DOCUMENT RESUME

ED 124 086 HE 007,950

AUTHOR Kennedy, W. Robert; Wile,.MarciaTITLE. Studies of Medical Students' Activities on Core

Surgical Clerkships:A Preliminary Report.',PUB DATE Apr 76NOTE 35p.; Presented at the American Educational Research

Association Annual Meeting (San Francisco,ft,California, April 1976)

EDRS PRICE .MF-$0.83 HC-$2.06 Plus Postage.DESCRIPTORS *Clinical Experience; Conference Reports; Field

Experience Programs; Health Occupations Education;*Higher EducatioA Internship Programs'; *MedicalEducation; Medical Students;Thys.icians; PracticumSupervision; *Student Experience; *Surgical

,TechniciansIDENTIFIERS *Case Western Reserve University

'ABSTRACTThe core surgical clerkship is described as the most

intensive clinical experience during the student's first three years,and one which is extremely difficult to examine systematically. Theresearch strategy, methodologies, data collected, and major findingsof a study of such clerkships are 'deported. The data from more than1600 hours of observation and self-reports of 77 miedical studentsprovided a substantial base of descriptive information aboult thecommonality and diversity of experiences. No judgment as to thequality of the experiences has been undertaken; rather, questionsabout students' activities have developed that have begun a processof examination to determine if such experiences are consistent orirnconsistent pith good educational planning. Major concerns areoutlined regarding equitable distribution of time, student-patientcontact without direct supervision, purposes of conferences, rolesand responsibilities of faculty towardthe medical clerk, proceduresthat all students Should learn, and instructional possibilities inthe operating room- it is concluded that the-se studies are abeginning of a systematic examination to determine whether learningunder the circumstances of he core clerkship can be optimized.(LBH)

i

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1

X

Studies of Medical Students' Activities

on Core Surgical' Crkships:

A Preliminary Repoist e-

W. Robert Kennedy, ';Th.D.; Marcia.Z.,Wile, Ph.D.

Case Western Reserve University

School of Medicine

U S DEPARTMENTOF HEALTH,

EDUCATION &WELFARENATIONAL INSTITUTE OP

EDUCATION

THIS DOCUMENT HAS BEEN REPRO.DUCE 0 EXACTLY AS RECEIVED FROMTHE PERSON ORORGANIZATION ORIGIN.AT tpC. IT POINTS

OF VIEW OR OPINIONSSTATED DO NOTNECESSARILY REPRE-SENT OFFICIAL

NATIONAL INSTITUTE OFEOUf.AT ION POSITION OR POLICY

Presented at the American Educ ational Research

Asociation Annual ceting, April 1976, San

Francisco, Californi4. 54E6;5) 0

2

A

ti

. I

Studies of Medical Students' ActAlti on Core Surgical Clerkship

A Prellminary Report

W. Robert kennedy,, Ph.D., Marcia Z. Wile, Ph,D.

Case Western Reserve Onivers4ty Sch000l Of Medicine

.11

The c1ertship as an:educational...expert ce has Acome an est blished

paft of the medical school curriculum. It is gene ally the 11 tinten&ive

clinical experience during the students`ftrst three and directly

follows the basic science core. Although it has critical importance ty,the

development of the student as a physician, it is one of the most difficult

segments of the curriculum to examine systematically. A number of significant

reasons extst for this situayon including theoriability of hospital

services; diversity of attending faculty and house staff as to-their roles,

activities and interest; the patient census; ,the lack,of a fund of informa-

tion,common to the firstjao-years of medical education; and the problems

of clinical evaluation of students. These factors are 'compounded by, in

many instances,' the 'institutionalization" of'-the,clerkship experience.

That is, many departments have become so accustomed to having the program that

faculty often have great'difficultksteppt4ba&-to determine Whetheieduca-,

tional goals are clear and logical, if activities are.indeed meaningful

experien or students, and what, if any, changes pre necessary. Many

times specific goals and objectives are not described or even available,

making student and faculty expectations, roles, and activities even more

va'iable and-learning, potentially,,mpre episodic.

For these reasons, the Core Clerkship Coordinator, Dean for Medical /Education, and the Division of Research in Medical Education'undertook

a series of three studies to simply define "what the students were doing on

the clerkships." This paper describes the research strategy, the Methodologies

developed and used, the data collected, and major finding& of the study.

STRATEGY

The clerkship experience at Case Western Reserve University School of

Medicine has-been in a process of evolution for.over twenty years. The

development of'the formal Inodel!_for. the cur-riulum in the-early 1950's.1

included the teaching by subject committee and introduction of three,

phase,t,,(Ham, 1962) Phase 1 -- Normal Biology of Man. -

Phase 2 -- Pathologic W13,siologY and Principles,\' of Medicine -7

Phase 3 -- Clinical Medicine. and Patient Care

In 1964, the Comdttge on Clinical Teaching reported; on the status of under-,

graduate education to the CoTmittee on Medical Educition (CME). The 'eME.,

then-made recommended changes in the third and fourth years which included-

completion of the basic clinical experience by the end orthe third year, and,,

the fourth,year as an elective program in advahOed'clinical science with

increased patient resRonsibility. I.n 1967, efforts were undertaken to

describe specific educational goals and objectives for the introductory and4 '

core clerkship using the.cognitive, affective, anti psychoMotor,domains.

Although significant efforts were 'made in these directions, riot all clerkships,

.'weft "so described and p a tices-continued as previously.

4- Beginning in the lat sixties, serious efforts to increase enrollment i

_ were undertakers _and clas4sim'increased-neatly sixty percent-over three years.. .

1 .

Of necessity, ditionallhospitaTs and services were added for clerkships with, I

. Most beirig unfamiliar with such eduCational-missions and responsibilities.i

,. .This 'created other 0oblIems ih addition to tkose previously listed. StudentI-

4., grievances included pooff definition-Of the clerkship experience, lack ofi

-appropriate supervision too much scut-work,'and a general lack of confidence

-in evaluatibn approache

3

)During 1973, a strategy began tg evolve- concerning the examination of

the clerkships. Built` from the "discrepancy model," quesOgns concerning the

#*sible lack ofcongrbence between intended and actual periences began td

emerge. Such questiops as "what are the students-doing?" muchtime do4

they read?" how mulch patient contact are they having?" evolved. fjUantifcatiOn,k'

and pbt the making of value judgements about the quality Of the egkeriences

(

was the researoh thrust.- 1

In January 1974, a pilot study of approximately 400 hours of observation'

of students' activities on the pediatric, medicfne, surgery, obstetriCs/gyne-

f

coloby, and psychiatry clerkshipEdwas completed (Figure 1). The purposes were

pre-testing and refinement of forms, data collection.procedures, and the4

development of the necessary logistic1 support . Thd form used (Figure 2)

had been carefull.rdvolved`with the assistan p of several fourth-year students

and approved by the clinical faculty. F owing the study,,the instrument ,

was,revi5ed to include students' level of particiOation in the activity_ .

.

(performing, assisting, observing, and/or discussing) and those persons Slith,

whom they wereworking (Figure 3). These changes were the product of both

Alb

ti

research interests and the demonstrated capabilities of the observers to

validly collect such information. 1

Study 1: Structured Observations of Medical Students' Activities on.the

( Core' Surgical Clerkship

Based upon the results of the,pilot study, clerkship director the

Department of Surgery were appr9ached about pursuing an intensive de criptive

study of their services. Since this Department had developed an ex ensive

'definition of goals and objectives (DePalma 1974) which were being ollowed /

at two of the four hospitals, it was felt an anal)Itis of students' activities

might be useful,to faculty: The intent was not Oatd collection f r change

applications; but rather description'of current experiences.

5

_

r

VIThe *poses of the planned study were to:

f

(A) observe and'rec6rd studgnts' activities on the ward,and in the

operating.room;1

(B) define the, levels of responsibility they exercised in patient contact

and with ,whom (faculty, house staff, nurses, oth0s);

*

(C) the quantity'and varieties of verbal interactions they had in the4

operating room.

Data Collection Procedures

Observers:. Thirteen undergraduate pre-medic,al,studenWaere employed,

as observers and given an eight -hour training session which incliided four

hou'm of actual observation df medical students, reCording of information,----e

and familiarization with all 'sites, faculty,,andprocedures. The,study was

conducted duringt.ptersessignp January 1975, when the obser;/ers were free from

academic responsibilities and could follow their assigned surgery schedules.

Sites: 'The four affilidted training sites participating in this

study were a large metropolitan qosOi.tal--Sife 1, a university ho4ital--Site 2,

a veteransAhOspital--Site 3, and a commun.! hospital--1 Site 4..

.

Instrumentation tI

s

The forms previously described (Figure 3) were usled in-this study and a 4

,...-

...h,

second sectioa was added to' include operating room verbal. interact' (Ffgure 4interactionThecobservers were regutred to indicate in fifteen minute units thcmprima

. .(

'activity which had occurred for the entire period\ q observation (generally11

eight hOurs). In the event they could not make such a d etermination, they

6

were encouraged to. ask -their medical student for assistance.

cheduling-the observations

The 4pedule for data collIction was developed with the following

parameters:

(a) o bservations would b e'don.e during the working day (I = 7 a.m..to 3 p.m.)

and evening (II = 3, p.m. toll p.m.), foe the period January 6 -01.:Ough 31, inclusive.4:161,

AP

6

(b) a 20 percent 11\inimumof the possible. student work gays would be

observed . For exampld,%a site with 4 stUdents would have 80 possible obser-

vation periods (4 x 20 days withOut weekends). Twenty perceht of this.would

4

be 16 possible observations. As such, the schedule-for the four sites was: ,

Site Planned` Observations Saturday/Sunday

1 50 Yes

2 53

\25Yes

3

4 ,t7 **.No

The 20 percent minimummas used as a guideline with deviations being made to

,sample subrotationsat different sites a specific nutber of times;' For

example, the director wantedonesithrotation seen three times at night. TKis:

was donebut:resulted in additional- observations to the pre-determined'

number. II. . /-. '.

t

(c clerkship directors would determine those subiotatidns td.be sampled

,. .

and theolumber of desired observations for each (i.e., neurosurgery, ENT,

._

general, surgery)..

(di) assignAents for observers at each site would be rahAom by subrotation

I.

. . -

anderhourunitst ..throughout students on

the rot4tion,at the assigned tithe'were also randothly selected from available

.E.

'Schedifes and.i.f., for any reason, they were unavailable, the observer was/ .

Oven lternate 'names.

7 A

Final Scheduled-

The fpllowing table compares the planned and actual obser-vations.by

subrotation and time (I or II), at each 13f the 'four sites.

Gen. Surg.I II

, SITE 1

teuro ERI a I Ii

OrthoI II

Ped Burns Clinic. TotalI II I II

PLANNED ' 8 3 5.

5

7

8

2r-411,

1

3

1

1

1

0 ,

1

0

1

0

o

50

44ACTUAL

10 2 5 2

SITE

Neur6 Anesth. Plastic Ortho ER

I II II I. II I II II

Ped Burns i! Total

I II., I II,- ,

PLANNED 2- 3 6 0 0 0 0 0 1 , 4 4 1 15s 17 53

ACTUAL 6 1, 3 0 1 0 1 0 2 3 2 Q 22 5 46

.1

SITE 3

tiaj .Surg.

I II

-Mi nor -Surg... Total

I II

PLANNED 11 . 3 25

ACTUAL 11 '5 . 4 25

SITE 4

Ortho ER

I I I I , II

tr

ENT CV-Thor Gen. Sufg. Total

Ho I' r I I II

'PLANNED 4 2 0 . jo, 2 2 5 1 7 4 27

ACTUAL 4. 0 1 1 2 0 4 . 1 6 7 - 26

8

9

WI/

'11

, .

Findings

The data derivedfrom the 1000 hours of observation are. presented in. %AL ,

selected forrsince the amount of information as massive and more pertinent

(as was intended) for hospital service application.

"What are the students doing in specific types of in-pient

activities?".

The tables in Appendix A show the number of,hours and percent time, per

activity for "morning", "evening", and "total" for,students observed across

the four training sites.

The four nfajor categories of.activitiei defined in the'observational

study were: patient contact -- scheduled group activities- -- surgery --

diunscheduled activities.' Included in "unscheduled activities" was reading.

A comparison of these major categories across the four sites is presented

in the following -bar graphs.

Patient Contact(Admitting-and follow -up)

Site Time

3 I

II

4 7). I

II

FP 1=1=30.2

AumwommwawinftrommeZmumnrowAW

20.2

45.5

W. I.IIIIIMIAINVOM

.TVe 19.3

mumarrarriurAmilmu

rsuaavowaromesur.0,744WIRge

1 1

.11I

25.8

49.8

53.0

0 30"' 40 50 60 percent

9

I

a

ptiv*ar

Site'

I

..2 3

Time

II IY

Wo con

VM

O&

LU

IN

Sc

duled.Grou

Activities

s, vv tantroun s,

ospital

rences'and\student conferences)

7 1.

19.3'

Oft

M7.

1011

470,

171.

7.1,

4.7A

4re0

"..4

.04,

1740

1411

7/71

/41%

11.5

4I r========itlg.8

6 4

..

Site

Time

7

I

II I

,II

.4

28.3

28.4

I

.71

10

20

30.

740

50

percent

C,

24

Surgery

(Operatingcroom, preand post

operative care and waiting)

26.1'

rn

2.2

27.2

MIN

SIM

EN

IZA

MIA

16.0.

477g

wtv

ra0:

47.q

34.9

AP7

7.0"

1411

4,14

4.46

6-44

6064

1FA

V"

18.3

37.2

10

420

30

40

50

percent

Site

Time

1

Unscheduled Activities

(Reading, in-transit, meals/coffee,

sleeping, eri-ands, miscellanesous)

I'73====gZSE21 24.4

II I

3.2=

q=5:

22:=

24.0

III

/50WWWWIEWAIMORAMOGREM

36.5

3I II

.drg

agra

mpr

o:or

.22.`7

.4

.

'4

I31.8_

II

1

43.0

49.6

Site

Time

10

20

30

t

_Reading-

(A portion of unscheduled activities)

50

perce t

3'

r

Students' activities differed "patieA

evening shits with the greater percentage a

and"surgical pursuits, and hospital adniiss

prevailed' across all sites.

r.

t contact" frgil thejnorning to

night due to fewer "scheduled"

on procedures. The pattern

"Scheduled activities" differed on the morning rotations because Sitev

2 and 3 allotted more time to "Work rounds" and "student conferences.'

"Visitant' rounds" were fairly constant across sites as were "h spital

conferences," with Site 1 having fewer ,student attendees. Overall, similar

patte prevailed for evening activities across sites with servicediffering

in visitant rounds (Site 1 having the lowest of 0.2 percent) and student

conferences, (Site 3 having 6.7 percent; and the others ofr2 or less percent).

"Surgery activities" tended to occur primarily dyring the morning

.

'

rotations as would be expected. Evening surgery did not reach the level at,,

Sitesl and 2 as did Sites 3 and 4. However, at the latter two,.,

sites, the

nr

surgery was primarily done, not by faculty; bueby residents; and students on

these rotations were encouraged to assist them. {Upon questioning the students

stated they enjoyed both the'experience and the responsibility assumed).

The number of students on these clerkships was 4 (as compared with 10 and

11 at Sites 1 and 2), and this may haves contributed to closer relationships.'

The evening hours we?- -Without the structure common to the morning routines.

-

Therefore, more time was'spent'reading, going to x-ray or labs (in- transit),

having coffee/meals,orjust sitting around talking or doing personal errands

(a trip to the-W-11< or to the library). Unscheduled activities prevailed, with -

more,patient-admitting (all sites) and patient followup (Sites 2 and 3) than

during the day. )This generally occurred on the general surgery and emergency

room subrotations (s.ee tables in Appendix B).

.

rt

11

AB

. I

"In 'patient-contact,' whit levels of responsibility, areaercised and With whom Ifaculty; house staff, nurses, others?"

The summarY-Tika des'cribe morning and'evening rotations for each site

and are presented in tabular form in Appendix C.

It_was found that at least 60 percent of students' "patient-contact"

was spent performing the admission/follow-up activities (ranging from 64 roent

at Sjte 2 to 91 percenfat Site 1). Activities in "assistance" "observing"

were constant except far, Site 2 which had a higher perc-. --agin these

./categories46This was possible due to the hig tuber of clerks (10) on this

service and their having greater oppor i'ty to "watch" house staff rather

-than "perform.* Site °3 had a higher incidence of "performance" since there are

no interns at this hospital and students fill this role quite readily.

-----1--,Efforts were madee determine with whom the students interact during

the "patient-contact" acties The next table presents this information.

The vast majority of the time was spent with house staff; with house officers

and facility accounting for 100 percent of all the-supervision, discussion, etc.

with students. At no time was any other person (i.e., nurse) observed in

Athis ca-Patity.

Patient Contact

HOUTS of Contact With-,--

SITES

1 2 ,3" 44

Faculty 11.00 11.75 1.56 4.00

House Officers 59.25 58.50 18.00 11.25

Nurses/-

0 0 0 0

.Others 0 . 0 11- 0.

Student Alone...--

TOTAL HOURS

* 18.7 45.50 36.00 15:75,,

\

89.00 115.75 55.50 31.00'

I

, .

12

"Whaf-guantity and varieties of verbal interactions occurred

in the operating room ?"

\\,,,

The purpose of collecting these data was to examine students interactions

in the operating room. Were they included in discussions of procedures,.far

anatomy, physiol9gy, or were they ignored? The tables in Appendix D

present the cumulative totals of all operating room interactions which were

observed at the four sites. Interpretation is difficult and individual

criticgl incidents are much more meaningful to faculty. Many variables

tenet° interact to make this situation of value to students. It was found

that individual personalities, the patient's problem, number of persons in

the room were fattors that tended to make the situation rather unpredictable.

I certain instances, howerver, consistent patterns of behavior were found,I

:.such as. the surgeon'who consistently fajlitd to note the Presence of the'

,

-clerk. _Other surgeons not only were aware of the medical student's presence,

but actively engaged in a lively oriented discussion to familiarize

the clerk ith the marry facets of the simgical intervention. Dependingdon

various factors, students also. interacted 4ith the residents, and occasionally

with nurses and anesthesiologists,

13

Study 2: Task Analysis of Medical Studentt.44ctivities on Core '1-frgica'S,Clerkships

The second component of the surgical clerkship study was an analysis of

the'tasks and activities experiehced by third-year medical students at the

four training sites. Its objectivewas tQ describe the 6pes of experiences

and the students' level of participatioriin the activities.

Instrumentation 4

\\The general surgery taskjnventory of 319 ?iems,preliiously used in a

house officer survey, served as the model for the data collection. The

six clerkship directors Were asked to select tasks which they would expect to

be experienced by clerks during the two-month rotation on their surgical

C.service. Within this list, high priority tasks were designated. Following

final individual review of the inVentoryty the clerkship directors, they met

as a group with thy Clinicall coordinator and the authors to determine the final

1

_ item selections. The criterion for inclusion was the appropriatepets of the

task for medical students at this particular phase of their educational

experiehce, and 200 tasks arid activities were'-identified.

A second consideration was the description of the "level of pafticipa-

tion" of the clerks in each activity. At the group meeting, it was decided

to use the following descriptive categories for the tasks: np experience;

NNonly observed; only assisted; observed and assisted; observed aeld performed

NN

with supervision; essistedsand performed with ,supervision; observed,

assisted and performed with supervion; performed with superviSion; and

performed without supervision. For another group of activities sucWas

"attending grand rounds" and "presen4ng reports in conferences" the, two

responses were "experienced the activity" or "did not experience the

activity."

14

The revised 200 item inventory was distributed to the clerkship directors

for their critique and approval. Based upon their comments a final inventory

consisting of 196 items was evolved, the content validity of which had been

ascertained by the subject expert consensus--that is, the persons who were

directing the educational experience.

It should be.str ss d tth the purpose of the instrumentwas to describe

the overall clerkship activities and not to assess individual student performance

or to compare training sites. The emphasis was on providing information con-_

e,rning the breadth and depth of the surgical clerkship experience without

the implication that the clerks should have performed or had contact with .

all the tasks and activities identified

Figure 5 and 6 present the cover letter and a sample page of the inventory.

L.--The inventory was distributed to each 6T -the medical students who had been

- ..

assignedvlto surgical clerkship rotations in the period.December 1, 1974 to

January 31, 1975. This incldded the one monthl'n which the observation stiAly

was completed. The same inventory was given to the students who had served

on the surgical clerkships from February 1, 1975 to March 31, 1975, and

April, 1975 to May 31, 1975, and was completed during the final of their4

clerkships. The students recorded,their responses on optical scanning sheets

and were given the option to remain anonymous, and to write suggestions fdr

improvement of the clerkship or any other comments they could off6r. The

optical scanning sheets-were then computer-processed to provide frequency

distributions for each item. The subjective comments were transcribed and ,

the data analyzed for each training site for.e ch rotation.

Student Particpation

Of the 91 students assigned o the surgical ckei<ships for the Ihree

rotations, 77 returned completed inventories. Twenty-two were from the first

0. rotation (32 assigned), Rwere from the second ,rotation (31 assigned}, and

assigned).26 were from the third rotation (28 asslgned). The observation study was

a factor in lowering the respopse in the first rotation, especially at one

hospital. In spite of ine fact that medical students were told that they

were not being eValutted, during the last week some of the clerks at Site 1'

failed to complete the instrument. The number :of respondents from each

site for each rotation is presented in the following table.

Task and Activity Inventory Respondents

OspitalSite / Rotation 1.

12/1/75 - 1/31/ 5

Respondents Assigned

Rotation 2

2/1/35 - 3/31/75

Respondents Assigned

Rotation.3

4/1/75-5/31/75

Respondents Assigned

1 5 12 10 11 8 8

9 12 10 11 10 11

3 4 '4 4 3

4 4 5 5 5

TOTAL 22 32 29 31 26 28

Findings

The diversity of the experience reported by students at each of the four

training hosRitals Was very apparent. This was reflected in both the number of

experiences and the degree of involvement. A profile was identified for each,.

hospital site which was consistent throughout the three rotations of data

collection.

i 6

16

It,was anticipated that certain activities would be experiehced by all

students in all hospitals. However, the only one which was indicated by all

77 students was participation in special "student conferences." All but two

persons mentioned they had conferred-with peers or physicians regarding

patient-agement. For instance, there were a few students who had not ,

participated in teaching rounds at three of the sites; at one site two students

had not engaged in work rounds; and nine Students did not attend grand rounds

at one site. More than a third of the clerks indicated that they had not been

c-

given opportunities to suggest topics for classes or conferelies and only about

half mentioned that they'had presented reports in conferences. Ten percent of

the clerks responded that they had not read or reviewed general medical 'litera-

ture during their clerkship and thirtypercent indicated that they had had no

expeiience researching the literature regarding a particular patient's problem.

Mostof the items referred to specific tasks and to the level of particiPa-

,

tion in which the students engaged--from no experience to performance without

'supervision. There were no tasks in which every student repoked performance

without supervision. All but one or two ,clerks indicated they had performed ,

unsupervised the ophthalmoscopic and otcadpic examinations, auscultation of .

heart and luK.Q1 fields, and palpation of pulses. _Eighty-three percent/students reported they had, obtained and recorded medicaysurgical histories

without supervision, with the remaining studentstindicating they had performed

this task under supervision. One student's experience with the initial physical

examination was limited to observation only; the rest of the clerks actually

.performed the examination, with all but eight doing this Unsupetvised. Five

students reported they had had no experience in taking vital signs at any time

in their clerkship. Four of these students had been assigned to the same train-

ing site and represented, all th4Te rotations. With one exception, the otherNN,

clerks' ocompl-ished this task with no supervision. .

AThere was reported liore direct and unsupervisdd experiences in bask

involving physical exalt nation and work-up,.interpretng laboratory results

evaluating signs and symptoms, and patient communicati6n, and education. 0

Three-fourths of the studAts reported they had answered-patients' questions

and informed patients of prOcedures without supervision. Most of them

indicated experiences reassuring patients, explaining mtnor surgical

procedures, and instructing 'patients in care of their incision. However, /

about a third reported no experience in counseling the patienetfid/or the

family regarding a terminal illness or counseling related to a ptychomatic

complaint:

Among the six broadly defined objectives for the core surgical-Oerkship

was the acquisition qf coihon psychomotor techniques. Diagnostic manual.

skills 'included lumbar puncture, tharacentesis, and arterial puncture;

therapeGtfc manual skills included intravenous cut-dowh.and cardi.ac resus-..

0

citation; adjuvant manual skills included -nasogastrie intubation and-bladder

catherization. The responses to the task gems 'related to tt4se skills

revealed that a significant proportion of clerks at,a'il sites had had no

experience whatsoeveh with these skills including observation; 43 students

indicated no experience with thbracentesis; 37 had no'contact with an infra-.

venous cut-down; and 27 students responded "no aperier46 with external

'cardiac massage. From two to nine students indicated no experience.with)-

venipuncture, arterial puncture, catheter insertion, Bladder catherization,

nasogastric intubation, tracheal intubation and protpscopy.

In the observation component of this investigation, it was found that

operating room activities occupied from 17 percentto 27 percent of'the

clerks' time. However, there were many surgical procedures with which most

students reported limited experiences. These included aspiration of breast

cysts, hemorrhoidettomy, vagotomy, hiatus hernia repair, vein ligation,

adrenalectom', and pancreatiocoduodenectomy. Specific items concefning

participation in lung, cardiac, esophageal, urologic, spinal c. d; and ophthal-

,

Szologic surgery for example, revealed few students had beenin olved in these4-

procedures other than observing, and many - indicated no experience.

Limitations

The accuracy of the, ttiCients' self-reports concerning t ose activities.

which they had expepeenced and'at what level they had-parti ipaied, is

difficult to determine. In several instances, the validity of the responses

was qiiestioned, p rticularly concerning the performance of certain surgical

` procedures. For/example, two students indicated they had erformed laparasopy

without supervision, 10 clerks reported they had prescribed medications

#,

unsupervised, and 2 indicated they had petformed aneurys ectomies under" -

supervision.

Since These were retrospective observations and co plpted anonymously,

cheCking was not possible. The critical factor was not the identification

of these possible "invalid" or "inappropriate",inciden s.Rather,the emphasis,

was on the overall profile of tasks common across the our sites. Such profiles,

:did emerge which werd`Gansistent throughout the three lerkhip rotations, as

a =1",

well as unique to each.

19 .

Discussion

These studies were-directed at the description of the four surgical

core clerkships through the regular activitie of third year_students, %

assigned totheM. . The intent was tocollecCinformation which would define

the experience in terms of:

- What the students were-doing

Whe7F7tiiia_activities were being done

-- Where they took placer

- - And with Whom the students were interacting.

Clinical core clerkships are a,dramatic change in the educational activfties

of the medical-student. `Learning, quickly becomes a more personal responsibility

without reliance or guidance from "cognitive testt;" it is more epis" and, .

the product of interactions with patient's, interns', and visitants; and-it tends0'

to be relatively unstructured without the core of information so readily

identifiable in previous instruc,tional situations. The "clerkshig, depending-

upon the motivations of inaldual students can either be a- very good, average,

or very poor learning-experience. However, since not all the responsibijity

should be the students' exclusively, what arethe characteristics of a "good

clerkship"? What shOuld the medical students be,expected to doand/or learn

in these situations?

At the CWRU School of Medicine, the goals and objectives of the core

surgery clerkship have been described-and implemented to varying degrees -in

each of the four services. With this as a starting point, research efforts

were directed toward the determination of the degree of discrepancy,if any,4.1.

between what faculty thought students were doing and what was actually

occurring. The rationale for this approach was to categorize questions about

the purposes and merits of students' activities prior to the introduction to4,st

any "change" orientation.

201I

20

AAny exomination of the clerkship as an educational pursuit must begin

with the premise that "divgrsity" is commonplace. Na ply do vatients

differ, bbt also hospital routines, attending faculty, interns, residents,

and others. Such diversity, however, 'should not be equated with overOelmina

disequfl rium. Students-have, and will probably continue, to TearriT-to

professionalize,*and to become practitioners oimedticine. The critical concern

is whether there is sufficient guidance system, to facilitate the students'

development toward these ends. For example, should students know what toA

expect on a clerkship beyond the schedule of nights on`Ynd off? What compe-

tencies are to be evolved? What services are they to render and under whatF

circumstances?. Undoubtedly, many such questions prevail across clerkships.

However, since each site is unique, each must work within its idiosyncratic

constraints. Students learning on a service without interns will probably,.

have greater respon'sibility and learn more through experience than cervices

with interns. Services with male and female. patients will provide mored 4\

learning exper;ienthan those with only,males. These-characteristics are

' to be buit upon es much as posSibltand to' do this, data about actual

activities are of value.e

The data from more-than-a thousand hours of observation and.self-reports

of 27 medical students have Oovided a substantial base of descripti\e.informa-.

,

tion about the commonality and ,diversity of experiences across the four sites.j. e .

No judgement as to the "quality" of the experiences has been undertaken,as yet;

rather, questions about students' activities have developed which have b un

ia process of examination to determine if such experiences are consistent or

inconsistent with good educational planning. Among the major concerns

,identified thus far are the following:

C

* What is an equitable distribution of time across "patient contact",

"structured activities", "surg ", and,"unstructured activities"? When

does an area become Overemphasized (greater than 30% per category)?

* Should' the stuaents be "peric-aing" so much t area of "patient

,' contact'; without direct su*rvis.ion? Who is available to-identify (and

correct) constant errors which may be occurring?

* Wt are the purposes of conferences? How are topics determined far

discussion. Should students be:given greater roles in selection?

What should faculty roles and responsibilities 15e, relatiA to the

medical clerk?

* What procedures should all students learn? ,Are there any at all?.

* In the 0. R.,what are the instructional possibilities? Is it merely

a passive situation or should more active roles be ascribed'to clerks?

Many other-questiont have evolved. These istudes are a beginning of

a systematic examination'to'deTermine whether learning under the circumstances

of the core clerkship can b0441timized. At minimum, can the potential_of

r

the experience be more early delineated so that students can have a greater

understanding of wilat they are to learn, how they may learn it, and thole

eas for -which they and accountable?

I

a

rr

J

"

SURGICAL CLERKSHIP STUDY

SUMMARY OF MORNINGOBSERVATIONS

ma

.

-ACTIVIM,CATEGGRYt

.,..

At

.er,,

IA

A. hrs

0 14e

.-------/

At

1A hrs

gt L vL.-11

hrs.

At

'

C2

,

4Ars.

Q hrs

- %

Q2

A hrs

B hes

A%

131;

A hrs

.,.............e.s..=.

I.

Patient Contact

AdtOttfn;

**follow-up

,

Subtotal

_13q,001

(53.25)

,..1

i.

Ill

2

S.8

2.2

1,31

.00

.%4

i44 2.5

131111

.....i72.1))--...

14

I{r

9.50l

i ,....,..t2

0,1.

:1

12.1

_nW5.)-

4

20.2

.17-

19

(1!4.75)

20.9

'(152.25)

.1

L..

gl.

Scheduled Cv-oa, ActIvIt

es

-*'

Vork Pounds

visita-R-Noun s

'''

lidspltal Frulds,

Student conter

ex%

n)

9.2

.

-T7r----.7-

10.50

2,00

3.3

ft]

_.L.7......__4_51-24_....

INCEP

lin;

---6

p..lo

19

_Sp.

(.151._

m._

Ra.0

it

17.75 )

4.4

g8

1L.17-2.51:___

-1174

28.3

024 (74,51.11

D .

o;

it*

.i0.2

'

11

/1.2L/

Subtotal

.'

19.3

(39.75)

284.4

(3211aL

1e.8

173.00) ._.2169.50),

,..... __

III,

Surgery o. a.

also

-74.0

65_21

10-1

'

1!)...501

MIL

EV

Pre/Post-0p

11.00

0.

.5

1.1

1.75)

.00)

(197.M._

:.3

0.0

12.2.

1.;

q__.5.7...q._-..

O.

2t

9.75)

(46.25)

30.1

1(210.25)

Vatting

0.1

.

.25

2.(

.0

\_3.5

.0

34.4

(715

Subtotal

26.1

(51 23):

21__

IV, Unachtdaled Attly Cles

10

5,3

.A.9

'

o;

0.2

.

J-7

. DO

R.o

1c

.1).2)

142(11/%5)

-tft

-Tra

ns.

:

16.00

-67-00)

2.:

}2R.001

lel

...6..01

1.25

...........,

7.00

(---1-725

1Qo

2.2

1 1.3_5a)---_

8. SL

6.

143 7c)

.2

0.3

'

1( 6.75)

.

Heals/Cott r

(15.15

4.7

-LLB)

'1Z25.1

6.2

sleeotno

Errands

1.2

,50 o

0.

2.29

1.1

90.9

).00y

Q 4

00.3

Ij

6.c192_____

Miscella

ous

4 2

t4.2

.0

2.9

( 3.25

86.

'

1 4

'

Subt

24.4

°(50.50)

24.0

....

...___

NIM

MO

NS.

/100.0

-(63.75)

,..........12.1.5......,,,..=.0.1.251,...______31

100 1

038.

24.7

1

(172,Z5L.

.

per

.....

.

to

o

eo

TOTALS

% hrs.

.

1J1116,11/11

62.8

11.

,-

65.9=MIMI

6..4

.

% tOta

hrs. observ.

411

z1.

...

..,....-

1111111111/111

MIMONIONIMOOMMIUMOONMS

Fr

4

. . -

Date

January

14

II

III

V

VI

17

HOURS OF VHCORRIT ORS

Pedi trics Psychiatry

10;25

0 9.75.

10.'00 - 10.00

18 11.50 12.00

21 10.25 8.50

22 11.75 12.00

VII 24

VIII 25

Totals

.r

10.00

9.50

'86.75

8.75

9.00

80.25

ADMISSION OF THE PATIENTHistoiv/Pnsicni 'axamProceduresDiagnostic (lab tests)Therapeutic

P4eparation of the RecordChart reviewPhone callsOther sources

Uriting the record_

INDIVIDJAL P;TIENT FOLLOW -UP.Sol-oz.:ea ::lszoryipnysica.

ION PER SERVICE

Medicine. Surgery ,OW/t-yn

12.75 -11.00 10.00

11.00

11.25

12.00

11.50

10.50,

12.00

13.00

93.00'

9.0d 12.00

10.00

9.00

12.00.

12.00

12.00

10.00

85.00

P160t2i-

5.5

8.0,

.10.75

10.00

8.50.

.8.25

73.00

exaraProceduresDiagnosticTherapauric

Record keepingErrands (perfo.ming-acarrier or _secretary service)

SCH,p--tROUP ACTIVITIESAor.- -ounds Lrt..sioents,

etns, st::.!ents)Isitant/attenaant rounds(visitant, resi.lents,interns, stuuenzs)Hospital conferences (allpersonnel)Stugint conferences

UNSCHEDULED CROVP ACT:VIT:ESStuaent with. rest. ent

internvisitantnursesocialpeersothers

Activities werework-r4lated

--othor

service

ADDITI=1- ACTIVITIESOff-ward procedures

SurgeryOther special

Readi-lsIn-transit (site to siteMeals, coffee breaksSleeping'Mrscellttgous .

24

Observer

Date

Student ObsCrved

Area Assignment

ADMISSION OF n PATIENTMr-tory/Physical ExamProcedures

Diagnostic (lab tests).Therapeutic

Preparation of he :cord*Chart revicw:__Phone CallOther sources

VrItinz the record

ec0

.4P. 0.4 1.1

20

M<I

I. W0 0 0C. .01

INDIVIWAL PATIENT 1.0:1.0.:41'

:elected hiscsry/physicalexam

/(54:!vres

- ensue

111-rap6tfcLace:.'. 1:ctFf.:;

Writing. order;P.rozrcts notes

Errands (perforJir7 carzte---,or cecretarirser cc 0

-$CUEOCLED OS3 ACTIV1TfVolk rot'. (residents. In-terns, tudencs1his .ntiattendcnt rounas

,"( sitabt,'residencs, in-ernststedents)_Hospital conferences (allpersonnel)Student conferences

___JVIISC1tEDLE6 MAT ACrIVITiSS

Studena withresiiicnt

intern_ -

visitant -ralcse

soda) servicepeersothers

Activitics werework-related

-Pawl

-LIZIIIONAL ACTIVITIESOff-ward pse.edviesSvkZeTY__Other special

Itradiot

lo-tiaostt to %ttst)

Itzal, coifs. Ds..A.::

SicepInit

HiscellAscou,

d MO 2m aO N 0d V0. 0.00 2 *0W 0 0a O0 X X glmu

W ,a44 0 00. o e e

4-teuze

. ,

//.

For ind4vidual observotl -code

participation in activiAl'=

,a .performingWactionb assistinW in fun:tionc observing fuhetion

0 0a a 0O ... V-0.0 2 0

70 v %I

... .C.) W1.1 0 0 0= U

Uail. 4. mO 0 0 00.° e e e

00I

0.e 5:...e:C1.. ;It

U UAO 0 0 0'

Co

.a.-

I i . I

II

, 1_21

t

IE]

25

.1:_-11-.±-E-1 LEM

4

. .

ie

Observer udent Observed

Date Time In O.R.

1st 2nd

STUDENT

InItlat Question to

tesponds to Question from

Participates in discussion wit

Responds to instructions from

Participation Code

i. performing functionb, assisting in function

c. observing function

1st 2ndSurgeon j Ass't. Ass't. Nurse, Ancsth. Other

Iist 15'j

2nd 151,

0

;4

ra

3rd '4th

Ej

STUDENT

MedicalStudentsThee Present

I.24'

3. -

4.

* * *

1st 2nd

Surgeon Assit. Ass't. Nurse Anesth. Other

e InItiafes'Question to

Responds to Questi;!,h from

Participates in discussion with

Responds to instructions from

MedicalStudents -Time Present *I 3rd 1.511

1.

2.

t

4th .151.44

1.

2.

3.

4:

26 .

9

.ACTIVITY CATEGORY:

At

82

11t.

is

SUR0I101. CLERKSHIP STUDY

i_SUMMARY OF OBSERVATIONS

t-.r

e 2.

s a

S.

.

,

A brs

AZ

A hrs

At

A hrs

'0 hrs

et

15 hrs

zff=

1,07

01~.

exm

oa-

A hrs

At

0 hrs

Ot

1.11

Patient Con(ect

Follow:1g-

31-1

/i4-9?)

1,

Adnittlrg

36 3

/26.9

-Subtotal

114

SCheduled Grcup Activities

York pounds

.Visitant Rounds

Hospital R.-40WS

1

40.

0 hrs

et

=Z

s

2 0/

Student Conferences

ri

/s.6

Subtotal

15.0

24.3

111.

Surgery O.R,

Pre/Post-O.

valtind

410

1Y.

UnsEhe led ctivities

Read! 9

j,

11.1

In-Trnsft

2.7 "w

)7.2

0.14

1.2

070.2

0.2

.510.8

0.1

otal

17.7

L'

8:7

Ax,.

2

..50

0.5

1.r0

7.4

.50

Neal /Coffee

Stee:Ina

-Err nds

-MPS elianeous

16.Er

A hrs

et

aN

o.

L25

(13.

00)

3.1

1.5

-

2:75)

1016-

TES

'a

r(130.25L

22.1

(4o.-oo)

74.7

.7

(56.50)

22.1.

(7 3.00)

5,$

17.3

1.8

17.751

6.1

( 2.50j

"

0 ,

:1:

1,

3..L

5q)

1.0

;14

.715

-.50

).-3

9'

(31

. 0 0

)

5.75

)

28.7

(291.241

6 4

(

2.!

17!

74)

29 cg)

7? 7c1c.,

(27.

00)

214.

t/7--

1/44

.50)

21.5

1 2.2

/(

19.2

(Is

00)

'7'4)

1.75)

1,3

11

sg)

-2.9

_150.50)

.30.7 ____15121

23,

Subtotal

----,.-2121994221-1-

26.8

Zr

mI

100:0

TOTALS

.119totalobserv.

Observed

10Q,0'

(319 00)

100.0

,

.%

.31.4.

,326

i-

L'`D

6:1 /.

,

10. 0)

8.3

3.251

'1.1

11.0Q

8.8

1,50

( 7.

00)

0.

2.001

16.25)

/5)

0.3

(.s

o)19

.1(35.25)

10.0

2.2

7.0

0.8

0.8

(.716-7.51_

(77 15)

71 8 25

(7.751

9.4 .

(35 )

8.o

(7o.00)

100.2

1184

0100.0

17.8

18.7

330.50

100.0

..

.

184.75)

8.o

28.8

100.0

100.

0

(RI 75)

(2.9

1,24

01-

(lot 5.25 .1.

.I

3 2

( ACTIVITT-1CPACCRY1

I.

Patient Contact

Adsittina

a Follow-uo

.,

Subtotal

It.

Scheduled Ottess Activit

--

,''

Rork Pounds

Visitant noun s

Hospital Rrulds

ft.^

-"`

-'

SURGICAL CLERKSHIP

STUDY

SUMMJ\RY OF MORNINGOBSERVATIONS

A. hrs

0 hrs

A% it

it

0%

I A hrs

n hrs

7334:o01-__

20.2

151,251

23,2 )

30.Q

Q28.3

(.74,5111

At

02

=======*==m

ilofrs

4 hrs

At

A hrs

02

11 hes

Student Colterc ces

Subtotal

(39.75)

2.2

J3-J

00

12.1

(14.75)

4%

A hrs

1,

LI

1(

1 51

. 25)

2814

(322151,

18.8

12001

52,50

1.00 (51.):

-74.0

0.

_165.15

.75

Li

5.p

21...2

(71.50)

l3_t

X50 5

.00)

34.9

39.7 3

0.0

22

,

30.1

(210.25)

IV.

Unsched.ted nett..

Readino

Irt-Transtt

PealstCoff

Sleeping

Errands

OuS

Subtotal

per

.4. nn

TOTALS

% hrs.

rrting tlbspry

; iota

hrs. observ.

24.0

(63.75)

100.0

79.6

(261.00)

25.1

57)

_IL.9

1,1

.i.35

0.8

1.2

7.00

1,2

1.1

C17

230.2

0.9

Fri.-

AP-

-0.4

1-11_

(.50)

2.9

C57153

0.1

[22.25)

17.5

100,1

(113

.75)

11,8

_38.752

99.9

65%9

(121.75)

6.3

Li 7c)

0.9

(( 6.251

0.9

6-Q91-__-

6.5

(45.25)

24.7

1(172-75/.

190.90

t4

69.4

j(704.751

,1

r^.

SURGICALeLERKSHIP STUDY

SUMMARY OF EVENING OBSERVATIONS

it

ACTIVITY CATECift:

----

-

So

Patient Contact

At

A hrs l,0 hrs

'

AO

.

it%IArSCWMPanlaWTOMOM

.

hrs

.

0 hrs

A%

Oi

A hrs

0 hrs

.

A%

et

A hrs

0 hrs

al

-a

..

A hrs

O r

rom=========

.-

=1=7.a

*

.,171..,5____,__

.-4,

-9

--8

ej,at:___-__A

U-431---

Ili(h

iTo.so

'

elkigi

Aimittlno

.1.11..u,

2..3

..2-1 5

...,....114.-

H118i(

.13.:.5.q-:......25

1-UAL-------

514---.==...-..4.545.1

_____45-8

1-(112A0,

Subtotal,

-45.5_

--=====p....--

v4,53.50)

-==..,==.

.41

-....

____116_25)

.

it,

Scheduled Crou, Activities

2.. 50)

4.75)

00)91(

7.75)

.( I.7C

(1.50)

[--..if-2.-----9.

(4.00l

..1...7-4UL.7.51---

1,3,

h_ool

( 2A.:254---

( 25.51),

vork Oct.dis

4.0

( 4.50)

'4 4

3.00

,

1177'01

.....3.0

1.1

0.0

2,2,

1.9'

/ .,

5)L______

(..5.251

Ylsitant Ncuads

0.2

f-.25)

Hospital- 12:on4S

-0.-

0)

? ?

6.4

8.2

.

Student Ccn.erences '

2.0

2.2;)

050

_6,2

11.5

'SiOtotal

===.....LL'...../X4)

8s5

===:-.....__---.._

-...........--.

._,=._.......:-.

di,'

2 a

18.3

8.751-6,7

,

J. 22.20

2.50.-

1.241

1( 26.50)

___.

lit.

Surgeryo. R

.(...245Q)

...---

2,2

014 9

1.1

*

11000i

l.72

0)

0-R

11

).75)

1.0

1)

(ti.52)J

8.5

0.2

L....2.51....a...;

L_.an.l.._7._%____a..n

__/...2 75)

ozo

0Pre/Poct-On

,o0

0.Q

16.0

I-7o(1.0.75),

.Vaitino

.0

7

.

( -1.5o)

sobt?t,)

......,-:...-...............

2.4

1_5.....sol_____2

001IL

.#_.

IV. Unscheduled Activities

Seadillst

inTransst

.La.so

19.o

12..75)

6.7L

9125)14:71'

3.0

.31.00

41419d----7

1_5

A.

1.00l

.2o.7.51

1L-50)-

.9

-5771

4.00)

25).__-____Q-8

'111::It " ,

4.)

.._2

08.6

.so)

0-6

(27.5r

(...2.0

1.2.00

115_,

5,50)

.25)

MeaIs/Coiien

Seepins

Errands

o.

._Lot00

t

.50

.4,50

1.1

.

'

22.7

100

1

.75)

3.75)(15,25)

0.0206

'69..

.00),

0.4I

.00(31.25)

.

3L5

ftlicelle.ncous

.1'

Subtotal

'

43.0

NllnMraIMIIIII

6i

0.

........16,5___

11

(24.5°

If

it

.

2 per

s-F.

TOTALS " % evening observation

35.3

(117q5)20.4

(67.501

37.2

(67.25)

34.1

-

(63.00)

30.6

(310 50)

-

2 total hirs. observ.

11,1

6_7

6.6-

,2

--

-.

.

-

.

,.

-S

T.*

r rIt

S

ROTATION: 8

' IUE GOLO

II I .

NERO

II I_

II'Ex

I IIORM*

I IIP60

`IBURNS

11

CLINIC

1 rrTOTAL

OBSERVATIONS: PLAN360 ' 8ACTUAL 10

3 I 8

2 i 4

3 5

3 d 5 WA5

_ 5111Malliell

8 1 i 1

0

1 I

,01

C

050

44TIME SPENT ,

.75

1111111MWINEI3.00 3.75' 4.5 11.0 31.2.- .50

- .1.00

.

66.00

Patient ContactAdrift ti 6.50 3-75Follow uo 012.25 3.03 i 346- 3.25 4.0 .53 13.5. 3.751 ' i 2.2, i 4.00 49.75II.. Stlid Pup Act's.hA. Kork Rounds fi 6.CC .50 2.50

i1.501 5.5*. 2.5CI I .25 .75 19.508. Vis. Rounds R. 1.25 11111n11111111111 .25 .2.5 1 6.5Hosp, Conf. I'

1 1.00 IA .7z1 ( 3.50

, . Stud. Cont.11 4.00 2.25i 5.25 1 1.C1" 1.7' i Loo 1 1.751 1 1.50 18.50III. Sur er 31.00 8 ,f, 4.25 .50 7.00 55.00Pr. and Post-0 - i .25 i .261 .75 i 1.25ilaitino j .251 I I -

1 a 5 .25IV. Re ing 3.25 2.75 1 1.25 4.5C 4.24.3.54 57.15 5.54 .75 3.251 1.00 35.50. In-Iransst 0 3.00 1 .25 .5d 1.03 1.5. .7- .7_91 .50- ' i .50 8.76Keals/Co f f e.-.----r649-1-1 -Oa 1_2..00 2.5X 3.5 3 2.03 6.29 .25 .753 .601_ 3 .50 r 26.25Side.' .50 ' .75 75 111.1111_11111111 -- 111.11M1.11.111111 ' 3.50Errands 0 .75 1 * IMIIINI11 -1 .75 i 1.50Miscellaneous 3.z5 i. co i 1.25 .2 1-75 .112.2 .50 23,50

Total Hours 79-.50 15.00 126.50 18.7 33.5 12.9. 35. 59.7'--8.00 :6.75 15.75 I 8-..00-:1 319.00

ROTATIOdi NEU

I

0

II

ARESTH.

1 11

ELASTIC

I if

ORTHO

I Ii

ER

t II

PED.

s

SURG.

:It

GEN.

I

SORG. ! TOTAL

II

05SCAVATIONS: PLANNED 2 3 6 0- 0.

-10 0, 0 I 4 i 4 15.

17 534' ACTUAL 6

I 1 3 0 1 - 0 2

10.00M1111.11._..01.50

3 1 2 ' 0 22

13.7'

5 g 46

.

2. 0

10.50i 610"

TIME SPENT

1. Patient Contact

Admitting __mg7.75 .1 0

o mqup

.1E. Sch Gran-K York Round: IN

5

01.5(/

1.25 1. 0

IIM111M119151111111110.110.11111111.1=1111

mNMI NEMZEin 5.21

, .9.

14 Vis. hcund-s

-...,..

e. lit 2-2 .1.11 1.00IIIIMIREMI ,,,, 14. ' 30.00

111. Surgery

N411111111111111111-- 114111111111111111.1111111111111111111111141.111111

11111111IMINEPr. and P.MTrifi

IY. teadIngI 5.75 nilliEl.50 11111 . 0 . Orraithilit

.25

1.00 I. 1.00 111.111Mr

t1 .0.111111[

.5d

-.

40.251.000. 8.25

.?5 , 17.75

.25 2.50

rn1 511

n- 'WS t1:CC ; 1.00 1 .2

Meals /Coffee IMIRM 0Sleeping 1.00

11111111111111111111111E1MEM=Errands MM.IMO=MiscellaneousMiscellanes

3 041191111111TOWTOTAL HOURS112

7.50

MIN6.75

EMIEn 16.00. 150.5

2.50!! 1$.5ff

33.251 330.00

30

0

Srre.

.

ROTATION: .

'o

tIAJOR

I IIH

1

NOR

ItTOTAL

08SERVATIMS: PLANUO I .11., .

S 5' 6 3 25ACTUAL 11 '5 - 5 4 25

Time Spent:

. I. Patient Contact .. Admitting , '1.00 8.50 1..50 8.50 19.50Follow uP

35Dn..

12 nn I arse 4 cn 1 r)4 P.

U. Schad CrotIp Act's.: A) Wirk Rounds

I 9.00

t: ,71

1.50 2.50 11.008) Vis: Rounds 4 2.00 .75 -2.76

Nosy. Conf, 1 1.25 . 3.75 5.00C) Student Conf. 1' 8_25 4.50 6.50 19.25 1

III. furgery1 18.75 . 6.75 , 15.75 : 3t25 44.50

- 1.,fre And Post -0o 1 1.00 . . .50 .25 .25 0 2.00haiting. 4.00

0 4.00_ IV. Tters--19'="-- .1 5 74 74 ) cn M in 6

In-Transit1 .50 1.75 .75 .25

2.00 1.50

1

1

3.25_

11.00Kcils/Coffee 5.00 2.50

Sleeping-1.25. 25.- 1 1

, 1.50. Eftands . .50 .75. .-

. .

.50 :.

--

1 1.75. Misttllaneous . .. 1.25: 2. 2.75

. t f fm I - . 7.80.'TOTAL NOURI.: 72.50' 44.00. .A1.25 23.25 '1 181.00 J

4-

App e.4'

ROtAT101/:. 4

.

. ORTHO

I II 'I I

EA

11

EHT

I II

CV-THOR.-I

11

air.

1

sm.I)

-TOTAL

)3SERVATI04il' PLANNED4 '2 1 0

01

2 5 1 4 27+ ACTUAL4 0 1 I 2 0 4 1 6 7

,---

26rinE SPENT:

1. Patient Contact' Admitting .74 2.25

.40 1 1.50

,.

10.74

.

1.5.75Follow up

II. Scharou-p-Act's.A Work Rounds

4.00'.2.5 3.001 .75

-

1.50 1.50 4.25 '.501 45.75

'-.. ,-

-' 3.25 1.7.

4 Vis Round";1.25 .50 1.00 .50Rosp. Conf. 1 1.00 I 1.50 ' 2.75 1.50 6.75C) Stud. Conf.

aI

.00 2.00 . . 1 .00 11.00111. Surgery ,

1.25 6.25" : 3.7575 3.00 19.25 . 4.00 50.75Pre end Post-O. I 2.50

. .25 1.251 1.2VattingL

. .IIIIIIIF

=MINN1.00

, 1.75

Mgs

IIIA

1.75

It

16.25

.50

1 4

111. Reading.

gs

IIIIITIIIIIMIMMNIM.75

1nTrAnsit. .25 .

heals/Coffee, 1.50 :.1.00 1.25 2.76

Sleeping

allig-Errands_

..5 0. Miscellaneous

1.00 .75 2.50 11.25 1.25 6. o

TOTAL HRS. 2 0 7. 5 8.00 14.50 SMINITIMIMI 46. 184.75

4-P

31

ROI44104:

0fiCR94710051

pAilt

irr Fe

1.1

ti.,?

trat

. OF

RE

SF

OM

MT

I. /T

Y

mission Q>,.

PERFORM

hrs

ASSIST

.

hrs

OBSERVE

hrs

DISCUSS

hrs

TOTAL POURS/

% HO1RS

His

tery

/Phy

lltal

W22.50

2.00

-

.

.4.50

29.00

(.26)

Procedures (eisy/thersp)

',40.

CO

5. /5

,...-.....

.75

' 16.50

(.15)

)record Prepsr4tion

i'75

:50

,..

. 25

)

L.50

-5.00

(.05)

IdrIcing the Record

.,

12.00

.

.75

41.kt....:,J...41,,,A1.

,12.75

(.12)

11c4-up.

ss.

.

Selected Physical Era".

7.25

1.00

.75

1.25

12.26

(Al)

Procedures :

9.75

5.25

5.75

'2.75

23.50

(.21)

Accord Keeping

11.75

o11.75

(.12)

sow

ww

w./N

NS

.;;A

ME

MO

MP

41"

.,

-

110.75

TOTAL NOLAS/

Ti MPS

79.00

'.,

(.71)

15.25

(.14)

12.00

(.11)

450

(.04)

ROTATION:

TOTA

ADOSERIATIOWS:

ATIEliT re

1

ti-e

-2,

LEVEL OF RESPONSIBILITY

64Ission

PERFORM'

hrs

ASSIST

hrs

OBSERVE

hrs

DISCUSS

Ars

TOTAL Howls/

S HOURS

H16t0r5 /Physical Esasa

10.25

1.50

.75

12.50

(.15)

Procedures (dSag/theraP)

.5.50

1.00

1.25

7.75

(.09)

lecord ?reparation

'2.50

.25

1.75

4.50

(.05)

Writing the Record

5.75

.50

.25

6.50

(.00

e.

11w

-up

C.

,

-

..

.

Selected tlySICil ELLS

5.75

2.00

3.00

10.75

(.13)

Procedures

..

15.25

7.00

.5.25

.60

20.00

(.33)

Record Keeping

if.75

2.75

"1.25

1.25

14.00

(.17)

......

04.00

'9-

--._-.

TOTAL HOURS/

SHMS

.53.75

(.64

)15.00

WO)

11.75

(.14)

.

3.50

(04).

i

.

,

ROTATIOM:

;Hog

rom

pvA

TIo

ns:

25.-

,.

.MEM CO:ITACT

LEVEL OF RCM:15181MT

!mission

EgroRm

hrs

ASSIST

hrs

-00SERVE

hrs

OISC6SS

I

hrs

(TDIAL HOURS/

S WOOS

HiStOry/PhySlel

12.00

,12.00

(.23)

FrocelOres (dfag/thew)

.50

.7S

1.25

(.01)

Record Preparation

.75

..75

(.01)

Writing the Record

5.50

,.

5.50

(.16)

Ilow

-op

4elected.Physfc41 Exio

75

1.00

25

4

2.00

(04)

Procedures

c20.75

1.75

50

23.00

(.43)

Record Keeping

-4.00

.50

0.50

(.10)

TOTAL HMS/

1 104145,

48.25.

(.91)

f

4.00

Goa

)<

.75

(.01

).

I43.00 ..._.

Fo1

FAT;EIT ro

ROTATtOII: :

IOTAL

OBSERVATIONS:

7

St-t

e-LEVEl. OF ILEsrONS1011.1/

a

clIsston

PERFORM

hrs

Asstt:'

.hrs

08SCAvE

hrs

DISCUSS

hrs

.TOTAL HWAS/

S 1

13(1

25

History/Physical Exam

9.50

.75

.

10.25

(.36)

Procedures

lig/therap

.25

.

..

25

(01)

cord Preparation

2.50

.

2.50

(.09)

rltng the

Rsc

or1.00

11.00

(.04i

rlow4P

0.

e ected 'hystce EXLM

.

F.

1.75

2.75 .

.25

4.75

(.17)

Procedures

4.50

1,75

1.25

7.50

(.27)

to _ Keeping

2.00

'4

.2.00

(.07?

TOTAL BovaS/-

IS BOUR5

,21.50

.76

4.50.

(.16)

2.25

(.04)

23:25

___

6

S VrE

,

.ROTATION:

TOTAL

SURGEON

1st

Asser

CSSERSATIEAS:

OPERA1 ro:m-acTivITIE$

VERBAL INTERACTIORS:

Initiated question it

2Z

Responded to

on IEFEM

1$

tertlEiOated fn discussion with

43

20

heisponded to instructions fiat.--

2916

TO

TA

L/ ITOTAL

107(.32)

IS(.19)

NUMOER OF OBSERVATIONS

sib

rOPSERvAIIONS:

ROTATION:

IVA-

QP(RAT

TOTAL/

.VER

OTHER

S TOTAL

72

(.21)

33

.17

!nit'

-49

Respo

(.15)

1710

'13

43

i146

(i1)

112

65(.20)

42(.13)

(.0413)(.0t7i)

03332

(.26)

',VERA

VER

POO

Rat

SirtI

404

ltzsoa

ROTATION: TOTAL

OD5ERIATI6471t

tert1

Res

s tTE

3

HUMBER OF OBSERVATIONS

IUGR014 ACTIVITIES

_.

SURGEON

Ist

ASST " -----ASSIT-

2nd

NURSE

AYES'

°TRES

TOT

%13

Al INTERACTIONS:

..,

Ard question to

34

26

1.

61

(.31

Ided to question from

.13

.

5.

I

14

Apated in discussion till

31

-35

2.

1.

13

71

(.2I

ded to instructions I=

,

.34

.

101

.

..

2

.

;41

-1..2

TOTAL/ % TOTAL

4T

112

(-EA)

76

. (.38)

4

'(.02)

1

(.01)

3

(.02)

.

3(.62)

.

I

191

.LAMM

S tre

HUVOER OF OBSERVATIONS

1110 R003 AGTIVITISS

01 INTERACTIONS:

3.SURGEON

ASST

..;

1st

2nd

ASST

NURSE

ARES'

OTHER

TOTAL/

% TOTAL

itequestIon to

§3

11

33

171

(.26)

idled to question from

32

/6

11

40

(.15)

mr

:Ipsted indtscbtion tin.

so

21

310

49

IC6

(.39)

Mod to instructions

rote31

175

(.65)

12

3,

33

52"

(.10

.

TO

TA

L/S TOTAL.

.SO

(.19)

-10

(.04)

16

'

('.C6)

0

(.03)

10

(.04)

269

.,

CI ASE WESTERN RESERVE UNIVERSI.T''Y. CLEIVEL'AND, OHIO 441d6.

. May 15, 1975

TO: Phase 3 Surgical Clerks

1. Cb 01?,e-

FROM: Clerkship Directors of the Department of Surgery:Drs. Frederick S. Cross, Ralph G. DePalma, BrownM.'Dobyns, Kent H. Johnston, James C. Jones, JerryS. Wolkoff

At the request of the Clerkship Directors of the Departmentof Surgery and the Dean for Medical Education,of the School ofMediciae,'a surgical clerkship s.tiidy is being/, undertakdn by the.Division of Research in Medical Education. As, part, of this stuAy,'we are asking yop to complete thA,enclosed task and activityinventory.-.

,,!

The Clerkship Directors of the Department of Surgery hayeidentified those tasks and activities which might be experiencedin the surgical- clerkships. The-informatioe provided by thisinventory will help determine if the surgical clerks af'the fourtraining sites participated in these experiences. This inventorydoes not imply that each clerk will have performed or even parti-cipated in all of,these activities. 'Its purpose-is to assess theclerkship; experience, not the student. Each hospital will be'identified. The'students may remain anonymous if_they do notwish to sign the.inventory. .

Please lase the answer sheets provided to recordyourresponses to the items. The answercode is indicated on eachpage of the inventory. Answer'sheet No. 1 isto be used forItems 1 through 100; answer sheet,fNo. 2 is to be used for Items1.4 through 196. Please return, the answer sheets to'the Directorof your clerkship,

'"If youhave any suggestions for the improvement of thesurgical clerkship, please write them on the blank sheet-provided.

Thank you for your invaluable assistance.

FSC/RGD/BMD/kHJ/JCJ/JSW/r1

chool of Medicine .

epartment of 3urgcry 34

*Plcouraz- January1975

Case Western Reserve Univerity'School of MedicineDepartmentof Surgery

Itr'

SURGICAL CLERKSHIP ACTIVITY/TASK .I4VENTORY

Use answer'sheet No. 1 for Items 1 = J00DIRECTIONS: For Items 1 through 9 answer "A" if you experienced

- the activity 4n your surgi,cal'clerkship; or."B" if you did notexperience the,.activity. 41acken the sliace.under the selectedletter On the anM,/et sheet.

A = experienced the activity. B did not experience the activity

1.- Participate in teaching rounds

Participate in work rounds

44Atteni,grand rtunds,

4. Atpend special student-oriented conferences

5. Suggest .topics for 0assc-eWc-Onferenal

G. Present reports in

7. Read/review etal medidal literature

search literature concerning a particular patient'sor,eblem

9. Confer with peers or M.D;'s on patient manageMent

DIRECTIONS: Use the key outlined belowito report youi experiencein' your surgical clerkship with each ofiCk2,following tasks. Selectthe category which describes how yOu most *EommonIly participated,_Blacken-the space under the selected answer on the answer sheet.Select -

"z's

A = No experience0B = Only observed-. !

C = Only assisted'p = Observed and assisted

= Observed and perfamed:*ith'supervision... Assisted and performed With supervision

G = Observed, assistdd and performed with supervisionH.= Performed with supervision.I = ferfOrmed without sup6Tvision

10. Obtain and recoTd medical /surgical history

11. Mike entries on medical recorcis

12. Plan/modify diagnostic procedures according to patienits.response/need

13. AsseSs patient's general appearance

35.