aspect of gender-specific differences: putative gender differences of medical students related to the acquisition of robotic suturing skills were examined. The students underwent a two-step DaVinci training; their performance was evaluated and compared. Female medical students performed significantly better in the virtual reality task of using a skin suturing pad and were able to complete more sutures with the robotic system than male students. However, no gender difference was noted with regard to the quality of the robotic suture [14].

The steadily declining interest in pursuing a career in surgery appears to be related to the generation shift in favor of the currently dominant generations Y and Z, whose major focus is not surgery. Social sciences have divided the five living generations into the “builders,” “baby boomers,” and the respective generations “X, Y, and Z” [16]. Generation Y consists of persons born between 1980 and 1995 [17]. According to the data of the Federal Statistical Office published in 2015, about 22% of the total population and 20% of the workforce in Germany were born between 1980 and 1999 [18]. Generation Y is believed to be predominantly well educated, and their relatives frequently have a university degree. They prefer to work in teams than in strong hierarchies and consider the joy of work more important than status or prestige. More freedom of choice, the opportunity of self-fulfillment, and more time for family and leisure are the prime demands of generation Y [19]; they do not wish to subordinate everything else in their lives to their professional career, but strive for a work–life balance and a meaningful job [20]. These attitudes are in stark contrast to the circumstances in most surgical disciplines. The workload in surgical disciplines is far in excess of those envisioned by generation Y.

Lafraira et al. [21] performed a study to evaluate current attitudes, experiences, and expectations of residents belonging to the generation Y in surgical fields. One half of the residents were satisfied with the residency program. However, the proportion of dissatisfied reached 40% with regard to the number of surgical interventions, and 80% with regard to professional mentorship. Thus, 62% of the residents were not confident about performing operations after their residency. The authors conclude that current residents are less satisfied with their job and more critical of the quality of training and teaching. These altered attitudes match the profile of generation Y, which is more iconoclastic than previous generations [21].

A study from Germany [3] included 1098 medical students in a survey to gain insights into the mechanisms underlying the decision in favor of or against a career in surgery. The majority of students were of the opinion that surgery is an interesting and meaningful profession. However, the majority of the students (89% females, 81% males) were unwilling to choose a surgical specialty. While the students are certainly willing to spend a large amount of time on their professional lives, they demand the option of being able to plan their lives and achieve a satisfactory work–life balance. Flexible working hours and an existing childcare program were identified as predominant factors for all students, especially females. Prestige and salary were less relevant than “self-fulfillment” in terms of respectful interaction and a well-balanced professional and private life [3].

The present study did not focus in detail on the pros and cons raised by medical students concerning a career in surgery. However, the data retrieved from the questionnaire confirmed that medical students belonging to generation Y are not primarily interested in a time-consuming surgical career. While 37.4% and 39.5% of medical students had low/rather low interest, respectively, 23% were still undecided. However, active involvement in a surgically oriented congress obviously increased the students’ overall interest in opting for a professional career in surgical disciplines, including those belonging to generation Y.