Minor Sam, Poenaru Dan
Department of Surgery, Queen's University, Kingston, ON, Canada.
Am J Surg. 2002 Nov;184(5):471-5. doi: 10.1016/s0002-9610(02)01001-2.
While on surgical rotations, clinical clerks spend more time on the ward and in the emergency department than in any other location. Consequently, their in-house experience is of great importance to their education-yet the teaching processes in these settings have never been fully explored. Unlike the structured pre-clerkship years, the exact breakdown of a clerk's hospital-based education is difficult to elucidate. To effectively evaluate a clerkship curriculum, it is essential to know what clerks are being taught outside of seminars, how that teaching occurs, and by whom. This study proposes a methodology by which a surgical clerkship curriculum can be evaluated.
For the purpose of the study, surgery clerks carried written and audio logs of their informal teaching encounters during one on-call period (30 hours). These included who taught them, where, by what methods, for how long, and what prompted the teaching. A survey of similar variables was administered to all clerks who rotated through general surgery over 4 months and to all general surgery residents.
Four clerks returned completed logs (100% response rate), and 17 clerks (85% response) and 15 residents (100% response) were surveyed. Audiotaped and written logs were similar, demonstrating good recall. Students recorded an average of 11 teaching encounters (range 3 to 20) per 30 hour period, lasting a total of 73 minutes (range 17 to 178) and each 6.7 +/- 14 minutes long. Both logs and surveys identified most teaching as unsolicited, done mostly by junior and chief residents, focused chiefly on diagnosis and using a Socratic style. Most teaching occurred in the operating room, yet its occurrence was unpredictable; in surveys the emergency room and clinic settings were perceived as more important. Staff surgeons contributed 27% of the logged encounters yet were perceived in surveys as the least contributors. Residents' and clerks' perceptions of teaching were similar except for residents overvaluing the amount of senior teaching (P = 0.04). The resident level correlated significantly with the comfort of teaching (r = 0.618, P = 0.04). Senior residents encouraged more problem-solving, whereas juniors favored minilectures. Only one resident had received formal teaching instruction.
Informal teaching of surgery clerks is variable and occurs through multiple short encounters in many settings and by various trainees. Efforts to improve the teaching process should focus on providing formal teaching instruction early in residency, specifically geared toward short encounters in flexible settings. Both the operating room as a learning environment and staff surgeons as informal teachers must be intentionally integrated into the teaching process.
在外科轮转期间，临床实习医生在病房和急诊科度过的时间比在其他任何地方都多。因此，他们在医院内部的经历对其教育至关重要——然而，这些环境中的教学过程从未得到充分探索。与结构化的实习前几年不同，实习医生基于医院的教育的确切构成难以阐明。为了有效评估实习医生课程，必须了解实习医生在研讨会之外所学的内容、教学是如何进行的以及由谁来教学。本研究提出了一种评估外科实习医生课程的方法。
为了该研究的目的，外科实习医生在一个值班期（30小时）内记录了他们非正式教学接触的书面和音频日志。这些记录包括谁教了他们、在哪里、通过什么方法、教了多长时间以及教学的起因。对在4个月内轮转普通外科的所有实习医生以及所有普通外科住院医生进行了关于类似变量的调查。
四名实习医生交回了完整的日志（回复率100%），对17名实习医生（回复率85%）和15名住院医生（回复率100%）进行了调查。音频和书面日志相似，显示出良好的回忆能力。学生们每30小时平均记录11次教学接触（范围为3至20次），总共持续73分钟（范围为17至178分钟），每次接触时长为6.7±14分钟。日志和调查都表明，大多数教学是主动进行的，主要由初级和主治住院医生完成，主要集中在诊断方面，并采用苏格拉底式教学风格。大多数教学发生在手术室，但手术室教学的发生不可预测；在调查中，急诊室和诊所环境被认为更为重要。主治外科医生贡献了记录接触中的27%，但在调查中被认为是贡献最少的。住院医生和实习医生对教学的看法相似，只是住院医生高估了高级教学的数量（P = 0.04）。住院医生级别与教学舒适度显著相关（r = 0.618，P = 0.04）。高级住院医生鼓励更多地解决问题，而初级住院医生则更喜欢小型讲座。只有一名住院医生接受过正式的教学指导。
外科实习医生的非正式教学是多样的，通过在许多环境中与不同学员进行的多次短暂接触来进行。改进教学过程的努力应集中在住院医师培训早期提供正式的教学指导，特别是针对灵活环境中的短暂接触。手术室作为学习环境以及主治外科医生作为非正式教师都必须有意地融入教学过程。
