The Surgical Subspecialty Experience Program (SSEP): A Single Institution Prospective Pilot Study

Corresponding author: Mr Jonathan H. Borden jonathan.borden@med.uvm.edu Institution: 1. Larner College of Medicine at the University of Vermont, 2. Vanderbilt Department of Neurosurgery, Vanderbilt University Medical Center, 3. University of Vermont College of Engineering and Mathematical Sciences, 4. Division of Neurosurgery, University of Vermont College of Medicine Categories: Curriculum Planning, Educational Strategies, Students/Trainees, Teaching and Learning, Research in Health Professions Education


Introduction
Despite limited exposure to surgical subspecialties during the preclinical years of medical school, residency positions in these fields remain highly sought after and competitive (Resnick, 2000). Prior reports have shown that two important factors in the decision to pursue a surgical residency are interest in surgery prior to the third year of medical school and student "fit" in the culture of the specialty (Erzurum et al., 2000;Berman et al., 2008;Allen et al., 2009;Goldin et al., 2012;Schmidt, Cooper and Guo, 2016;Zuckerman et al., 2016;George et al., 2017;Peel, Schlachta and Alkhamesi, 2018). Initial exposure to a competitive surgical field in the third year is often too late to impact students' specialty decision, as the push to acquire research and meaningful exposure to become a competitive applicant begins early in medical school.
To date, few medical institutions have described a formal model for a preclinical medical student exposure program to surgical sub-specialties, and most are restricted to a single sub-specialty (Allen et al., 2009;Grover et al., 2009;Lee et al., 2011;Patel et al., 2013;Zuckerman et al., 2016;Dallas et al., 2019;Lazow et al., 2019). At the Larner College of Medicine at the University of Vermont (LCOM-UVM), the current study sought to design, implement and examine the impact of a longitudinal program of increased exposure to multiple surgical subspecialties during the preclinical years of medical school, the Surgical Subspecialty Experience Program (SSEP), in order to provide students with an accurate, direct, firsthand exposure to residency and attending life as a surgeon.

Methods
In the fall semester of 2018, the SSEP was offered to all incoming first-year medical students at the LCOM-UVM. The program was organized by medical students (years 1-3), supported by 18 surgeons from all included subspecialties, and led by the Neurosurgery Department Chief and Faculty. Institutional review board (IRB) approval was obtained from the University of Vermont for this prospective, quality-based research endeavor.

Initiation of Program
Specialties included in the program were selected based on the following criteria: (1) they were not part of the required clerkship curriculum and (2) they have their own surgical residency separate from general surgical residency. The authors determined that the research team had the capacity to manage six surgical subspecialties in this first iteration of the SSEP. Selected specialties included cardiothoracic surgery, neurosurgery, otolaryngology, plastic surgery, urology, and vascular surgery.
Attendings were selected in each subspecialty based upon their willingness to participate and interest in medical student education. Eighteen surgeons, three per specialty (6 women and 12 men) participated in the program by opening their operating rooms (OR) and clinics to students and leading surgical skills sessions.
A one-time Pre-SSEP lunch time orientation was held to recruit medical students by outlining the SSEP program as well as providing an opportunity for them to interact directly with participating Surgical Attendings.

Surgical Subspecialty Experiences
The SSEP provided three opportunities: (1) OR, (2) clinic, and (3) surgical skills sessions. Plastic surgery clinic was not offered as an experience because it was located off site of the main hospital campus.

Online Portal
The SSEP utilized a Microsoft Office SharePoint Server, an online content management portal designed to host documentation of any type and manage user access in a controlled environment. This portal was already integrated with the medical students' user database and was hosted behind a secure, LCOM-UVM firewall. The SharePoint platform allowed the SSEP to share documents, build and maintain a group calendar for posting shadowing opportunities, and manage scheduling (participant sign-ups) in a secure environment while preserving data for future analysis.

Surveys
All surveys were developed and distributed using the open source survey software tool, LimeSurvey 3.21.4 (LimeSurvey, 2020). Survey questions were developed and adopted from existing published sources that explore factors that influence medical student interest in specialties (American College of Surgeons, 2020; Schwartz et al., 1989;Dorsey, Jarjoura and Rutecki, 2003;Newton, Grayson and Thompson, 2005;Clinite et al., 2013Clinite et al., , 2014) and on the personal experiences of the medical student research team and surgeons involved in the SSEP. Surveys were voluntary and consent was implied with completion. Students were asked a series of questions to create a "unique Questions utilized a Likert scale to determine the impact of the experience on student interest (1-decreased, 2-stayed about the same, 3-increased) as well as the quality of the experience.

Statistical Analysis
Comparison of Pre-vs Post-SSEP survey responses were analyzed using paired-sample t-tests. Post-Experience survey responses were analyzed using a one sample test of proportions. Analyses were conducted using SAS 9.4 (Cary, NC: SAS Institute Inc), with significance level (α) set at 0.05 (two tailed). Complete detailed tables of statistical analyses can be found in the e-supplement material, Supplemental File 1 and Supplemental File 2.
A complete step-by-step Handbook to implementing and managing the SSEP is made available publicly at https://github.com/SSEPUVM/SSEP-supplemental-materials.git. The handbook was created as a road map for other institutions to implement their own pre-clinical experience program. Copies of all survey measures are included within the Handbook.

Results
Eighty students (male= 33.75%, female = 65%, no answer =1.25%) with a mean age of 24.2 ± 2.1 years completed the Pre-SSEP survey. Twenty-four students (male = 41.67%, female = 58.33%) subsequently completed the Post-SSEP survey after their first year of medical school, a 30% (24/80) response rate. Of the 24 students that completed both the Pre-and Post-SSEP Surveys, 14 of the students, a 58% (14/24) response rate, completed Post-Experience Surveys which indicates that the average number of experiences participated in per participant was 3.6 ± 2.5.
Pre-SSEP vs Post-SSEP Surveys: Change in Interest No significant changes were observed in the mean change in interest per specialty (  Pre-SSEP vs Post-SSEP: Change in impact of specialty specific characteristics on interest Though overall interest in each sub-specialty did not change, the importance of specific variables on the students' interest within four specialties did change (Table 5). These changes indicated an increasingly negative impact of specialty specific characteristics on student interest in cardiothoracic surgery, neurosurgery, plastic surgery, and vascular surgery. 2.3 ± 0.5 1.7 ± 0.5 -0.7 ± 0.5 0.03

Post-Experience Survey: Effect of Experience Type on Student Interest
The post-experience survey had a completion rate of 70% (109/155). 48 unique students participated in 155 experiences. Across all experiences, interest "increased" for 67% (n=73), "stayed about the same" for 28% (n=31) and "decreased" for 5% (n=5). A one sample test of proportions indicated that significantly more than half of participants' interest increased after OR shadowing (p<0.001) and clinical shadowing (p=0.01) but this was not the case after skills sessions (p=0.56), Table 6.

Discussion
We successfully designed and implemented the Surgical Subspecialty Experience Program (SSEP) for preclinical medical students to supplement the medical school curriculum at the LCOM-UVM. Although participation in the SSEP was not associated with statistically significant changes in the mean interest per specialty (Table 4), we clearly see a trend of decreasing interest (Pre-vs Post-SSEP) occurring when we examine the change in interest at the participant level and the impact of specialty specific characteristics on interest (Table 5). Specifically, we found that our program negatively influenced perceptions of the diversity of procedures, (cardiothoracic surgery and vascular surgery) patient outcomes (neurosurgery and vascular surgery), work hours per week in practice (neurosurgery), and amount of call nights during practice (plastic surgery).
Our goal was to provide opportunities and experiences for students to develop their own interests or disinterests in Borden J, Callahan K, Zuckerman S, Leonard K, Heiser A, Rathmell C, DiBona K, Dunne E, Eubank M, Okamoto L, Callas P, Russell S, Durham S, Jewell R MedEdPublish https://doi.org/10.15694/mep.2020.000205.1 Page | 7 surgical subspecialties. Surgical subspecialties consistently have the highest rates of burnout and attrition (Dimou, Eckelbarger and Riall, 2016). It is important for us to help students discover their passions as well as to identify fields in which they do not see themselves practicing. We consider a decrease in interest after participation a success, as it indicates that we have informed students of the realities of a career in a surgical subspecialty that would not have been a good fit. A young student enamored with the idea of being a surgeon without knowledge of the long hours and endurance required is likely to enter their residency program and become quickly disenfranchised with fields that are unequivocally grueling at times. Rather than holding an idea or ill-defined concept of what the training and career of a surgeon entails, we believe that through the SSEP, students experienced an accurate representation of these careers.
One possible explanation for the low Post-SSEP Survey response rate is student disinterest after participation, such that they were no longer engaged enough to complete the survey. Additionally, as part of our study design, when signing up for an experience, we did not allow students to choose the type (OR vs. clinic) or specialty in order to avoid selection bias. Although our goal in doing this was to ensure that students experienced a diverse array of specialties, we recognize that this lack of control may have contributed to students' disinterest in continued participation. If a lack of interest in surgical subspecialties after participation is indeed the reason for the low response rate, our primary goal was accomplished by helping students discover their own interests and disinterests.
Post-Experience survey responses indicated ( Table 6) that experiences in the OR were more likely to be associated with an increase in interest (85%) as compared to surgical skills sessions (54%). One possible explanation for this is that student interest is influenced by more than just the skills and techniques specific to a field. For most medical students in their pre-clinical years, the OR represents a completely novel environment. Moreover, each surgical subspecialty is distinct, such that the environment within their respective ORs is different. We believe that it is within these real-life settings where medical students can ascertain a truly holistic understanding of these surgical fields. Although medical students may be less engaged in the actual operations, due to the inherent high-risk nature, our results indicate that the act of simply being present within the OR setting may be the most important shadowing experience for pre-clinical medical students.
Of note, although Pre-SSEP interest in surgical subspecialties was low, we were able to engage 40.34% (48/119) of the class of 2022 enough to voluntarily attend at least one SSEP experience. It is likely that our program's one-time Pre-SSEP lunchtime orientation was beneficial to increasing student recruitment and thus is recommended in all future iterations of this program. During the orientation, participating attendings introduced themselves by sharing their own paths to their specialty. We believe that this helped students better relate to them, making the goal of becoming a subspecialized surgeon a more attainable and realistic goal.
In summary, we created and demonstrated a sustainable model for coordinating experiences between medical students and surgical subspecialty attending physicians. We recognize that with the increasing demands of clinical and operative practices, often the barrier to medical student exposure is simply the lack of capacity to organize such experiences. Our model utilizes a team of medical students to lead the management of the day-to-day operations and coordination for the program. In doing so, we create new opportunities for students to engage directly with surgeons as well as becoming involved in the ongoing research and development of the program. Current student team members have participated in IRB processes, survey development, IT web development, team management, grant applications, poster presentations, oral presentations, abstract and manuscript development.

Limitations
There are several limitations of the present study. First, our low Post-SSEP survey response rate, 30%, limits our Borden J, Callahan K, Zuckerman S, Leonard K, Heiser A, Rathmell C, DiBona K, Dunne E, Eubank M, Okamoto L, Callas P, Russell S, Durham S, Jewell R MedEdPublish https://doi.org/10.15694/mep.2020.000205.1 Page | 8 ability to draw conclusions from our results. Moreover, because six specialties were included within the program, the sample size is spread across these subspecialties, resulting in lower statistical power. Future iterations should consider potential ways to increase the Post-SSEP survey response rate. Second, the LCOM-UVM Class of 2022 is composed of 65% women which is not typical of most medical schools. We acknowledge that this may limit the generalizability of the study to a wider medical student population. Third, LCOM-UVM is a program that traditionally attracts students that are interested in primary care. Per the AAMC State Physician Workforce 2019 data report, Vermont ranks second in the nation in primary care physicians per capita and first in active patient care primary care physicians per capita (AAMC, 2019). Fourth, one factor that may have contributed to the nonsignificant changes was that students did not pick their own specialty. It is conceivable that if students were able to select experiences in the areas of surgery that they were most interested in, ratings may be higher. In future iterations, we plan to allow students to choose their specialty and suggest other institutions do the same, as this may also improve student satisfaction.

Conclusion
We believe that it is necessary to provide medical students opportunities for early exposure to a wide array of surgical subspecialties for them to make informed decisions about their interests and future careers. Early exposure, and thus identification of career interests, will allow students the necessary time to pursue extracurricular research projects and mentorship relationships to be competitive in the surgical subspecialty residency match, which is now being described as an "arms race" due to the increasingly robust pre-residency criteria (Wadhwa et al., 2019).
Our goal was to create a formal model for a pre-clinical shadowing program that can be adapted to other medical universities and other specialties, including non-surgical. To aid in this effort, our team has created a Handbook that presents a step by step methodology to establish our program at other institutions: https://github.com/SSEPUVM/SSEP-supplemental-materials.git. As the SSEP continues to develop and mature, our team hopes to work with other institutions to help continually improve our methodology while ensuring students can explore and pursue their interests.

Take Home Messages
The SSEP is a sustainable model for shadowing during the medical school pre-clinical curriculum This shadowing model can be adopted at other institutions for any specialty Pre-clinical exposure to surgical subspecialties may decrease student interest Operating Room shadowing may have the most impact on medical student interest