Who's next?

Surgical Rounds®, August 2007, Volume 0, Issue 0

Bernard M. Jaffe, Professor of Surgery, Department of Surgery, Tulane University School of Medicine, New Orleans, LA

Bernard M. Jaffe, MD

Professor of Surgery

Department of Surgery

Tulane University

School of Medicine

New Orleans, LA

Since my retirement from clinical practice, in addition to teaching, I have spent a great deal of time interviewing applicants to Tulane University School of Medicine as a member of the Admissions Committee. I am incredibly impressed with many of the students' credentials, so much so that I am not certain I would be admitted to medical school today. In addition to the applicants' grades, extracurricular interests, and public service, I have been delighted with their commitment to exploring all aspects of medicine. So far, no one I have interviewed has expressed a dominant career goal. As I converse with these particularly good candidates, I cannot help but think how great it would be if we were able to recruit them into general surgery (there, my bias is showing).

Based on answers to a questionnaire filled out by virtually all medical students graduating between 1997 and 2004, a group from Washington University has characterized the factors that direct medical students into general surgery.* There were no surprises. Being female and graduating with an MD/PhD weighed against choosing surgery, whereas having an ethnicity other than white and completing a combined MD/other degree program favored a general surgical career. These variables, however, were preordained and established before students had any interaction with surgical faculty. The single most important and pliable factor was the perceived quality of the students' clerkship experience. This is an obvious no-brainer, but if used to appropriate advantage, it points the way to recruiting the best and brightest.

During my student years at NYU School of Medicine, I liked my medicine rotation but could never see myself spending 4 hours per day on rounds. I found OB/GYN too limited in scope for my taste. I loved caring for children but ruled out pediatrics, because I disliked dealing with mothers. That pretty much left surgery, and I loved my surgical clerkship. It was this 3-month experience that guided my life's choice, and I would be surprised if it wasn't the same for many of you, as well.

Over the more than 40 years that I have been involved in medical education, I have evaluated what qualities constitute a good surgical clerkship. As I see it, there are four factors: broad exposure to surgical diseases, direct involvement in provision of care, positive role models, and high-quality teaching. Allow me to illustrate these characteristics from my rotation experience.

Broad exposure to surgical diseases—My exposure to surgery began explosively. On the first day of my clerkship at the old Bellevue Hospital, I was riding up the elevator, along with a patient in a wheelchair. His shirt was pulsating in the middle of his chest for reasons I did not understand. As the elevator arrived on the eighth floor, the man experienced three massive bouts of pulsatile hematemesis and died instantly. After a little reading, I learned that my first clinical, although incidental, patient contact involved a syphilitic thoracic aortic aneurysm that had already eroded through the sternum; when it fistulized with the esophagus, the patient simply exsanguinated in front of my eyes. Talk about exposure! Even though there was nothing we could do for the patient at that time, I was hooked.

Direct involvement in provision of care—At Bellevue and all municipal hospitals in the 1960s, medical students were given rather free (in retrospect, far too free) rein to provide care. As a clerk, I spent one whole night sewing the myriad facial lacerations of a derelict who had bulls-eyed the windshield in an automobile accident. Nowadays he would be sutured by a plastic surgeon, but at that time, I was expected to provide fine-tissue approximation. I was very proud of my finished work and looked forward to seeing the patient in clinic to see the results of my handiwork. I was devastated when he failed to show up at the scheduled time. Months later, the same man was trying to earn money to buy alcohol and washed my car windshield on the Bowery (skid row at that time). He looked so good I did not recognize him, but since he had stared up at me all night while I was sewing him together, he spotted me immediately. I got a warm welcome, perhaps because he thought our familiarity would make me more likely to abet his habit. He excitedly pointed out how pleased he was with the cosmetic result of my endeavors. I asked why he had not come back to the clinic, and I will never forget his answer. He informed me that there were two ways to remove sutures: painstakingly with a fine pair of scissors as I had planned or with an electric razor. He had elected the second approach. While that kind of direct patient care by medical students is no longer possible (correctly), there are less dramatic but equally effective alternatives to provide inspiration.

Positive role models—I was not particularly enthusiastic about the surgical skills of some of my attendings, but I worked with one resident who impressed me enormously. I wanted to be just like him. Even then, Jay Grosfeld, recently retired chair of surgery at the University of Indiana and immediate past-president of the American Surgical Association, had white hair and a sure step. He exuded confidence, knew the literature, and could cut. He was a terrific role model at that time and has remained so for many others throughout his distinguished career.

High-quality teaching—I remember the teaching I received. Rounds were incredibly instructional, even at 5 AM, and I relished the information that was disbursed. Medical students were taught but not spoon-fed. We were expected to fill in the gaps and learn independently, as well. There were three excellent conferences per week directed at students, and we were also expected to participate in a morbidity and mortality conference. Being a medical student offered no protection from a piercing question by one of the attendings. While I thought the quality of the teaching was first-rate, current educational paradigms should be even better. They now generally involve guidance by a professional educator and the use of computers and simulators.

who's next

Applying these four elements—offering broad exposure to surgical diseases, allowing direct involvement in provision of care, serving as a positive role model, and providing high-quality teaching—should constitute a terrific clerkship and help recruit the next generations of surgeons. By taking pride in our process, we will be able to influence .

Reference

J Am Col Surg.

*Andriole DA, Klingensmith ME, Jeffe DB. Who are our future surgeons? Characteristics of medical school graduates planning surgical careers: analysis of the 1997 to 2004 Association of American Medical Colleges? Graduation Questionnaire National Database. 2006;203(2):177-185.